20 Trauma Kapitis

8/22/2019 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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20 Trauma Kapitis