8. Lindsberg PJ, Roine RO. Hyperglycemia in acute stroke. Stroke. 2004 ; 35. :
363 - 64 ... Penatalaksanaan hiperglikemia pada stroke akut. In : Misbach J,.
62
DAFTAR PUSTAKA
1. Konsensus nasional : Pengenalan dan penatalaksanaan demensia alzheimer dan demensia lainnya. Edisi 1. Jakarta : Asosiasi Alzheimer Indonesia ; 2003. 2. Cerebrovascular disease. In : Victor M, Ropper AH, editors. Principles of Neurology. 8th ed. New York : McGraw-Hill ; 2005. p. 660-746. 3. Kurtzke JF. Epidemiology : Stroke, Pathophysiology, Diagnosis and Management. 1st ed. New York : Churchill Livingstone ; 1996. p. 3-19. 4. Gubitz G. Acute stroke management and prevention of recurrences. In : Candelise L, Hughes R. Liberati A, Uitdehaag BMJ, Warlow C, editors. Evidence-based neurology : management of neurological disorders. Minnesota : Blackwell Publishing ; 2007. p. 113 - 26. 5. Gusev, Skvorsova VI. Brain Ischemia. 1st ed. New York : Kluwer Academic/Plenum Publisher, 2003 : 1-72. 6. Sjahrir H. Stroke iskemik. Medan (Indonesia) : Yandira Agung Medan ; 2003. p. 1 -35. 7. Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke : A guideline from the American Heart Association / American Stroke Association. Stroke. 2007 ; 38 : 1655 - 711 8. Lindsberg PJ, Roine RO. Hyperglycemia in acute stroke. Stroke. 2004 ; 35 : 363 - 64
63
9. Garg R, Chaudhuri A, Munschauer F, Dandona P. Hyperglycemia, insulin, and acute ischemic stroke : a mechanistic justification for a trial of insulin infusion therapy. Stroke. 2006 ; 37 : 267 - 73. 10. Vancheri F, Curcio M, Burgio A, Salvaggio S, Gruttadauria G, Lunetta MC, et al. Impaired glucose metabolism in patients with acute stroke and no previous diagnosis of diabetes mellitus. Q J Med. 2005 ; 98 : 871 - 78. 11. Gentile NT, Seftchick MW, Huynh T, Kruus LK, Gaughan J. Decreased mortality by normalizing blood glucose after acute ischemic stroke. Acad Emerg Med. 2006 ; 13 : 174-80. 12. Weir CJ, Murray GD, Dyker AG, Lees KR. Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long term follow up study. BMJ. 1997 ; 314 : 1303-6. 13. Capes SE, Hunt D, Malmberg K, Pathak P, Gerstein HC. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients : a systematic overview. Stroke. 2001 ; 32 : 2426 - 32. 14. Kagansky N, Levy S, Knobler H. The role of hyperglycemia in acute stroke. Arch Neurol. 2001 ; 58 : 1209 - 12. 15. Fuentes B, Casarrubios MAO, Jose BS, Castillo J, Leira R, Serena J, et al. Persistent hyperglycemia >155 mg/dl in acute ischemic stroke patients : how well are we correcting it? : implications for outcome. Stroke. 2010 ; 41 : 2362 - 65. 16. Baird TA, Parsons MW, Phanh T, Butcher KS, Desmond PM, Tress BM, et al. Persistent poststroke hyperglycemia is independently associated with
64
infarct expansion and worse clinical outcome. Stroke. 2003 ; 34 : 2208 14. 17. Christensen H. Acute stroke : a dynamic process. Dan Med Bull. 2007 ; 54 : 210 - 25. 18. The European Stroke Organisation (ESO) Executive Comittee and The ESO Writing Committe. Guidelines for management of ischaemic stroke and transient ischaemic attack. Cerebrovasc Disc. 2008 ; 25 : 457 - 507. 19. Johnston KC, Hall CE, Kissela BM, Bleck TP, Conaway MR. Glucose regulation in acute stroke patients (GRASP) trial : a randomized pilot trial. Stroke. 2009 ; 40(12) : 3804 - 9. 20. Kernan WN, Viscoli CM, Inzucchi SE, Brass LM, Bravata DM, Shulman GI, et al. Prevalence of abnormal glucose tolerance following a transient ischemic attack or ischemic stroke. Arch Intern Med. 2005 ; 165 : 227 33. 21. Penatalaksanaan hiperglikemia pada stroke akut. In : Misbach J, Lumbantobing SM, Lamsudin R, Ranakusuma TAS, Alfa AY, Baoezier F, et al, editors. Guideline stroke 2007. Jakarta : Kelompok Studi Stroke PERDOSSI ; 2007. p. 59 - 66. 22. Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc. 2004 ; 79(8) : 992 - 1000. 23. Pittas AG, Siegel RD, Lau J. Insulin therapy for critically ill hospitalized patients. Arch Intern Med. 2004 ; 164 : 2005 - 11.
