Iskandar Japardi

Departemen Ilmu Bedah Saraf

Fakultas Kedokteran USU / RS.H.Adam Malik
MEDAN
ANATOMI KEPALA

 KULIT
 TULANG TENGKORAK
 DURAMATER
 ARACHNOID
 PIAMATER
PEMERIKSAAN CEDERA KEPALA DI UGD

 PRIMARY SURVEY

 Airway
 Breathing
 Circulation
 Disability
 Exposure
 SECONDARY SURVEY

• KEPALA DAN LEHER

• THORAKS
• ABDOMEN
• EXTREMITAS
TERMINOLOGI YANG DAPAT DIPAKAI UNTUK MEMBAWA
PENDERITA KE RUMAH SAKIT

 Primary care: dilakukan pada tempat kejadian

 Primary hospital : perawatan pertama pada
rumah sakit (rural)
 Primary transport : pertama dipindahkan ke rumah
sakit terdekat
 Secondary transport : dipindahkan dari primary
hospital ke secondary center untuk perawatan
definitive
 Tertiary transport : antara rumah sakit besar,
penderita multiple trauma, pindah ke pusat dialisis
MANAJEMEN AWAL CEDERA KEPALA, HINDARI

 HIPOKSIA
 HIPERKARBIA
 HIPOTENSI
 HIPOVOLEMIA
GELISAH

 HYPOXIA
 RETENTION URINE
 NYERI
 PROSES INTRACRANIAL
 Intracranial contents,
 Brain (including the neurological elements [70%] and
interstitial fluid [10%] ) ;
volume 1400 ml or 80%
 Blood (arterial and venous) ;
volume 150 ml or 10%
 Cerebrospinal fluid (CSF) ;
volume 150 ml or 10%
PEMERIKSAAN NEUROLOGIS

 TINGKAT KESADARAN
 PUPIL DAN GERAKAN BOLA MATA
 REAKSI TERHADAP RANGSANG DARI LUAR
 REAKSI MOTORIK
 POLA PERNAFASAN
 SINDROMA HERNIASI
 BRAIN DEATH
 GLASGOW COMA SCALE
• Eye Response. (4)  Motor Response. (6)
1. No eye opening 1. No motor response
2. Eye opening to pain 2. Extension to pain
3. Eye opening to verbal command 3. Flexion to pain
4. Eye open spontaneously 4. Withdrawal from pain
5. Localizing pain
• Verbal Response. (5) 6. Obey Commands
1. No verbal response
2. Incomprehensible sounds Klasifikasi
3. Inappropriate words Mild 14 - 15
4. Confused Moderate 9 - 13
5. Orientated Severe 3-8
 SYMPTOMS AND SIGNS
 Headache, worse at night or recumbent position,
because of the increase in CO2 tension and increased
venous pressure
 Nausea and vomiting
 Ataxia, papilledema, and cranial nerve paralysis
 Irregular breathing patterns
 Decorticate or decerebrate
 Pupillary inequality
PEMERIKSAAN RADIOLOGIS

 FOTO POLOS KEPALA

 FOTO CERVICAL
 FOTO THORAX
 FOTO LUMBAL
 CT SCAN / COMPUTED TOMOGRAPHY
 MRI / MAGNETIC RESONANCE IMAGING
 Indikasi CT Scan
 Kesadaran menurun (GCS<15).
 Skull fracture.
 Tanda fraktur basis kranii.
 Sakit kepala menetap/ muntah.
 Cedera penetrasi.
 Kejang.
 Neurologic defisit (lateralization).
 Indikasi rawat
 Kesadaran menurun
 Sakit kepala (sedang sampai berat).
 Riwayat kesadaran menurun > 15 minute.
 Fraktur tulang tengkorak.
 Rhinorea – otorhea.
 Cedera penetrasi.
 Alkohol/drugs intoxication.
 Significant multiple trauma.
 Abnormal CT Scan.
 Amnesia.
 No family at home.
 CEREBRAL BLOOD FLOW
 Normal 55 to 60 ml/100 gr brain tissue/minute
 In the gray matter is 75 ml/100 gr brain tissue/minute
 In the white matter 45 ml/100 gr brain tissue/minute
 The most significant factor that determines CBF is the CPP
which is the effective blood pressure gradient across the
brain
 MAP is the diastolic pressure plus one-third of the pulse
pressure ; increased ICP is tendency for the CPP to
decrease
 MACAM MACAM FRAKTUR

