20 Trauma Kapitis
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Trauma kapitisProf.DR.Dr.Hasan Sjahrir SpS(K)
Departemen Neurologi FK USU
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definisi
Trauma kapitis : adalah trauma mekanikterhadap kepala baik secara langsungataupun tidak langsung yangmenyebabkan gangguan fungsi neurologis
yaitu gangguan fisik, kognitif, fungsipsikososial baik temporer maupunpermanen.
Sinonim: cedera kepala= head injury=trauma kranioserebral=traumatic braininjury
75% KLL
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epidemiology
Incidence head trauma
350 per 100.000 in Europe, 200 per
100.000 in North America,
US hospitalization rates due to traumaticbrain injury (TBI) are on the rise,
85% mild head injury,
15% moderate - severe Head injury
Severe head injury intracranialhaemorrhagic lesion 10-27%
Less than 2% require neurosurgery
1.Baandrup L & Jensen R. Cephalalgia 2005; 25:132138.
2.National Institute of Health Traumatic Coma Data Bank
3.Ropper AH, Gorson KC. N Engl J Med 2007;356:166-724.Thomas & Kegler. Morb Mortal Wkly Rep. 2007;56:167-170
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Berat ringan cedera otak tgt:
Besar & kekuatan benturan
Arah & tempat
Posisi/keadaan kepala
Lesi yang terjadi:
Lesi bentur(coup) Lesi media/antara
Lesi kontra(counter coup)
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Akibat lesi bentur thd otak
Blockade ARAS
Retensi cairan & elektrolit
TIK meninggi Perdarahan
Kerusakan otak primer
Kerusakan otak sekunder
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Pemeriksaan neurologis
Monitor batang otak Besar & reaksi pupil, refleks kornea
Dolls eye phenomen
Monitor pernafasan Cheyne stokes lesi hemisfer
Centr neuro hyperventilation lesi mesensefalon-pons
Apneustic breathing : lesi pons
Ataxic breathing lesi medula oblongata
Monitor fungsi motorik
Brills hematon, likuorrhea,battles sign Funduskopi
Radiologi
EEG
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TBI (Traumatic Brain Injury)
Closed head injury
Primary injury Concussion
Contusion Hematoma epidural, subdural, intraventricular,
subarachnoid
Secondary
Hypotension, hypoxia, acidosis, edema, ischaemia orother subsequent factors that can secondary damage
brain tissue
Penetrating head injury
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Eye Opening
Score 1 Year 0-1 Year
4 Spontaneously Spontaneously
3 To verbal command To shout
2 To pain To pain
1 No response No response
Best Motor Response
Score 1 Year 0-1 Year
6 Obeys command
5 Localizes pain Localizes pain
4 Flexion withdrawal Flexion withdrawal
3 Flexion abnormal (decorticate)Flexion abnormal
(decorticate)
2 Extension (decerebrate) Extension (decerebrate)
1 No response No response
Best Verbal Response
Score >5 Years 2-5 Years 0-2 Years
5 Oriented and converses Appropriate words Cries appropriately
4Disoriented and
conversesInappropriate words Cries
3Inappropriate words;
criesScreams
Inappropriate
crying/screaming
2Incomprehensible
soundsGrunts Grunts
1 No response No response No response
Normal Skor
pada anak:
< 6 bulan : 126-12 bulan : 12
1-2 thn : 13
2-5 thn : 14
> 5 thn : 14
Normal skor
Dewasa
4+5+6=15
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klasifikasi TK non Operatif
Komosio cerebri
Kontusio c
Impresio fraktur non neurologik (< 1 cm)
Fraktur basis kranii
Fraktur kranii tertutup
TK operatif
Hematoma intrakranial > 75 cc Epidural, subdural, intraserebral/serebellar
Fraktur kranii terbuka ( + laserasio)
Impresi frk dengan kelainan neurologik (> 1 cm)
Likuorrhoe yang tidak berhenti
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Klasifikasi trauma kapitis
berdasarkan WHO: (......ICD) Patologi:
Komosio serebri Kontusio serebri
Laserasio serebri Lokasi lesi
Lesi diffus Lesi kerusakan vaskuler otak Lesi fokal
Kontusio dan laserasi serebri Hematoma intrakranial
hematoma ekstradural(hematoma epidural) hematoma subdural hematoma intraparenkhimal
hematoma subarakhnoid hematoma intraserebral hematoma intraserebellar
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Kategori SKG Gambaran Klinik CT Sken otak
minimal 15 Pingsan (-),defisit
neurologi(-)
Normal
Ringan 13-15 Pingsan < 10 men,defisit neurologik (-) Normal
Sedang 9-12 Pingsan >10 men s/d 6
jamDefisit neurologik (+)
Abnormal
Berat 3-8 Pingsan>6 jam, defisit
neurologik (+)
abnormal
Catatan: Jika abnormalitas CT Sken berupa perdarahan intrakranial,
penderita dimasukkan klasifikasi trauma kapitis berat
Klasifikasi berdasarkan SKG di triase
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Diagnostik : Trauma kapitis ringan(TKR) Mild Head injury:
SKG 13-15,
CT Sken normal,
pingsan < 30 menit,
tidak ada lesi operatif,
rawat Rumah sakit < 48 jam,
amnesia pasca trauma (APT) < 1 jam
TKS=Moderate Head Injury SKG 9-12 dan dirawat > 48 jam,
atau SKG > 12 akan tetapi ada lesi operatif intrakranial
atau abnormal CT Sken, pingsan >30 menit- 24 jam, APT 1-24 jam
TKB=Severe Head injury: SKG < 9 yang menetap dalam 48 jam sesudah trauma,
pingsan > 24 jam, APT > 7 hari.