65
24. Fogelholm R, Murros K, Rissanen A, Avikainen S. Admission blood glucose and short term survival in primary intracerebral haemorrhage : a population based study. J Neurol Neurosurg Psychiatry. 2005 ; 76 : 34953. 25. Matz K, Keresztes K, Tatschl C, Nowotny M, Dachenhausen A, Brainin M, et al. Disorders of glucose metabolism in acute stroke patients. Diabetes Care. 2006 ; 29 : 792-7. 26. Gelgel AM. Hubungan kadar gula darah puasa penderita stroke non hemoragik waktu masuk rumah sakit dengan hasil neurologik memakai tolok ukur skala Koma Glasgow dan indeks Barthel [tesis]. Semarang (Indonesia) : Universitas Diponegoro ; 1996. 27. Basu S, Sanyal D, Kroy, Bhattacharya KB. Is post-stroke hyperglycemia a marker of stroke severity and prognosis : a pilot study. Neurology Asia. 2007 ; 13-19. 28. Martin A, Rojas S, Chamorro A, Falcon C, Bargallo N, Planas AM. Why does acute hyperglycemia worsen the outcome of transient focal cerebral ischemia? : Role of corticosteroids, inflammation and protein Oglycosylation. Stroke. 2006 ; 37 : 1288 - 95. 29. National Institute of Neurological Disorders and Stroke. New tool allows early prediction 2010
May
21
;
cited
2010
Dec2].
Available
from
:
http://www.ninds.nih.gov/news_and_events/news_articles/pressrelease_str oke_outcome_063001.htm
66
30. Kasner SE, Chalela JA, Luciano JM, Cucchiara BL, Raps EC, McGarvey ML, et al. Reliability and validity of estimating the NIH stroke scale score from medical records. Stroke. 1999 ; 30 : 1534 - 37. 31. Baird AE, Dambrosia J, Janket SJ, Eichbaum Q, Chaves C, Silver B, et al. A three-item scale for the early prediction of stroke recovery. Lancet. 2001 ; 357 : 2095 - 99. 32. National Institutes of Health Stroke Scale [internet]. California (USA). c2010 [updated 2010 ; cited 2011 Jan 7]. Available from : http://www.nihstrokescale.org/ 33. Endress M, Dirnagl U. Ischemia and stroke. In : Alzheimer C, editor. Molecular and cellular biology of neuroprotection in the CNS. New York : Kluwer Academic/Plenum Publishers ; 2002. p. 455 - 72. 34. Endocrine functions of the pancreas & regulation of carbohydrate metabolism. In : Ganong WF, editor. Review of medical physiology. 21st ed. San Fransisco : McGraw-Hill ; 2003. 35. Noerjanto M. Management of acute stroke : masalah-masalah dalam diagnosis stroke akut. Semarang (Indonesia) : Badan Penerbit Undip ; 2002. 36. Misbach J, Jannis J, Kiemas LS. Stroke, aspek diagnostik, patofisiologi, manajemen. Jakarta : Balai Penerbit FKUI ; 1999 ; p. 46 - 54. 37. Markus HS. An introduction to stroke. In : Markus HS, editor. Stroke genetics. New York : Oxford University Press ; 2003. p. 1 - 30.
67
38. Furie KL, Smirnakis Sm, Koroshetz JW, Kitsler JP. Stroke due to large artery atherosclerosis. In : Furie KL, Kelly PJ, editors. Handbook of stroke prevention in clinical practice. New Jersey : Humana Press ; 2004. p. 151 66. 39. Basic pathology, anatomy, and pathophysiology of stroke. In : Caplan LR, th
ed. Philadelphia : Saunders
; 2009. p. 22 - 63. 40. Ginsberg MD. Adventures in the pathophysiology of brain ischemia : penumbra, gene expression, neuroprotection. Stroke. 2003 ; 34 : 214 - 23. 41. Joesoef AA. Aspek biomolekuler dari iskemia otak akut. Pendidikan kedokteran berkelanjutan : stroke in depth now and the future, di Surabaya ; 2004 Mar 13 - 14. Surabaya (Indonesia) : FK Universitas Airlangga ; 2004. 42. Syntichaki P, Tavernarakis N. The biochemistry of neuronal necrosis : rogue biology?. Nature Reviews. 2003 ; 4 : 672 - 84. 43. Royter V, Gur AY, Bova I, Bornstein NM. Hyperglycemia and acute ischemic stroke. Isr Med Assoc J. 2004 ; 6 : 607 - 9. 44. Batjer HH, Caplan LR, Friberg L, Greenlee RG, Kopitnik TA, Young WL. Cerebrovascular disease. Philadelphia : Lippincot-Raven ; 1997. p. 23 40. 45. Iskandar J. Panduan praktis pencegahan dan pengobatan stroke : stroke iskemik. Jakarta (Indonesia) : PT Bhuna Ilmu Populer Kelompok Gramedia ; 2002.
