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Trauma kapitis

Prof.DR.Dr.Hasan Sjahrir SpS(K)
Departemen Neurologi FK USU
definisi
 Trauma kapitis : adalah trauma mekanik
terhadap kepala baik secara langsung
ataupun tidak langsung yang
menyebabkan gangguan fungsi neurologis
yaitu gangguan fisik, kognitif, fungsi
psikososial baik temporer maupun
permanen.

 Sinonim: cedera kepala= head injury
=trauma kranioserebral=traumatic brain
injury
 75% KLL
epidemiology
 Incidence head trauma
 350 per 100.000 in Europe, 200 per
100.000 in North America,
 US hospitalization rates due to traumatic
brain injury (TBI) are on the rise,
 85% mild head injury,
 15% moderate - severe Head injury
 Severe head injury intracranial
haemorrhagic lesion 10-27%
 Less than 2% require neurosurgery
1.Baandrup L & Jensen R. Cephalalgia 2005; 25:132–138.
2.National Institute of Health Traumatic Coma Data Bank
3.Ropper AH, Gorson KC. N Engl J Med 2007;356:166-72
4.Thomas & Kegler. Morb Mortal Wkly Rep. 2007;56:167-170
 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)
Akibat lesi bentur thd otak
 Blockade ARAS
 Retensi cairan & elektrolit
 TIK meninggi
 Perdarahan
 Kerusakan otak primer
 Kerusakan otak sekunder
Pemeriksaan neurologis
 Monitor batang otak
 Besar & reaksi pupil, refleks kornea
 Doll’s 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
 Brill’s hematon, likuorrhea,battle’s sign
 Funduskopi
 Radiologi
 EEG
TBI (Traumatic Brain Injury)
 Closed head injury
 Primary injury
 Concussion
 Contusion
 Hematoma epidural, subdural, intraventricular,
subarachnoid
 Secondary
 Hypotension, hypoxia, acidosis, edema, ischaemia or
other subsequent factors that can secondary damage
brain tissue
 Penetrating head injury
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
4
Disoriented and
converses
Inappropriate words Cries
3
Inappropriate words;
cries
Screams
Inappropriate
crying/screaming
2
Incomprehensible
sounds
Grunts Grunts
1 No response No response No response
Normal Skor
pada anak:
< 6 bulan : 12
6-12 bulan : 12
1-2 thn : 13
2-5 thn : 14
> 5 thn : 14
Normal skor
Dewasa
4+5+6=15
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


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
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
jam
Defisit 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
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.
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
Kontusio serebri (15-19%)
 Definisi: perdarahan interstitiil parenchym
otak,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

Kontusi serebri pada anak2
 Fase latent
 Fase akut serebral (II)
 Fase regenerasi
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
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
Gejala EDH fossa posterior
 Lucid interval tidak jelas
 Fraktur krainii oksipital
 Kehilangan kesadaran cepat
 Gangguan serebellum, batang otak,
pernafasan
 Pupil isokor
 Prognosa jelek
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
Intraserebral hematom
 Dwf: pecahnya arteri
intraserebral/serebellar
 Mono- multiple
Fraktur basis kranii
 Anterior
 Media
 Posterior
 Diagnosa tgt gejala ,sebab x
foto hanya 50%(+)
X foto
 X foto tengkorak 30% , fraktur
(+)
 3-5% kelainan intrakranial
 kepentingan:
 Kematian 80% fraktur (+)
 Medikolegal
 kepentingan pengawasan klinik
Penanggulangan trauma
kapitis 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
 Def: peninggian cairan intra/ekstra sel
otak o.k. proses lokal atau umum
 Jenis
 Vasogenik
 Sitotoksik
 Osmotik
 hidrostatik
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
 Vasogenik : Tr kapitis, stroke,
meningitis, ensefalitis, SOL, hipertensi
malignan, konvulsi
 Sitotoksik: asfiksia, cardiac arrent, zat
toksik
 Osmotik: water intoxication, hemodialisis
 Hidrostatik: hidrosefalus
 Hipertonik sol: manitol ,gliserol
 Kortikosteroid
 Barbiturat
 Hipothermi
 Hiperventilasi artifisiil
INDIKASI OPERASI PENDERITA
TRAUMA KRANIOSEREBRAL
 EDH (epidural hematoma) ;
 > 40 cc dengan midline shifting pada daerah
temporal / frontal / parietal dengan fungsi
batang otak masih baik.
 > 30 cc pada daerah fossa posterior dengan
tanda-tanda penekanan batang otak atau
hidrosefalus dengan fungsi batang otak masih
baik.
 EDH progresif.
 EDH tipis dengan penurunan kesadaran bukan
indikasi operasi.
 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 / kontusio
serebri disertai midline shifting dengan
fungsi batang otak masih baik.
 Indikasi operasi ICH pasca trauma sama
seperti stroke hemoragis.
 Fraktur impresi melebihi 1 (satu) diploe.
 Fraktur kranii dengan laserasi serebri.
 Fraktur kranii terbuka (pencegahan infeksi
intra-kranial).
 Edema serebri berat (disertai tanda
peningkatan TIK) ------ pertimbangan
dekompresi.
INDIKASI OPERASI PENDERITA
TRAUMA KRANIOSEREBRAL
 Coma acute brain functioning failurebrain stem and/or
cerebral hemisphere lesion
 Persistent vegetative state ( coma vigile)eye are
open(respons to sounds) but not respond to any kind of
stimulation(total lack of cognitive function)=apallic state
absence of neocortical functions
 Locked-in syndrome (LIS)quadriplegia, lateral gaze
palsy, paralytic mutism, fully conscious and aware of
environment  ventral of pons lesion
 Minimally responsive state
 Akinetic mutismlack of movement (not completely
paralyzed) & speech, can eye open  lesion frontal basal
and posterior region of mid brain
Jose Leon-Carrion et al. Brain Injury Treatment.2006
PARAMETER OF POOR PROGNOSIS IN PATIENTS IN PROLONGED STATE
OF COMA
Brain Injury Treatment,
2006
CHARACTERISTIC
with
recovery
without
recovery significance
SIGN OF
HYPOTHALAMIC
Fever 30% 57% p<0.03
perspiration diffuse 16% 54% p<0.005
MOTOR REACTIVITY
No answer 8% 92%
Decerebrate 49% 51%
Decorticate 73% 30%
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
The temporal lobes & frontal
lobe are commonly injury



Physiologic disruption of hippocampal
function



Disturbing memory storage and retrieval



Post Traumatic Amnesia (PTA)
(Retrograde and Anterograde Amnesia)





the duration of PTA is related to the
degree of residual memory deficit ,
disability and a higher probability of
personality change after TBI





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.

Neuro behavioural
problems of TBI
 Behavioral and emotional problems 
cognitive impairmentcontribute 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

Neurobehavioural
symptoms post TBI
 Poor sleep patern
 Poor drive and motivation
 Tiredness
 Socially withdrawn
 Headache
 Impulsive
 Aggressive
 Anxiety
 depression
Aggressive behaviour is a frequent
sequela of TBI
A 70% incidence of postraumatic
irritability of which 20% was defined
as violent behaviour
patient who display aggresion
postraumatic 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
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