 FRAKTUR LINEAR
 FRAKTUR DIASTASE
 FRAKTUR COMMUNITED
 FRAKTUR DEPRESSED
 FRAKTUR KONVEKSITAS / KUBAH
 FRAKTUR BASIS CRANII
 ANTERIOR - ANOSMIA, RHINORRHOE
 MEDIA - OTORRHEA, HEMATYMPANI, BATTLE’S SIGN
 POSTERIOR - INFRA TENTORIAL
TANDA FRAKTUR BASIS KRANII

 HAEMOTYMPANUM
 OTORRHEA
 RHINORRHEA
 RACOON EYES
 BATTLE’S SIGN
 CEREBRAL EDEMA
 VASOGENIC EDEMA
 Increased permiability of capillaries ; the tight junctions
between the endothelial cell become incompetent,
allowing plasma filtrate to escape into the intercellular
space
 Contrast enhancement because of the breakdown of the
BBB
 Edema is more marked in white matter than in gray
matter
 Edema is seen with trauma, tumor, and abscess
 CYTOTOXIC EDEMA
 Hypoxia of the neural tissue and water intoxication
 Hypoxia affects the ATP-dependent sodium pump
mechanism in the cell membrane, promoting an
accumulation of intracellular sodium and subsequent
flow of water into cell to maintain osmotic equilibrium
 Edema is intracellular and affects all cells : endothelial
cells, astrocytes, and neurons (interstitial space is
narrowed)
 Subtle or no changes in CT scan, indicative in early
phases of ischemic stroke
 INTERSTITIAL EDEMA
 Transudation of CSF in obstructive hydrocephalus
 Best observed on CT or MRI as periventricular low
density areas because of the retrograde transependymal
flow of CSF into the interstitial space of the white
matter (mostly in frontal region) , indicates active
hydrocephalus requiring surgical therapy
TYPES OF BRAIN HERNIATION
 CINGULATE HERNIATION
 Focal mass lesion in the supratentorial compartement
pressure locally on the ipsilateral hemisphere
 The mass lesion may displace the cingulate gyrus, which
is next to the free edge of the falx cerebri, and cause it to
herniate under the falx to the opposite side
 Usually displacement of the ventricular system
 Arterior cerebral artery, tight, sharp edge of the falx
 No clinical signs and symptoms specific
 UNCAL HERNIATION
 When lesions of the middle cranial fossa, such as acute
epidural hematoma, subdural hematoma, temporal lobe
contussions, or temporal lobe neoplasms
 An expansile mass of the middle fossa cause the uncus,
the inferomedial structure of the temporal lobe, to
herniate between the rostral brainstem and tentorial
edge into posterior fossa
 The medial displacement of the brainstem may cause
compression of the brainstem againts the opposite
tentorial edge, producing a notch called Kernohan’s
notch (ipsilateral hemiplegia)
 CENTRAL TRANSTENTORIAL HERNIATION
 Mass lesions located to the tentorial hiatus
 Bilateral mass lesions, such as bilateral subdural
hematomas, can also cause herniation
 Downward displacement of the diencephalon and
midbrain centrally through the tentorial incisura
 Clinical symptom,
 Bilaterally small, reactive pupils
 Cheyne-Stokes respirations
 Loss of vertical gaze
 TONSILLAR HERNIATION
 The tonsil of the cerebellum herniates through the
foramen magnum into the upper spinal canal,
compressing the medulla
 Manifestations of acute medullary compression are,
 Cardiorespiratory impairment
 Hypertension
 High pulse pressure
 Cheyne-Stokes respirations
 Neurogenic hyperventilation
 Impaired consciousness
 Stiff neck or opisthotonic position
 Decorticate or decerebrate posturing
INDIKASI OPERASI
 Epidural Hematoma (EDH)
- EDH >30 ml
- EDH,Koma,GCS <9, pupil anisokor
- Bila EDH <30 ml dan ketebalan <15 mm
serta midline shift <5 mm dan GCS >8 tanpa
fokal defisit ------ tidak operasi
 Akut Subdural Hematoma (SDH)
- ketebalan >10 mm atau midline shift >5 mm
pada CT Scan
- koma (GCS<9), ketebalan <10 mm dan
midline shift <5 mm,operasi bila GCS
menurun 2 atau lebih (waktu antara kejadian
dan masuk RS) atau ICP >20 mmHg
- koma (GCS<9) ----- monitoring ICP
 Traumatic parenchymal lesions
- GCS 6-8 dengan kontusi frontal atau
temporal <20 ml, midline shift >5 mm
dan kompresi sisterna pada CT Scan
- lesi >50 ml