68
46. Sacco RL, Adams RJ, Albers GW, Alberts MJ, Benavente O, Furie KL, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack. Stroke. 2006 ; 37 : 577 - 617. 47. Han J, Bae HJ, Wong LKS. Pathophysiology and mechanism whereby hypertension may cause stroke. In : Aiyagari V, Gorelick PB, editors. Hypertension and stroke : pathophysiology and management. New York : Humana Press ; 2011. p. 77 - 96. 48. Stoll G, Bendszus M. Inflammation and atherosclerosis : novel insights into plaque formation and destabilization. Stroke. 2006 ; 37 : 1923 - 32. 49. Gott AM. Evolving concepts of dyslipidemia, atherosclerosis, and cardiovascular disease. J Am Coll Cardiol. 2005 ; 46 : 1219 - 24. 50. Gau GT, Wright RS. Pathophysiology, diagnosis, and management of dyslipidemia. Curr Probl Cardiol. 2006 ; 31 : 445 - 86. 51. Tahapan terjadinya aterosklerosis. In : Tugasworo D, editor. Patogenesis aterosklerosis. Semarang : Badan Penerbit Universitas Diponegoro ; 2010. p. 15 - 24. 52. Modifiable lifestyle and environmental factors. In : Wiebers DO, Feigin VL, Brown RD, editors. Handbook of stroke. 2nd ed. Philadelphia : Lippincott Williams & Wilkins ; 2006. p. 305 - 11. 53. Sangiorgi G, Mauriello A, Kolodgie F, Trimarchi S, Zoccai GB, Virmani R, et al. Pathobiology of the asymptomatic atherosclerotic carotid plaque. In : Moussa ID, Rundek T, Mohr JP, editors. Asymptomatic carotid artery
69
stenosis : risk stratification and management. London : Informa Healthcare ; 2007. p. 19 - 38. 54. Rundek T, Meyers PM, Crutchfield K. Cerebrovascular anatomy and physiology and mechanism of first-ever ischemic stroke in patients with carotid artery stenosis. In : Moussa ID, Rundek T, Mohr JP, editors. Asymptomatic carotid artery stenosis : risk stratification and management. London : Informa Healthcare ; 2007. p. 39 - 62. 55. Mayes PA. Biokimia Harper edisi ke 25. Jakarta : EGC ; 2002 ; p. 195 204. 56. Cryer PE. Williams textbook of endocrinology. 8th ed. Philadelphia : WB Saunders Company ; 1992 ; 1223 - 48. 57. Stover JF, Sakowitz OW, Thomale UW, Kroppenstedt SN, Unterberg AW. Norepinephrine-induced hyperglycemia does not increase lactate in brain injured. J Intensive Care Med. 2002 ; 28 (10) : 1491 - 7. 58. Neuroendocrine control of metabolism and growth. In : Longstaff A, editor. Neuroscience. 1st ed. Oxford : BIOS Scientific Publisher Ltd ; 2000. p. 274 - 82. 59. Romero LM, Butler LK. Endocrinology of stress. Int J Comp Psychol. 2007 ; 20 : 89 - 95. 60. Martini SR, Kent TA. Hyperglycemia in acute ischemic stroke : a vascular perspective. J Cereb Blood Flow Metab. 2007 ; 27 : 435 - 51. 61. for neuroprotection. J Neurol Neurosurg Psychiatry. 1999 ; 67 : 1 - 3.
70
62. Du XL, Edelstein D, Dimmeler S, Ju Q, Sui C, Brownlee M. Hyperglycemia inhibits endothelial nitric oxide synthase activity by posttranslational modification at the Akt site. J Clin Invest. 2001 ; 108 : 1341 - 48. 63. Cai S, Khoo J, Channon KM. Augmented BH4 by gene transfer restores nitric oxide synthase function in hyperglycemic human endothelial cells. Cardiovasc Res. 2005 ; 65 : 823 - 31. 64. Cosentino F, Eto M, Paolis PD, Loo BVD, Bachschmid M, Ullrich V, et al. High glucose causes upregulation of cyclooxygenase-2 and alters prostanoid profile in human endothelial cells : role of protein kinase C and reactive oxygen species. Circulation. 2003 ; 107 : 1017 - 23. 65. Cosentino F, Hishikawa K, Katusic ZS, Luscher TF. High glucose increases nitric oxide synthase expression and superoxide anion generation in human aortic endothelial cells. Circulation. 1997 ; 96 : 25 - 8. 66. Ding QF, Hayashi T, Packiasamy ARJ, Miyazaki A, Fukatsu A, Shiraishi H, et al. The effect of high glucose on NO and O2 through endothelial GTPCH1 and NADPH oxidase. Life Sci. 2004 ; 75 : 3185 - 94. 67. Aronson D, Rayfield EJ. How hyperglycemia promotes atherosclerosis : molecular mechanism. Cardiovasc Diabetol. 2002 ; 1 : 1-10. 68. Inoguchi T, Li P, Umeda F, Yu HY, Kakimoto M, Imamura M, et al. High glucose level and free fattty acid stimulate reactive oxygen species production through protein kinase C-dependent activation of NADPH oxidase in cultured vascular cells. Diabetes. 2000 ; 49 : 1939 - 45.
71
69. Forstermann U, Munzel T. Endothelial nitric oxide synthase in vascular disease : from marvel to menace. Circulation. 2006 ; 113 : 1708 - 14. 70. Sercombe R, Vicaut E, Oudart N, Sercombe C, Girard P. Acetylcholineinduced relaxation of rabbit basilar artery in vitro is rapidly reduced by reactive oxygen species in acute hyperglycemia. J Cardiovasc Pharmacol. 2004 ; 44 : 507 - 16. 71. Morigi M, Angioletti S, Imberti B, Donadelli R, Micheletti G, Figliuzzi M, et al. Leukocyte-endothelial interaction is augmented by high glucose concentrations and hyperglycemia in a NF-
-dependent fashion. J Clin
Invest. 1998 ; 101 (9) : 1905 - 15. 72. Andersen SK, Gjedsted J, Christiansen C, Tonnesen E. The roles of insulin and hyperglycemia in sepsis pathogenesis. J Leukoc Biol. 2004 ; 75 : 413 21. 73. Maxwell WL. Cellular responses to ischaemic CNS injury. In : Berry M, Logan A, editors. CNS injuries : cellular responses and pharmacological strategies. New York : CRC Press ; 1999. 74. Coppede F, Migliore L. Genetic and environmental factors in neurodegenerative diseases. In : Qureshi GA, Parvez SH, editors. Oxidative stress and neurodegenerative disorders. Amsterdam : Elsevier ; 2007. p. 89 - 114. 75. Turner
AJ,
Nalivaeva
NN.
