Subdural hematoma

Definision:
A subdural hematoma forms because of an accumulation of blood under the dura mater, one of
the protective layers to the brain tissue under the calvarium.

Etiologi :
In the pediatric patient, trauma is the most common cause of subdural hematoma. Cranium
extraction device use and traumatic birth delivery accounts for a majority of the SDH in the
newborn period. However, after the newborn period until age 2 years,  the cause of SDH is
predominantly due to accidental injury or intentional head injury. SDH due to intentional
injury is frequently referred to as "shaken baby syndrome" The term correlates with the back-
and-forth motion of the brain in the skull, held by the fragile bridging veins that rupture after
violent, repeated movements against the inertia of the brain.

Pathophysiology:
In shaken baby syndrome or battered infant syndrome,[4] the acceleration and decelerating
forces of the brain during violent shaking of the head causes the brain to move in an opposite
direction to the meninges causing the bridging veins to rupture and bleed in the subdural space.
This potential space may accumulate a significant quantity of blood in various stages to exist in
an acute or sub-acute form. Often, the bleeding is undetected initially, discovered as a chronic
subdural hematoma. When there is a sufficient accumulation of blood to occupy a large
intracranial space, the brain midline shifts toward the opposite side, encroaching on the brain
structures against the inner surface of the calvarium after decreasing the volume of the lateral
third and fourth ventricles. As the intracranial space becomes limited, the volumetric forces push
the uncal portion of the temporal lobe toward the foramen magnum causing herniation of the
brain.

Histopathology:
The examination focuses on the visualization of various cellular components of the dura and
within the clot itself. Red blood cells, leukocytes, phagocytes, fibroblasts, hemosiderin
containing cells, fibrin and proliferation of blood vessels. Clots that contain relatively intact
blood cells without significant differentiation nor evidence of lysis are acute. Once the subdural
clot organizes with fibrin, macrophages laden with hemosiderin and red blood cells and lysed red
blood cells in the center, the clot is subacute.

Treatment
The immediate treatment of a subdural hematoma initially includes management of the airway,
breathing with stabilization of the circulation for the critical care professional. After
stabilization and monitoring of the patient, a secondary plan of care should follow. The
management must include the involvement of neurosurgery and neurological consultation with a
consensus on the injury and a determination of the immediate and long-term consequences.
Conservative non-surgical management for subacute and chronic subdural hematomas is
appropriate if the accumulation has not extended further into the calvarium as to cause
impingement on the brain or the brain stem. In contrast, a subdural hematoma that is quickly
increasing or causing any signs of increased intracranial pressure, for example, hypertension,
bradycardia with erratic respirations should prompt surgical evacuation and is paramount to
preserve vital functions. In the interim, the clinician must begin immediate medical management.
These measures include sedation, neuromuscular blockade when appropriate, moderate
hyperventilation to a Pc02 (32 to 36), adequate oxygenation to maintain Sp02 greater than 95%,
head elevation, and avoidance of hyperthermia. The infusion of hypertonic saline or mannitol
serves to decrease the intracranial pressure by promoting osmotic changes in the brain and
transiently affecting the rheologic properties of the cerebral blood flow, respectively.[
Prognosis:
The prognosis of children affected by subdural hematoma is widely variable and depends on the
extent of the intracranial injury. Many cases of subdural hematoma either traumatic or abusive
remain undetected. However, many children live with severe neurological deficits including
seizures, neurodevelopmental delay with static encephalopathy because of severe, devastating
neurological injury.