 Lesi fossa posterior

lesi dengan distorsi,dislokasi, atau obliterasi
ventrikel IV, sisterna basalis, atau obstruksi
hidrosefalus

 Depressed skull fractures

luka terbuka dan lebih dari 1 tabula
 TREATMENT
MANNITOL
 It increases serum osmolality and to draw fluid from the
brain parenchyma into the vascular space
 The osmotic effect of mannitol is
 Decrease CSF production
 Increases cerebral blood flow and cerebral oxygen
consumption
 Decrease blood viscosity, thereby improving perfusion
INDIKASI EVAKUASI HEMATOMA

 Tidak semua lesi intrakranial cedera kepala berat

tertutup dilakukan kraniotomi
 Traumatic Coma Data Bank
37% penderita koma dilakukan operasi intrakranial
hematoma
 25% keadaan klinis menurun pada penderita dengan
lesi intrakranial atau gambaran radiologi
menunjukkan bertambahnya hematoma
 Explorasi burrhole
 Tidak dilakukan bila ada fasilitas CT Scan
 Life saving : rural area, jarak transfer ke
lokasi CT Scan cukup jauh atau tidak
memungkinkan
 Lokasi burrhole
 frontal,parietal dan temporal
 dilatasi pupil ……… ipsilateral
 hemiparesis …….. kontralateral
 fraktur ……. ipsilateral
 bila tidak ada didaerah temporal, dilakukan
burrhole didaerah frontal, dan parietal
 bila ketiga tempat ini tidak ada, dilakukan pada
sisi berlawanan
LOKASI BURR HOLE
INSIDENCE DEPRESSED FRACTURE

 3% fraktur tulang tengkorak pada cedera kepala

ringan
 65% fraktur tulang tengkorak pada cedera
kepala berat, dengan atau tanpa kerusakan dura
atau otak
 >50% fraktur frontal dan memerlukan
perbaikan kosmetik
fraktur depressed
fracture depressed
 INSIDEN EPIDURAL HEMATOMA

 2%-6% dari cedera kepala, dengan atau tanpa fraktur

tulang tengkorak
 30% penderita, hematoma bertambah dalam 6 jam
pertama setelah cedera
 10%-50% berhubungan dengan hidrosefalus bila
lokasi hematoma fossa posterior
SUBDURAL HEMATOMA

 Simple atau intradural hematoma

 Complicated atau mixed subdural hematoma
 Akut
 Subakut
 kronik
CHRONIC SUBDURAL HEMATOMA (CSDH)

 Subdural hematoma is older than 3 weeks

 Result of rupture of small bridging veins
 Caused by minor head trauma or fall, often not
remembered by the patient or relatives
 Bilateral clots about 20% of cases
 Risk factor
 Old age
 Alkohol abuse
 seizures
 CSF shunts
 Anticoagulation
 Patients at risk for falls
 DATA KEMATIAN AKIBAT TRAUMA
(Meislin,Rogers,et.al.,1997)

 Very early deaths, 35%-50% dari total ; kerusakan CNS

permanen
 Early deaths (dalam 4 jam), 18%-30% dari total;
biasanya karena perdarahan atau problem jalan nafas
 Hospital deaths dalam 24 jam, 20% dari total
 Hospital deaths setelah beberapa hari atau minggu,
20% dari total; multiple system failure dengan sepsis
KESIMPULAN
 Tidak ada obat atau miracle treatment untuk
memicu penyembuhan saraf paska trauma
kepala
 Penanganan konservatif dan operatif sesuai
indikasi
 Pengobatan terbaik mencegah cedera sekunder
 Pengetahuan molekuler penting, menyusun
kombinasi terapi penanganan cedera otak
sekunder
TERIMA KASIH