New
insights
into
the
roles
of
metalloproteinases in neurodegeneration and neuroprotection. In : Bagetta
72
G, Corasaniti MT, Lipton SA, editors. The neuroinflammation in neuronal death and repair. California : Elsevier ; 2007. p. 114 - 36. 76. Vermeer SE, Sandee W, Algra A, Koudstaal P, Kappelle J, Dippel DWJ, et al. Impaired glucose tolerance increases stroke risk in nondiabetic patients with transient ischemic attack or minor ischemic stroke. Stroke. 2006 ; 37 : 1413 - 17. 77. Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack. Stroke. 2011 ; 42 : 227 - 76. 78. Park JW, Lee SY, Kim SY, Choe H, Jee SH. BMI and stroke risk in korean women. Obesity. 2008 ; 16 : 396 - 401. 79. Chen HJ, Bai CH, Yeh WT, Chiu HC, Pan WH. Influence of metabolic syndrome and general obesity on the risk of ischemic stroke. Stroke. 2006 ; 37 : 1060 - 64. 80. Ni K, Naz L, Mushtaq S, Rukh L, Ali S, Hussain Z. Ischemic stroke : prevalence of modifiable risk factors in male and female patients in Pakistan. Pak J Pharm Sci. 2009 ; 22 : 62 - 7. 81. Mehta S. The glucose paradox of cerebral ischaemia. J Postgrad Med. 2003 ; 49 : 299 - 301 82. Furie KL, Singhal AB, Kistler JP. Cardiac embolism. In : Furie KL, Kelly PJ, editors. Handbook of stroke prevention in clinical practice. New Jersey : Humana Press ; 2004. p. 187 - 98.
73
83. Furie KL, Lev MH, Koroshetz WJ, Greer DM. Evaluation of acute stroke etiologies. In : Greer DM, editor. Acute ischemic stroke : an evidencebased approach. New Jersey : John Wiley & Sons ; 2007. p. 197 - 212
74
75
JUDUL PENELITIAN PENGARUH KADAR GLUKOSA DARAH SEWAKTU TERHADAP KELUARAN NEUROLOGIK PADA PENDERITA STROKE ISKEMIK FASE AKUT NONDIABETIK INSTANSI PELAKSANA
: RS DR. KARIADI SEMARANG
PERSETUJUAN SETELAH PENJELASAN (INFORMED CONSENT)
Berikut ini naskah yang akan dibacakan pada Responden / Keluarga Responden Penelitian : Bapak / Ibu / Sdr Yth Anda terpilih sebagai responden penelitian yang berhubungan dengan kadar glukosa darah sewaktu sebagai faktor risiko pada penderita stroke yang anda / keluarga anda alami. Tindakan yang akan Bapak / Ibu / Sdr alami : Dilakukan anamnesis (menggunakan kuesioner) dan pemeriksaan fisik neurologik (menggunakan palu reflek dan senter). Pengambilan sampel darah untuk pemeriksaan kadar glukosa darah yang akan dilaksanakan 2 kali, pertama saat pasien masuk ke bangsal rawat inap penyakit saraf dan kedua setelah 24 jam berikutnya. Dilakukan penilaian status neurologik menggunakan skor NIHSS pada perawatan hari ke 0, 1 dan saat pasien pulang atau hari ke 7. Terimakasih atas kerjasama Bapak / Ibu / Sdr. Setelah mendengar dan memahami penjelasan peneliti, dengan ini saya menyatakan SETUJU / TIDAK SETUJU untuk ikut sebagai responden penelitian. Semarang, ................................ Peserta penelitian
(
Saksi
)
(
Peneliti
)
(dr. Edward Y.N)
76
DAFTAR PERTANYAAN DATA DASAR PENELITIAN NO. 1 2 3 4
PERTANYAAN IDENTITAS Nomor penelitian Tanggal pemeriksaan Nama Alamat
5 6 7
Nomor CM/Register Tanggal/jam masuk RS Jenis kelamin
8 9
Umur (tahun) Status perkawinan
10
Pendidikan
11
Pekerjaan
12 13 14
ANAMNESIS Defisit neurologis Tanggal/jam serangan Kedinian datang ke RS
15
Riwayat DM
16
Riwayat hipertensi
17
Riwayat merokok
18
PEMERIKSAAN FISIK Tinggi badan (cm)
JAWABAN
1. Laki-laki 2. Perempuan 1. Kawin 2. Janda/duda 3. Belum kawin 1. SD 2. SLTP 3. SLTA 4. S1 5. Tidak sekolah 1. PNS / TNI 2. Wiraswasta 3. Pedagang 4. Buruh / Tani 5. Tidak bekerja
1. < 48 jam 2. 49 - 72 jam 1. Ya 2. Tidak 1. Ya 2. Tidak 1. Ya 2. Tidak
77
19 20
Berat badan (kg) Body Mass Index
21 22 23 24 25 26
Glasgow Coma Scale Tekanan darah (mmHg) Nadi (x/menit) Suhu (°C) Pernafasan (x/menit) Jantung
27
Pemeriksaan EKG
31
PEMERIKSAAN NEUROLOGIS Skor NIHSS < 48 jam onset Skor NIHSS 49 - 72 jam onset Skor NIHSS hari ke 7 onset PEMERIKSAAN PENUNJANG Lokasi infark
32 33 34 35 36
Kadar Hb (gr%) Leukosit (mm3) Trombosit (mm3) Hematokrit (%) Kadar glukosa darah sewaktu
37 38 39 40