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Komosio serebri (80%)
Definisi: disfungsi neuron otak sementara,
makroskopis normal
Gejala:
Pening/sakit kepala Tidak sadar < 30 menit
Amnesia retrograde (AR) ,Amnesia anterograde (PTA)
Mual muntah
Pasien harus opname minimal 48 jam
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Kontusio serebri (15-19%)
Definisi: perdarahan interstitiil parenchymotak,tanpa putusnya kontinuinitas jaringan.
=/= laserasio serebri Gejala gangguan neurologi fokal (+/-) Gejala
Tidak sadar > 30 menit FASE I :Fase shock FASE II : FAse hiperaktif sentral FASE III : serebral oedem FASE IV: fase regenerasi/rekovalesens
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Kontusi serebri pada anak2
Fase latent
Fase akut serebral (II)
Fase regenerasi
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Epidural hematom
Def : antara tabula interna- duramater
Lucid interval pendek
Jarang pada anak2
Hematom massif:
Arteri meningea media
Sinus venosus
Dx: Brain ct scan
X foto polos
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Gejala epidural H
Lucid interval (+) pendek : yaitu periode sadar diantara 2 fase penurunan
kesadaran Kesadaran makin menurun Hemiparese terlambat Pupil anisokor Babinsky (+) Fraktur menyilang di temporal Kejang bradikardi
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Gejala EDH fossa posterior
Lucid interval tidak jelas
Fraktur krainii oksipital
Kehilangan kesadaran cepat
Gangguan serebellum, batang otak,pernafasan
Pupil isokor
Prognosa jelek
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Subdural hematom
Def : duramater arakhnoid
=/= hygroma subdural
Hematom:
Bridging vein robek Kausa: Tr.Kapitis, keheksi, ggan darah
Lokasi frontal ,parietal, temporal
Gejala/klasifikasi Akut : Lucid interval 0-5 hari Subakut : 5-15 hari
Kronik : 15 hari - tahun
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Intraserebral hematom
Dwf: pecahnya arteri
intraserebral/serebellar
Mono- multiple
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Fraktur basis kranii
Anterior
Media
Posterior Diagnosa tgt gejala ,sebab x
foto hanya 50%(+)
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X foto
X foto tengkorak 30% , fraktur
(+)
3-5% kelainan intrakranial
kepentingan:
Kematian 80% fraktur (+)
Medikolegal
kepentingan pengawasan klinik
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Penanggulangan traumakapitis akut Atasi shock
Air way
Evaluasi kesadaran
Amati jejas kepala & tubuh Awas fraktur servikalis
Klinik neurologi & X ray
Atasi oedema serebri
Keseimbangan cairan & elektrolit, kalori
Monitor tek intra kranial
Pengobatan konservatif
Refer bedah satraf atas dasar indikasi
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Oedema serebri Def: peninggian cairan intra/ekstra sel
otak o.k. proses lokal atau umum
Jenis Vasogenik
Sitotoksik
Osmotik
hidrostatik
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VASO SITO OSMO HIDRO
pato BBB sod pump osmotik gga LCS
lokalisasi subs alba alb+grisea alb+grisea alba
permeable meninggi normal normal normal
histologis ekstrasel intra eks+intra ekstrasel
unsur plasma plasma air air+Na
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Vasogenik : Tr kapitis, stroke,
meningitis, ensefalitis, SOL, hipertensi
malignan, konvulsi Sitotoksik: asfiksia, cardiac arrent, zat
toksik
Osmotik: water intoxication, hemodialisis Hidrostatik: hidrosefalus
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Obat anti oedema Hipertonik sol: manitol ,gliserol
Kortikosteroid
Barbiturat
Hipothermi
Hiperventilasi artifisiil
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INDIKASI OPERASI PENDERITA
TRAUMA KRANIOSEREBRAL EDH (epidural hematoma) ; > 40 cc dengan midline shifting pada daerah
temporal / frontal / parietal dengan fungsibatang otak masih baik.
