Top Banner
Dr. Ida Ratna Nurhidayati, Sp.S Bagian Ilmu Penyakit Saraf Fakultas Kedokteran Universitas YARSI
54

Neurologi Neurotrauma

Dec 17, 2015

Download

Documents

b
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
  • Dr. Ida Ratna Nurhidayati, Sp.S

    Bagian Ilmu Penyakit Saraf Fakultas Kedokteran Universitas YARSI

  • Trauma Kepala

  • Pendahuluan

    Di AS jutaan org dirawt krn cedera kepala

    45% krn kll, 26% jatuh dari ketinggian, 17% sbb lain

    >

    Biaya tinggi dlm perawatan

    Indonesia?

  • Trauma Kepala

    Sinonim

    Trauma kapitis = cedera kepala = head injury = trauma kranioserebral = traumatic brain injury

    Definisi

    Trauma mekanik thp kepala, langsung/tdk lgs, yg menyebabkan gg fs neurologis fisik, kognitif, psikososial (temporer/permanen)

  • Klasifikasi

    Patologi

    1. Komosio serebri

    2. Kontusio serebri

    3. Laserasio serebri

  • Klasifikasi

    Lokasi lesi 1. Lesi difus

    2. Lesi kerusakan vaskuler otak

    3. Lesi fokal 1. Kontusio & laserasi serebri

    2. Hematoma intrakranial 1. Hematoma ekstradural (hematoma epidural)

    2. Hematoma subdural

    3. Hematoma intraparenkhimal

    1. Hematoma subarakhnoid

    2. Hematoma intraserebral

    3. Hematoma intraserebelar

  • Klasifikasi Kategori SKG Gambaran Klinik CT scan otak

    Minimal 15 Pingsan (-), defisit neurologi (-) Normal

    Ringan 13-15 Pingsan < 10 menit, defisit neurologi (-) Normal

    Sedang 9-12 Pingsan > 10 menit s/d 6 jam, defisit neurologi (+)

    Abnormal

    Berat 3-8 Pingsan > 6 jam, defisit neurologi (+) Abnormal

    1. Tujuan klasifikasi ini u/ pedoman triase di gawat darurat 2. Jika abnormalitas CT scan berupa perdarahan intrakranial, penderita dimasukkan

    klasifikasi trauma kapitis berat

  • Diagnosis

    Anamnesis Trauma kapitis + gg kesadaran + interval lucid Perdarahan (otore/rinore) Amnesia traumatika (retrograd/antegrad)

    Pemeriksaan Fisik Status Neurologis Radiologi fraktur

    (linier/impresi/terbuka/tertutup) Foto kepala : AP/lat/tangensial Foto servikal

    CT scan kepala + bone window

  • Tanda-tanda Suspek Fraktur Basis Kranii

    Brill hematoma / Racoons eye / Hematoma periorbita 1

    Battles sign / Hematoma retroaurikular 2

    Otorrhea / Rhinnorhea 3

  • Fraktur Linear

  • Fraktur Impresi

  • Epidural Hematoma

  • Subdural Hematoma

  • Subarachnoid Hematoma

  • Manajemen

    Survei Primer ABCD

    Survei Sekunder EF

  • Manajemen

    Manajemen TTIK

    Elevasi kepala 300

    Manitol 20% (awal 1 gr/kgBB dlm -1 jam drip cepat lanjut 0.5 mg/kgBB)

    Analgetika

  • Manajemen

    Manajemen komplikasi

    Kejang

    Infeksi

    Gastrointestinal

    Demam

    DIC

  • Manajemen

    Manajemen cairan & nutrisi adekuat

    Roboransia, neuroprotektan sesuai indikasi

  • Indikasi Operasi

    EDH > 40 cc dg midline shift (temporal/frontal/parietal) dg fs batang otak

    baik > 30 cc pd fossa posterior dg tanda2 penekanan batang

    otak/hidrosefalus dg fs batang otak baik EDH progresif

    SDH SDH luas (> 40 cc) dg GCS > 6, fs batang otak baik SDH dg edema serebri/kontusio + midline shift dg fs batang otak baik