Kadar kolesterol total (mg%) Kadar Trigliserida (mg%) Kadar HDL (mg%) Kadar LDL (mg%) KETERANGAN Alasan pulang sebelum hari ke 7 onset
28 29 30
41
1. Kurus (< 18,5) 2. Nomal (18,5-25) 3. Overweight (25-30) 4. Obesitas (> 30)
1. Normal 2. Tidak normal 1. Normal 2. Tidak normal
1. Kortikal 2. Subkortikal 3. Batang otak 4. Campuran 5. Normal
1. < 48 jam onset 2. 49 - 72 jam onset 3. Hari ke 7 onset
78
NATIONAL INSTITUTES OF HEALTH STROKE SCALES (NIHSS)
NIHSS 1a
1b
1c
2
3
4
5a
5b 6a
Derajat kesadaran 0 = sadar penuh 1 = somnolen 2 = stupor 3 = tidak respon atau hanya terdapat reflek Menjawab pertanyaan 0 = dapat menjawab dua pertanyaan dengan benar (misalnya bulan apa sekarang dan usia pasien) 1 = hanya dapat menjawab satu pertanyaan dengan benar / tidak dapat berbicara karena terpasang pipa endotrakeal atau disartria 2 = tidak dapat menjawab kedua pertanyaan dengan benar / afasia / stupor Mengikuti perintah 0 = dapat melakukan dua perintah dengan benar (misalnya buka dan tutup mata, kepal dan buka tangan pada sisi yang sehat) 1 = hanya dapat melakukan satu perintah dengan benar 2 = tidak dapat melakukan kedua perintah dengan benar Gerakan mata konyugat horisontal 0 = normal 1 = kelumpuhan parsial 2 = deviasi konyugat yang kuat atau paresis konyugat total pada kedua mata, tidak dapat diatasi dengan manuver okulosefalik Lapangan pandang pada tes konfrontasi 0 = tidak ada gangguan 1 = hemianopia parsial 2 = hemianopsia total 3 = hemianopsia bilateral (termasuk juga buta kortikal) Paresis wajah 0 = normal 1 = paresis ringan (sulkus nasolabialis mendatar, terdapat asimetri) 2 = paresis parsial (paresis total/hampir total wajah bagian bawah) 3 = paresis total (tidak ada gerakan dari wajah atas dan bawah) Motorik lengan kiri 0 = tidak ada simpangan bila pasien disuruh mengangkat lengannya pada posisi 90°/45° selama 10 detik 1 = lengan menyimpang ke bawah sebelum 10 detik 2 = lengan terjatuh ke kasur atau badan atau tidak dapat diluruskan secara penuh 3 = tidak dapat melawan gravitasi 4 = tidak ada gravitasi 9 = tidak dapat diperiksa Motorik lengan kanan (idem) Motorik tungkai kiri 0 = tidak ada simpangan bila pasien disuruh mengangkat tungkai pada posisi 30° selama 5 detik 1 = tungkai menyimpang ke bawah sebelum 5 detik 2 = tungkai terjatuh ke kasur atau tidak dapat diluruskan secara penuh 3 = tidak dapat melawan gravitasi 4 = tidak ada gravitasi 9 = tidak dapat diperiksa
1
2
3
79
6b 7
Motorik tungkai kanan (idem) Ataksia anggota badan 0 = tidak 1 = pada satu sisi 2 = pada kedua sisi 9 = tidak dapat diperiksa 8 Sensorik 0 = normal 1 = defisit ringan-sedang 2 = defisit berat (gangguan rasa raba pada wajah, lengan dan tungkai) 9 Bahasa terbaik 0 = tidak ada afasia 1 = afasia ringan sedang 2 = afasia berat 3 = mutisme 10 Disartria 0 = artikulasi normal 1 = disartria ringan sedang (masih dapat dimengerti) 2 = disartria berat 9 = tidak dapat diperiksa 11 Neglect / tidak ada atensi 0 = tidak ada 1 = gangguan bilateral dari salah satu modalitas berikut : pengenalan personal, visual, taktil, dan spasial 2 = gangguan pada lebih dari satu modalitas SKOR TOTAL NIHSS
80
HASIL ANALISIS DATA Je nis ke lam in * Kate gori NIHSS hari ke 7 Cros s tabulation
Ringan Jenis kelamin
Laki-laki Perempuan
Total
Count % of Total Count % of Total Count % of Total
7 21,9% 5 15,6% 12 37,5%
Kategori NIHSS hari ke 7 Sedang Berat Sangat berat 9 1 2 28,1% 3,1% 6,3% 7 1 0 21,9% 3,1% ,0% 16 2 2 50,0% 6,3% 6,3%
Total 19 59,4% 13 40,6% 32 100,0%
Des criptives Umur
Mean 95% Conf idence Interval f or Mean
Statistic 53,94 50,58
Low er Bound Upper Bound
Std. Error 1,649
57,30
5% Trimmed Mean Median Varianc e Std. Deviation Minimum Max imum Range Interquartile Range Skew nes s Kurtosis
53,85 53,00 86,964 9,325 34 74 40 13 ,188 -,155
,414 ,809
um ur 51 * Kategori NIHSS hari k e 7 Cross tabulation
Ringan umur 51
30) Count % w ithin Count % w ithin
BMI BMI BMI BMI
7 35,0% 4 40,0% 1 50,0% 12 37,5%
Kategori NIHSS hari ke 7 Sedang Berat Sangat berat 11 1 1 55,0% 5,0% 5,0% 5 0 1 50,0% ,0% 10,0% 0 1 0 ,0% 50,0% ,0% 16 2 2 50,0% 6,3% 6,3%