Jalur motoric dan sensorik tubuh

Jalur motoric = system pyramidal dan system ekstrapiramidal

System pyramidal =
- Jalur kortikospinalis : jalur kortikospinal adalah jalur yang menghantarkan impuls dari
korteks serebri ke medulla spinalis dan akan bersinaps dengan neuron perifer untuk
mempersarafi ekstremitas tubuh. Badan sel dari jalur kortikospinal berada di korteks
serebri, kemudian jaras kortikospinal ini akan turun melalui kapsula interna. Setelah itu,
jaras ini akan turun melalui midbrain, pons, dan medulla oblongata. Di medulla
oblongata, jaras kortikospinalis akan mengalami penyilangan sebesar 90% yang disebut
dengan kortikospinal lateralis dan sebesar 8% tidak menyilang di medulla oblongata
namun akan menyilang di setinggi vertebra tempat saraf perifer akan bersinaps
dengannya yang disebut dengan kortikospinalis ventralis. Dan sebesar 2% dari jaras ini
tidak akan mengalami penyilangan yang disebut dengan kortikospinalis lateralis
ipsilateral sehingga jaras ini akan mempersarafi bagian tubuh yang ipsilateral
(Corticospinal pathways are pathways that transmit impulses from the cerebral cortex to
the spinal cord and will synapse with peripheral neurons to innervate the extremities of
the body. The cell bodies of the corticospinal pathway are in the cerebral cortex, then this
corticospinal pathway will descend through the internal capsule. After that, this pathway
will descend through the midbrain, pons, and medulla oblongata. In the medulla
oblongata, the corticospinal pathways will cross 90% which is called the lateral
corticospinal and 8% will not cross in the medulla oblongata but will cross at the level of
the vertebra where the peripheral nerves will synapse with them which is called the
ventral corticospinal. And as much as 2% of this pathway will not experience a crossing
called the ipsilateral lateral corticospinal so that this pathway will innervate the ipsilateral
body part.)
 - Jalur kortikomesensefalik :jalur kortikomesensefalik adalah jalur yang menghantarkan
impuls dari korteks serebri(broodman 8/ frontal eye field) menuju midbrain untuk
bersinaps dengan saraf kranial yang berfungsi dalam pergerakan bola mata.
- Jalur kortikobulbar : jalur kortikobulbar adalah jalur yang menghantarkan impuls dari
korteks serebri menuju batang otak untuk bersinaps dengan saraf kranial V,VII,IX,X,XI,
dan XII.

PATOFISIOLOGI PTSD

The pathophysiology of posttraumatic stress disorder involves alterations in the neurotransmitter

and neurohormonal functioning. Individuals with PTSD have shown to have normal to low levels
of cortisol and elevated levels of corticotropin-releasing factor (CRF) despite their ongoing
stress. CRF stimulates the release of norepinephrine by the anterior cingulate cortex, which leads
to an increased sympathetic response, which manifests as increased heart rate, blood pressure,
increased arousal, and startle response. Also, some studies have shown altered functioning of
other neurotransmitter systems such as GABA, glutamate, serotonin, neuropeptide Y, and other
endogenous opioids in patients with PTSD. There is a decrease in GABA activity and an increase
in the glutamate, which fosters dissociation and derealization. Serotonin concentration is also
decreased in dorsal/median raphe, which likely changes the dynamic between the amygdala and
the hippocampus. Plasma neuropeptide Y concentration is also reduced.
Also, PTSD is associated with the change in the neurophysiology and anatomy of the brain. The
size of the hippocampus is reduced, and the amygdala(processing emotions and modulating fear
response) is overly reactive in individuals with PTSD. The medial prefrontal cortex (inhibitory
control over the emotional reactivity of amygdala) appears to be smaller and less responsive in
patients with PTSD.

Jaras sensori dalam tubuh kita ada banyak dan dengan fungsinya masing masing. Dalam
pertemuan ini kita akan membahas tentang 3 jaras sensori.

Jaras sensori yang akan kita bahas dibagi menjadi 2 yaitu jaras spinothalamikus dan jaras
posterior column medial lemniscus.
Jaras spinothalamikus dibagi menjadi spinothalamikus anterior dan lateral.
Ketiga jaras ini memiliki fungsinya masing masing. Spinothalamikus anterior menghantarkan
sensasi sentuhan dan tekanan, spinothalamkus lateral menghantarkan nyeri dan suhu.
Sedangkan PCML menghantarkan rangsangan getar, propioseptif dan diskriminasi 2 titik.
Dalam perjalanan tiap tractus melewati 3 jenis neuron yang berbeda. Neuron pertama akan
menghantarkan impuls dari reseptor menuju medulla spinalis, neuron kedua akan
menghantarkan impuls dari medulla spinalis ke thalamus, dan neuron ketiga akan
menghantarkan impuls dari thalamus ke korteks sensori. Tetapi Konsep tiga neuron ini tidak
berlaku untuk semua jaras, ada beberapa jaras yang lebih dari tiga neuron bahkan ada yang
kurang dari dua neuron