    ICH Penurunan kesadaran progresif Cushing reflex Perburukan defisit neurologi fokal

  • Indikasi Operasi

    Fraktur impresi > 1 diploe

    Fraktur kranii dg laserasi serebri

    Fraktur kranii terbuka (pencegahan infeksi intrakranial)

    Edema serebri berat dg TTIK (dekompresi)

  • Trauma Medulla Spinalis

  • Pendahuluan

    Trauma medulla spinalis/spinal cord injury (SCI) defisit neurologis & hendaya permanen

    Tujuan menegakkan diagnosis & memulai terapi secepatnya mencegah defisit lanjut (primer & sekunder)

  • Epidemiologi

    AS, 2006 Insidens + 50 / 1 jt populasi, 14.000 ps/th (AS,

    2006)

    Pria : wanita = 2,5 - 3 : 1

    80% pria dg SCI (spinal cord injury) berusia 18-25 th

    Australia, 2006 Insidens 12 / 1 jt populasi / th

    Indonesia ??

  • Etiologi Acute Spinal Cord Injury (ACSI)

    Kecelakaan bermotor 50 Mobil Motor Sepeda Jatuh 15-20 Kekerasan individual 15-20 Luka tembak Kekerasan lain Olahraga dan rekreasi 10-15 Menyelam (2/3 kasus dalam kategori ini) Football dan rugby Hoki Senam Gulat

    Etiologi Perkiraan Persentase Dari Keseluruhan SCI

    Neurotrauma. Narayan RK, Wilberger JE, Povlishock JT. 1996.

  • Anatomi & Patofisiologi

    Segmen servikal MS paling rentan

    Thoracolumbar junction rentan (15%)

    Komplit VS Inkomplit SCI

    Komplit : sensoris & motorik di bawah level (-)

    Inkomplit : sensoris & motorik di bawah level (+) prognosis >>

  • Anatomi & Patofisiologi

    Trauma MS Primer

    Deformasi lokal & transformasi energi dr kompresi akut, laserasi, distracting, atau regangan

    Sekunder Kaskade biokimia & proses selular kerusakan /

    kematian sel

    Perubahan vaskular, perubahan kadar ion, akumulasi neurotransmiter, produksi radikal bebas & lipid peroksidase, efek opioid endogen, edema, inflamasi, ATP

    Critical Care and Resuscitation 2006;8:56-63

  • Neurosurgery 1999;44:1027-40

  • Grade A Complete No motor/sensory function is preserved in the sacral segments S4-S5 Grade B Incomplete Sensory but not motor function is preserved below the neurological level and extends through the sacral segments S4-S5 Grade C Incomplete Motor function is preserved below the neurological level, and the majority of key muscles below the neurological level have a muscle grade less than 3 Grade D Incomplete Motor function is preserved below the neurological level, and the majority of key muscles below the neurological level have a muscle grade greater than or equal to 3 Grade E Normal Motor and sensory function are normal

    ASIA (American Spinal Injury Association)/ IMSOP (the International Medical Society of Paraplegia)

    Impairment Scale

    Neurotrauma. Narayan RK, Wilberger JE, Povlishock JT. 1996.

  • Terapi

    Methylprednisolone / MP (corticosteroid)

    Tirilazad mesylate (corticosteroid)

    Naloxone

    GM-1 ganglioside

    Indian Journal of Neurotrauma (IJNT) vol 4, No. 1, 2007

  • Methylprednisolone

    Efek neuroprotektif MPSS (MP-sodium succinate)

    Menghambat lipid peroksidase

    Menghambat influks kalsium

    Menghambat iskemia

    Efek anti inflamasi

    MP in ACSI. Guidelines Department Of Surgical

    Education, Orlando Regional Medical Center. 2004.