Total 20 100,0% 10 100,0% 2 100,0% 32 100,0%
82
Des criptives GDS < 48 jam
Mean 95% Confidence Interval for Mean
Low er Bound Upper Bound
5% Trimmed Mean Median Variance Std. Deviation Minimum Max imum Range Interquartile Range Skew nes s Kurtosis
Statistic 117,47 106,74
Std. Error 5,260
128,20 115,69 106,00 885,289 29,754 73 194 121 35 1,073 ,639
,414 ,809
Tes ts of Norm ality a
GDS < 48 jam
Kolmogorov-Smirnov Statistic df Sig. ,187 32 ,006
Statistic ,904
Shapiro-Wilk df 32
Sig. ,008
a. Lilliefors Signif icance Correction
Des criptives GDS 49 - 72 jam
Mean 95% Conf idence Interval f or Mean
Low er Bound Upper Bound
5% Trimmed Mean Median V arianc e Std. Deviation Minimum Max imum Range Interquartile Range Skew nes s Kurtosis
Statistic 115,06 105,46
Std. Error 4,707
124,66 113,52 108,00 708,899 26,625 71 182 111 32 1,070 ,772
,414 ,809
Tes ts of Nor m ality a
GDS 49 - 72 jam
Kolmogorov-Smirnov Statistic df Sig. ,160 32 ,036
a. Lillief ors Signif icance Correc tion
Statistic ,906
Shapiro-Wilk df 32
Sig. ,009
83
Des criptives KOL. TOTA L
TRIGLISERIDA
HDL
LDL
Mean 95% Conf idence Interval f or Mean 5% Trimmed Mean Median V arianc e Std. Deviation Minimum Max imum Range Interquartile Range Skew nes s Kurtosis Mean 95% Conf idence Interval f or Mean 5% Trimmed Mean Median V arianc e Std. Deviation Minimum Max imum Range Interquartile Range Skew nes s Kurtosis Mean 95% Conf idence Interval f or Mean 5% Trimmed Mean Median V arianc e Std. Deviation Minimum Max imum Range Interquartile Range Skew nes s Kurtosis Mean 95% Conf idence Interval f or Mean 5% Trimmed Mean Median V arianc e Std. Deviation Minimum Max imum Range Interquartile Range Skew nes s Kurtosis
Low er Bound Upper Bound
Low er Bound Upper Bound
Low er Bound Upper Bound
Low er Bound Upper Bound
Statistic 202,75 189,81
Std. Error 6,344
215,69 202,83 202,50 1287,742 35,885 129 280 151 44 -,034 -,110 122,13 102,73
,414 ,809 9,512
141,52 117,31 105,00 2895,145 53,807 61 273 212 48 1,492 1,850 43,81 40,82
,414 ,809 1,468
46,81 43,40 40,50 68,931 8,302 32 63 31 11 ,772 -,061 125,56 114,71
,414 ,809 5,322
136,42 124,92 122,50 906,190 30,103 79 184 105 38 ,427 -,530
,414 ,809
84
Tes ts of Normality a
KOL. TOTAL TRIGLISERIDA HDL LDL
Kolmogorov-Smirnov Statistic df Sig. ,100 32 ,200* ,189 32 ,005 ,177 32 ,012 ,140 32 ,115
Statistic ,986 ,842 ,925 ,943
Shapiro-Wilk df 32 32 32 32
Sig. ,938 ,000 ,028 ,089
*. This is a low er bound of the true signif icance. a. Lillief ors Signif icance Correction
Je nis ke lam in * Kate gori NIHSS hari 7Gabung Cr os stabulation
Jenis kelamin
Laki-laki Perempuan
Total
Count Ex pected Count Count Ex pected Count Count Ex pected Count
Kategori NIHSS hari 7Gabung Sedang+ Berat+Sangat Ringan Berat 7 12 7,1 11,9 5 8 4,9 8,1 12 20 12,0 20,0
Total 19 19,0 13 13,0 32 32,0
Chi-Square Te s ts
Pearson Chi-Square Continuity Correctiona Likelihood Ratio Fisher's Exact Test Linear-by -Linear Ass ociation N of Valid Cas es
Value ,009 b ,000 ,009
,008
df 1 1 1
1
Asy mp. Sig. (2-s ided) ,926 1,000 ,926
Exac t Sig. (2-s ided)
Exac t Sig. (1-s ided)
1,000
,607
,927
32
a. Computed only for a 2x2 table b. 1 cells (25,0%) have expec ted count less than 5. The minimum expec ted count is 4,88.
85
Riw ayat Hipe rte ns i * Kategori NIHSS hari 7Gabung Cross tabulation
Riw ayat Hipertens i + Total
Count Expected Count Count Expected Count Count Expected Count
Kategori NIHSS hari 7Gabung Sedang+ Berat+Sangat Ringan Berat 9 16 9,4 15,6 3 4 2,6 4,4 12 20 12,0 20,0
Total 25 25,0 7 7,0 32 32,0
Chi-Square Te s ts
Pearson Chi-Square Continuity Correctiona Likelihood Ratio Fisher's Exact Test Linear-by -Linear Association N of Valid Cases
Value ,110 b ,000 ,108
df 1 1 1
,106
Asymp. Sig. (2-sided) ,740 1,000 ,742
1
Ex act Sig. (2-sided)
Ex act Sig. (1-sided)
1,000
,535
,744
32
a. Computed only for a 2x 2 table b. 2 cells (50,0%) hav e expec ted count les s than 5. The minimum expected count is 2,63.