> 30 cc pada daerah fossa posterior dengantanda-tanda penekanan batang otak atau
hidrosefalus dengan fungsi batang otak masihbaik.
EDH progresif.
EDH tipis dengan penurunan kesadaran bukan
indikasi operasi.
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SDH (subdural hematoma) SDH luas (> 40 cc / > 5 mm) dengan
GCS > 6, fungsi batang otak masih
baik. SDH tipis dengan penurunan
kesadaran bukan indikasi operasi.
SDH dengan edema serebri / kontusioserebri disertai midline shifting dengan
fungsi batang otak masih baik.
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Indikasi operasi ICH pasca trauma samaseperti stroke hemoragis.
Fraktur impresi melebihi 1 (satu) diploe.
Fraktur kranii dengan laserasi serebri.
Fraktur kranii terbuka (pencegahan infeksiintra-kranial).
Edema serebri berat (disertai tandapeningkatan TIK) ------ pertimbangandekompresi.
INDIKASI OPERASI PENDERITA
TRAUMA KRANIOSEREBRAL
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Low-level responsivestates Coma acute brain functioning failurebrain stem and/or
cerebral hemisphere lesion
Persistent vegetative state ( coma vigile)eye are
open(respons to sounds) but not respond to any kind ofstimulation(total lack of cognitive function)=apallic stateabsence of neocortical functions
Locked-in syndrome (LIS)quadriplegia, lateral gazepalsy, paralytic mutism, fully conscious and aware ofenvironment ventral of pons lesion
Minimally responsive state
Akinetic mutismlack of movement (not completelyparalyzed) & speech, can eye open lesion frontal basal
and posterior region of mid brainJose Leon-Carrion et al. Brain Injury Treatment.2006
PARAMETER OF POOR PROGNOSIS IN PATIENTS IN PROLONGED STATE
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PARAMETER OF POOR PROGNOSIS IN PATIENTS IN PROLONGED STATE
OF COMA
Brain Injury Treatment,
2006
CHARACTERISTICwithrecovery
withoutrecovery significance
SIGN OF
HYPOTHALAMIC
Fever 30% 57% p
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5 factors that correlated
with poor outcome
Age older than 60 years
Initial GCS score of less than 5
Fixed dilated pupil
Prlonged hypotension or hypoxia
Presence of surgical intracranial mass
lesion The traumatic coma data bank
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The temporal lobes & frontallobe are commonly injuryPhysiologic disruption of hippocampal
function
Disturbing memory storage and retrieval
Post Traumatic Amnesia (PTA)
(Retrograde and Anterograde Amnesia)
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Duration of PTAthe duration of PTA is related to the
degree of residual memory deficit ,
disability and a higher probability of
personality change after TBI
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Amnesia from Head Injury
British boxer Nigel Benn lands a punch to the head of American boxer Gerald
McClellan during a 1995 fight in London.
McClellan suffered severe brain damage in the fight that left him blind and that
impaired his ability to form new memories and access long-term memories.
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Neuro behavioural
problems of TBI
Behavioral and emotional problems
cognitive impairmentcontribute more to
persistent disability than do physical
impairment sequelae in 72% of patients
surviving head trauma
Kewman DG, Siegerman C,et al,1985
Brooks N,McKinlay W et al.Brain Inj 1987
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Neurobehavioural
symptoms post TBI
Poor sleep patern
Poor drive and motivation
Tiredness
Socially withdrawn
Headache
Impulsive
AggressiveAnxiety
depression
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Neurobehaviouralsymptoms post TBIAggressive behaviour is a frequent
sequela of TBI
A 70% incidence of postraumaticirritability of which 20% was defined
as violent behaviour
patient who display aggresionpostraumatic exhibit significantly
more verbal & executive deficits.Wood RL,Liossi C. J.Neuropsychiatry Clin Neurosci 2006;18:333-341
The locus of TBI is the key
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The locus of TBI is the key
predicator of behavioral
problems Frontal lobe :changes in emotional control,
initiation, motivation, inhibition
Temporal lobe:
agression, memory loss,aphasia
Limbic system:distorts emotion, difficulty
perception/organization
Parietal lobe : apraxia, neglect, agnosia
Occipital lobe : acalculia, agnosia, alexia
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The end