  • Methylprednisolone

    MP (30 mg/kg IV loading dose followed by 5.4 mg/kg/h for the next 23 h NASCIS 2 regimen) may be considered in pts w/ blunt ASCI presenting less than 3 h after injury after considering the potential risks & benefits to the pt

    MP (30 mg/kg IV loading dose followed by 5.4 mg/kg/h for the next 47 h NASCIS 3 regimen) may be considered in pts w/ blunt ASCI presenting between 3 and 8 h after injury after considering the potential risks & benefits to the pt

    Steroids should not be administered to pts w/ blunt ASCI presenting greater than 8 h after injury

  • Methylprednisolone

    NASCIS II (1990, Class II) Prospective, randomized, double-blind multi-center trial in 487 pts w/ ASCI 3 arms :

    MPSS 30 mg/kg bolus given within 15 min, followed by 5.4 mg/kg/h infusion for 23 h

    Naloxone 5.4 mg/kg bolus given within 15 min, followed by 4.5 mg/kg/h infusion for 23 h

    Placebo infusion

    Naloxone improved systemic hypotension, spinal cord blood flow, neurologic recovery in animal lab

    Given within 12 h injury Conclusion :

    All primary outcome measures, including neurologic outcome & mortality, didnt differ between the 3 groups

    Post hoc subgroup analysis of fewer than 50% of those enrolled identified improved neurologic fx in pts treated w/ MPSS within 8 h of injury.

    Pts who received MPSS more than 8 h after injury demonstrated worse neurologic fx than did the placebo group

    Increased wound infection, GI bleeding, & pulmonary embolus in pts who received MPSS although these differences were not statistically significant

  • Methylprednisolone

    NASCIS III (1997, Class II) Prospective, randomized, double blind multi-center trial in 499 pts w/ ASCI All pts were administered MPSS 30 mg/kg & then randomized to 1 of 3 arms

    MPSS 5.4 mg/kg/h infusion for 23 h MPSS 5.4 mg/kg/h infusion for 47 h Tirilizad mesylate (enhance spinal cord recovery) 2.5 mg/kg bolus q 6 h for 48 h

    Treatment was initiated within 8 h in all pts Conclusion :

    Randomization didnt result in equal pt groups as 25% of Group 1 pts had normal motor fx while only 14% of Group 2 pts had normal motor fx

    Pts who received tirilizad demonstrated significantly worse motor fx than did patients who received MPSS

    Among the MPSS groups, all primary outcome measures werent different Post hoc subgroup analysis identified that pts who received their MPSS bolus more than 3 h

    post injury demostrated significantly greater motor fx if they received 48 h of MPSS rather than 24 h

    This excludes almost 70% of the study pts from further analysis Although improved motor & sensory scores were seen in the MPSS groups at 6 weeks & 6

    months post-injury, no differences in motor or sensory fx were detectable at 1 year There was 2x increase in severe pneumonia, 6x increase in mortality due to respiratory

    complications in the 48 h MPSS pts when compared to 24 h MPSS pts

  • Methylprednisolone

    Merola et al., 2002 perubahan jaringan scr mikroskopik thd pemberian MP dosis tinggi dilanjutkan 23 jam berikutnya pd tikus

    Edema & struktur yang berkaitan dg lokasi injuri dipertahankan

    Tdk mengubah perkembangan proses nekrosis / response sel astrosit pada lokasi injuri MS

  • Prognosis

    Ps hidup > 18 bl angka harapan hidup 70% (tetraplegia) & 84% (paraplegia)

    5 tahun setelah SCI, mortalitas : Septicemia 40x

    Pneumonia 13x

    Emboli paru 8x

    Penyakit jantung 3x

    Gg. berkemih 9x

    Bunuh diri 2x

  • Prognosis

    SCI segmen servikal, torakal, & torakolumbal prognosis perbaikan neurologis incomplete > complete

    Complete (prognosis perbaikan klinis dlm 1 th) servikal > torakal > torakolumbal (T11-T12, L1-L2)

    Incomplete (prognosis perbaikan klinis dlm 1 th) servikal = torakal > torakolumbal

    Ps dg komplit SCI < 5% perbaikan

    Jk komplit SCI menetap dlm 72 jam perbaikan 0

  • 43

  • 44

  • 45

  • 46

  • 47

  • 48