Dis lipide m ia * Kategori NIHSS hari 7Gabung Cros stabulation
Dislipidemia
+ -
Total
Kategori NIHSS hari 7Gabung Sedang+ Berat+Sangat Ringan Berat 11 14 9,4 15,6 1 6 2,6 4,4 12 20 12,0 20,0
Count Ex pected Count Count Ex pected Count Count Ex pected Count
Total 25 25,0 7 7,0 32 32,0
Chi-Square Te s ts
Pearson Chi-Square Continuity Correctiona Likelihood Ratio Fisher's Exact Test Linear-by -Linear Association N of Valid Cases
Value 2,060b ,987 2,302
1,996
df 1 1 1
1
Asymp. Sig. (2-sided) ,151 ,320 ,129
Ex act Sig. (2-sided)
Ex act Sig. (1-sided)
,212
,161
,158
32
a. Computed only for a 2x 2 table b. 2 cells (50,0%) hav e expec ted count les s than 5. The minimum expected count is 2,63.
86
Me rokok * Kategori NIHSS hari 7Gabung Cros stabulation
Merokok
+
Count Ex pected Count Count Ex pected Count Count Ex pected Count
Total
Kategori NIHSS hari 7Gabung Sedang+ Berat+Sangat Ringan Berat 3 6 3,4 5,6 9 14 8,6 14,4 12 20 12,0 20,0
Total 9 9,0 23 23,0 32 32,0
Chi-Square Te s ts
Pearson Chi-Square Continuity Correctiona Likelihood Ratio Fisher's Exact Test Linear-by -Linear Association N of Valid Cases
Value ,093 b ,000 ,094
df 1 1 1
,090
Asymp. Sig. (2-sided) ,761 1,000 ,760
1
Ex act Sig. (2-sided)
Ex act Sig. (1-sided)
1,000
,546
,764
32
a. Computed only for a 2x 2 table b. 1 cells (25,0%) hav e expec ted count les s than 5. The minimum expected count is 3,38. Infark Miokard * Kategori NIHSS hari 7Gabung Cros stabulation
Inf ark Miokard
+ -
Total
Count Ex pected Count Count Ex pected Count Count Ex pected Count
Kategori NIHSS hari 7Gabung Sedang+ Berat+Sangat Ringan Berat 5 4 3,4 5,6 7 16 8,6 14,4 12 20 12,0 20,0
Total 9 9,0 23 23,0 32 32,0
Chi-Square Te s ts
Pearson Chi-Square Continuity Correctiona Likelihood Ratio Fisher's Exact Test Linear-by -Linear Association N of Valid Cases
Value 1,742b ,835 1,708
1,687
df 1 1 1
1
Asymp. Sig. (2-sided) ,187 ,361 ,191
Ex act Sig. (2-sided)
Ex act Sig. (1-sided)
,240
,180
,194
32
a. Computed only for a 2x 2 table b. 1 cells (25,0%) hav e expec ted count les s than 5. The minimum expected count is 3,38.
87
Kolmogorov Smirnov BMI dengan NIHSS hari ke 7 Fr eque ncies BMI
Kategori NIHSS Ringan Sedang+Berat+ Sangat Berat Total
N 12 20 32
Tes t Statis ticsa Mos t Ex treme Dif f erences
BMI ,067 ,067 ,000 ,183 1,000
A bs olute Positive Negative
Kolmogorov-Smirnov Z A sy mp. Sig. (2-tailed)
a. Grouping V ariable: Kategori NIHSS hari 7Gabung
Skor NIHSS Skor NIHSS < 48 jam c. Skor NIHSS hari ke 7 = Skor NIHSS < 48 jam d. Skor NIHSS hari ke 7 < Skor NIHSS 49 - 72 jam e. Skor NIHSS hari ke 7 > Skor NIHSS 49 - 72 jam f . Skor NIHSS hari ke 7 = Skor NIHSS 49 - 72 jam g. Skor NIHSS 49 - 72 jam < Skor NIHSS < 48 jam h. Skor NIHSS 49 - 72 jam > Skor NIHSS < 48 jam i. Skor NIHSS 49 - 72 jam = Skor NIHSS < 48 jam
Tes t Statisticsb
Z A sy mp. Sig. (2-tailed)
Skor NIHSS hari ke 7 Skor NIHSS < 48 jam -4,268a ,000
a. Based on positive ranks . b. Wilc oxon Signed Ranks Tes t
Skor NIHSS hari ke 7 Skor NIHSS 49 - 72 jam -4,089a ,000
Skor NIHSS 49 - 72 jam Skor NIHSS < 48 jam -2,392a ,017
91
20
15
10
5
0 73 81 86 92 93 97 100 103 105 107 108 113 116 119 125 127 135 140 141 157 163 168 186 194
gds_0
D_NIHSS2 30
20
10
0 Observed -10
Linear 0
100
200
300
400
GDS_0
D_NIHSS2 = selisih NIHSS 48 jam onset dengan hari ke 7 onset
92
Cas e Proces s ing Sum m ary GDS_0 Positivea Negative Mis sing
V alid N (listw ise) 3 33 1
Larger values of the tes t res ult variable(s ) indicate stronger ev idenc e f or a positive ac tual s tate. a. The positive ac tual s tate is 105.