Impuls pertama akan datang dari saraf perifer ke spinal melalui dorsal root ganglion dan akan
berhenti sejenak di kornu posterior medulla spinalis. Di kornu posterior medulla spinalis akan
ada 2 cabang, yaitu cabang ke atas dan cabang ke bawah. Cabang ke bawah berfungsi untuk
refleks intersegmental. Kita akan focus pada cabang ke atas. Setelah saraf perifer berhenti
sejenak, dia akan naik satu sampai dua level spinal sampai akhirnya akan bersinaps diposterior
gray mater melalui posterolateral tract of lisauer. Setelah itu neuron ini akan menyebrang
melewati komisura ventralis hingga sampai ke terowongan masing-masing. Neuron yang
melalui terowongan besar disebut dengan spinothalamikus lateralis. Sedangkan neuron yang
melalui terowongan yang kecil disebut dengan spinothalamikus anterior. Setelah itu mereka
akan naik keatas melalui terowongannya masing masing . setelah sampai di medulla oblongata
kedua neuron itu akan bergabung menjadi satu dan berjalan di satu terowongan yang bernama
spinal lemniscus. Kemudian neuron itu akan terus naik dan akan bersinaps di thalamus.
Kemudian impuls ini akan dilanjutkan ke korteks sensori.
(There are many sensory pathways in our body and each with its own function. In this meeting
we will discuss about the 3 sensory pathways.

The sensory pathways that we will discuss are divided into 2, namely the spinothalamic
pathway and posterior column medial lemniscus pathway.
The spinothalamic pathway is divided into anterior and lateral spinothalamic.
These three paths have their respective functions. The anterior spinothalamus transmits touch
and pressure sensations, the lateral spinothalamus transmits pain and temperature.
Meanwhile, PCML delivers vibrational, proprioceptive and 2-point discrimination stimuli.
On the way each tractus passes through 3 different types of neurons. The first neuron will
transmit impulses from receptors to the spinal cord, the second neuron will transmit impulses
from the spinal cord to the thalamus, and the third neuron will transmit impulses from the
thalamus to the sensory cortex. But the concept of three neurons does not apply to all
pathways, there are some pathways that have more than three neurons and some even have
less than 3 neurons.

The first impulse will come from the peripheral nerves to the spinal cord through the dorsal
root ganglion and will stop for a moment in the posterior horn of the spinal cord. After the
peripheral nerve pauses, it ascends one to two spinal levels until it finally synapses in the
posterior gray matter via the posterolateral tract of lisauer. After that, these neurons will cross
through the ventral commissure to reach their respective tunnels. The neurons that pass
through the large tunnel are called the lateral spinothalamic. While the neurons that pass
through a small tunnel are called the anterior spinothalamic. After that they will go up through
their respective tunnels. after arriving in the medulla oblongata the two neurons will merge
into one and run in a tunnel called the spinal lemniscus. Then the neuron will continue to rise
and will synapse in the thalamus. Then this impulse will be continued to the sensory cortex.)
Impuls pertama berasal dari saraf perifer menuju medulla spinalis. Setelah sampai di medulla
spinalis neuron ini akan masuk ke dua fasciculus, yaitu fasciculus greacilis dan cuneatus.
Kemudian kedua neuron akan akan bersinaps di medulla oblongata. Setelah itu, kedua neuron
akan bersilang dan akan memasuki fasciculus medial lemniscus. Jaras tersebut menjadi satu dan
terus naik sampai bersinaps di thalamus. Setelah dari thalamus neuron tersebut akan
menyampaikan impuls ke korteks sensori
(The first impulse comes from the peripheral nerves to the spinal cord. After arriving in the
spinal cord, these neurons will enter two fasciculus, namely fasciculus greacilis and cuneatus.
Then the two neurons will synapse in the medulla oblongata. After that, the two neurons will
cross and will enter the fasciculus medial lemniscus. The pathways become one and continue
up until they synapse in the thalamus. After the thalamus, these neurons will convey impulses
to the sensory cortex)