ROC Curve 1.00
.75
.50
.25
0.00 0.00
.25
.50
.75
1.00
1 - Specificity Diagonal segments are produced by ties.
Are a Under the Cur ve Test Result V ariable(s ): D_NIHSS2
A rea .571
a
Std. Error .112
A sy mptotic b Sig. .689
A sy mptotic 95% Conf idence Interval Low er Bound Upper Bound .351 .790
The test result variable(s ): D_NIHSS2 has at least one tie betw een the positive actual state group and the negative actual state group. Statistic s may be biased. a. Under the nonparametric assumption b. Null hypothesis: true area = 0.5
93
Coordinate s of the Curve Test Res ult V ariable(s ): D_NIHSS2 Positive if Greater Than a or Equal To -1.00 .50 1.50 2.50 11.50 21.00
Sens itiv ity 1.000 1.000 .333 .000 .000 .000
1 - Specif ic ity 1.000 .667 .364 .152 .030 .000
The test result variable(s ): D_NIHSS2 has at leas t one tie betw een the pos itiv e ac tual s tate group and the negative ac tual s tate group. a. The smallest c utof f value is the minimum observ ed tes t value minus 1, and the largest cutoff value is the maximum observ ed tes t value plus 1. All the other cutof f v alues are the av erages of tw o cons ecutive ordered obs erved test values. Cor relations Spearman's rho
GDS_0
D_NIHSS1
D_NIHSS2
Correlation Coeffic ient Sig. (2-tailed) N Correlation Coeffic ient Sig. (2-tailed) N Correlation Coeffic ient Sig. (2-tailed) N
GDS_0 1.000 . 36 .176 .306 36 -.149 .386 36
**. Correlation is s ignificant at the 0.01 level (2-tailed).
Cas e Proces s ing Sum m ary GDS_0 Positivea Negative Mis sing
V alid N (listw ise) 1 35 1
Larger values of the tes t res ult variable(s ) indicate stronger ev idenc e f or a positive ac tual s tate. a. The positive ac tual s tate is 107.
D_NIHSS1 .176 .306 36 1.000 . 36 .671** .000 36
D_NIHSS2 -.149 .386 36 .671** .000 36 1.000 . 36
94
ROC Curve 1.00
.75
.50
.25
0.00 0.00
.25
.50
.75
1.00
1 - Specificity
Are a Under the Cur ve Test Result Variable(s ): D_NIHSS2
Area 1.000
a
Std. Error .000
Asy mptotic b Sig. .092
Asy mptotic 95% Conf idence Interval Low er Bound Upper Bound 1.000 1.000
a. Under the nonparametric assumption b. Null hypothesis: true area = 0.5
Coordinate s of the Curve Test Res ult V ariable(s ): D_NIHSS2 Positive if Greater Than a or Equal To -1.00 .50 1.50 2.50 11.50 21.00
Sens itiv ity 1.000 1.000 1.000 1.000 1.000 .000
1 - Specif ic ity 1.000 .686 .343 .114 .000 .000
a. The smallest c utof f value is the minimum observ ed tes t value minus 1, and the largest cutoff value is the maximum observ ed tes t value plus 1. All the other cutof f v alues are the av erages of tw o cons ecutive ordered obs erved test values.
95
Cas e Proces s ing Sum m ary V alid N (listw ise) 1 35 1
GDS_0 Positivea Negative Mis sing
Larger values of the tes t res ult variable(s) indicate stronger ev idence for a positive ac tual s tate. a. The positive actual s tate is 108.
ROC Curve 1.00
.75
.50
.25
0.00 0.00
.25
.50
.75
1.00
1 - Specificity Diagonal segments are produced by ties.
Regression V ariables Enter ed/Re m ovebd Model 1
V ariables Entered GDS_0a
V ariables Remov ed .
Method Enter
a. A ll requested variables entered. b. Dependent Variable: D_NIHSS2
Model Sum m ary Model 1
R .114 a
R Square .013
A djusted R Square -.016
a. Predictors: (Constant), GDS_0
Std. Error of the Estimate 3.321
96
ANOVAb Model 1
Regression Residual Total
Sum of Squares 4.926 375.074 380.000
df
Mean Square 4.926 11.032
1 34 35
F .447
Sig. .508 a
a. Predictors: (Constant), GDS_0 b. Dependent Variable: D_NIHSS2
Coe fficientsa
Model 1
(Constant) GDS_0
Unstandardiz ed Coef f icients B Std. Error 2.521 1.393 -.006 .010
Standardized Coef f icients Beta -.114
t 1.809 -.668
Sig. .079 .508
a. Dependent Variable: D_NIHSS2
Cut off point kadar GDS 105 mg/dl :
Kate gori NIHSS hari 7Gabung * Hiper glike m ia Cross tabulation Count
Kategori NIHSS hari 7Gabung
Ringan Sedang+Berat+ Sangat Berat
Hiperglikemia Euglikemia Hiperglikemia 7 5
Total
Nilai duga positif
= 11/20 = 55 %
Nilai duga negatif
= 7/12 = 58,3 %
Sensitivitas
= 11/16 = 68,75 %
Spesifisitas
= 7/16 = 43,75 %
Total 12
9
11
20
16
16
32
= (1-specificity) = 9/16 = 56,25 % = (1-sensitivity) = 5/16 = 3,25 % Likelihood ratio positive = 68,75 / 56,25 = 1,2 Likelihood ratio negative = 31,25 / 43,75 = 0,71