Nurkholis, dr.

, SpBS
 RUANG LINGKUP BEDAH SARAF
1. Trauma brain & spine:
a. COR, COS, COB, EDH, SDH, Higroma, SAH, ICH, IVH, Impresi,
FBC, Penetrating, Corpus alienum
b. Fraktur vertebra
2. Vaskuler: CVA bleeding, AVM, Aneurisma
3. Onkologi brain & spine: Tumor
4. Degeneratif (spine): HNP, Listhesis
5. Pediatri: Hidrosefalus, Meningoencepalocele, Myelocele,
Craniosynostosis,Tumor, Infeksi, Pendarahan spontan intrakranial
6. Infeksi brain & spine: Meningitis, Abses, Spondilitis TB
7. Fungsional: Hemifacial spasm, Trigeminal neuralgia, Epilepsi
NEUROSURGICAL EMERGENCY
1. Decrease of consciousnes

2. Intracranial Hypertension

3. Seizure

4. Infection

5. Sudden onset of chepalgia

 PRINSIP PENANGANAN TRAUMA
“ little can be done about the primary brain injury, but
a lot can be done to minimize
secondary brain injury“

• Close observation
• Prompt diagnosis and treatment
 CLOSE OBSERVATIONS
Survey Check Record & Correct
Airway Patent/ Noisy •Obstruction

•Rate & depth

•Air entry
Breathing Effective •Chest movement
•Cyanosis
•Pulse rate & volume
•Skin color
Circulation Adequate •Capillary return
•Hemorrhage
•Blood pressure

Disability Normal
•Conscious level: AVPU/GCS
•Pupillary light reactions
(neurological status)
•Limb movements: on command/
Exposure Other injuries? on painful stimulus
BRAIN INJURY
KLASIFIKASI (HEAD–BRAIN INJURY)

Berdasar:
1. Mekanisme
2. Severity
3. Morphologi
 Motorbike accident
Automobile collision
Tumpul
(Blunt) Falls
Blunt assault

1. Mekanisme Depends on:

the presence of dural penetration
Luka tembak
Penetrasi
Luka penetrasi
2. Severity:
1. Mild (GCS: 14-15)
2. Moderate (GCS: 9-13)
3. Severe (GCS: 3-8)

GCS
(Glascow Coma Scale)
 Linier/ satellite
Vault Depressed/ non depressed
Open/ Close
Skull With or w/o CSF leakage
Basilair
Fracture With or w/o N VII palsy

Vascular injury: EDH,SDH,ICH

3. Morfologi Axonal injury
Focal Contusion
Laceration
Intracranial
Lesions
Diffuse axonal injury
Diffuse Diffuse vascular injury:
multiple small hemorrhage
IMPRESI
EDH
(Epidural Hematoma)
SDH
(Subdural Hematoma)
Higroma
SAH
(Subarahnoid Hematoma)

ICH
(Intracranial Hematoma)
IVH
(Intraventrikel
Haemmorhage)
 PATOFISIOLOGI CEDERA OTAK
CEDERA KEPALA
Normal

CEDERA OTAK PRIMER

Tx adequad

INTRACRANIAL SYSTEMIC SECONDARY INSULT

SECONDARY INSULT

CIDERA OTAK SEKUNDER

 ICP, CPP
ISKEMIK-HIPOKSIK

MORTALITAS
MORBIDITAS
 1. Direct Impact
2. Acceleration – Deceleration
3. Shock waves
4. Angular force

CEDERA KEPALA CEDERA OTAK

1. DIRECT IMPACT (Gaya Langsung Kepala)

•Skull deformation
•Skull base fractures
•Brain laceration – abrasion
•Impulse transmitted
Other part of bones
Brain
2. ACCELERASI & DECELERASI
3. SHOCK WAVE & CAVITATIONS
4. ANGULAR FORCE
Infark basal ganglia

ICH
Cedera Otak Primer Cedera Otak Sekunder

Insult Systemic Insult Intracranial

– Hypoxemia – ICP ↑
– Hypotension • Brain herniation
– Hypercapnea • Mass lesion
– Hypocapnea • Edema
– Hyperthermia
• Hydrocephalus
– Hyperglycemia
– Vasospasme
– Hypoglycemia
– Hyponatremia – Seizures
– Infection
– Ischemic
 INTRACRANIAL PRESSURE
ICP = MAP – CPP

Normal ICP:
 Adult and Children : 10 – 15 mmHg
 Mild increased : 16 – 20 mmHg
 Moderate increased : 21 – 40 mmHg
 Severe increased : > 41 mmHg

CPP optimum > 70 mmHg

MAP optimum > 90 mmHg
FRAKTUR
VERTEBRA
 ANATOMI
VERTEBRA
• Kolumna vertebralis
dibentuk oleh
33 vertebrae:

– cervical 7
– thorakal 12
– lumbal 5
– sacral 5
– coccygeus 4
 ANATOMI VERTEBRA
• Setiap vertebra terdiri dari:
– Corpus/body
– Pedikel
– Prosessus artikularis superior dan inferior
– Prosessus transversus
– Prosessus spinosus
 Trauma vertebra
yang mengenai medula spinalis
dapat menyebabkan
defisit neorologis
 FRANKEL GRADING
• Grade A: Complete paralysis

• Grade B: Sensory function only below the injury level

• Grade C: Incomplete motor function below injury level

• Grade D: Fair to good motor function below injury level

• Grade E: Normal function

 LOKASI
• >> : Cervical 4-6 & Th12-L2

– Daerah yang mobile

– Peralihan antara curvatura post vertebra &

curvatura anterior lumbal  >> beban
 PENATALAKSANAAN
• Konservatif (postural reduction):
– Tidur telentang dengan alas yang keras
– Posisi diubah tiap 2 jam untuk mencegah dekubitus

• Operatif
– Laminektomi
– fiksasi interna dengan kawat atau plate
– anterior fusion atau post spinal fusion
 PROBLEM TRAUMA ???
1. Tingginya angka mortalitas & morbiditas  70%
accidental death
2. Terjadi pada usia tua
3. Resusitasi awal yang tidak adequad
4. Memerlukan diagnosis & terapi yang cepat & tepat
5. Proses rehabilitasi lama
6. Biaya mahal
 PROGNOSIS
• Quality of early management
• Severity of primary brain injury or frankel grading
• Adequate referral policy
• Prompt diagnosis and treatment
• Adequate prevent and treatment of complication
• Proper Rehabilitation
 When
the stroke patients
need surgery ?
 RASIO
Stroke Stroke
Pendarahan Iskemik
Asia 30 70
Eropa/ Amerika 15 85
 CURIGA BLEEDING/ INFARK ???
• Onsetnya
– Waktu aktivitas (>> bleeding)
– Bangun tidur (>> infark)
• DM (>> infark)
• Hipertensi (>> bleeding)

Penanganan Pertama  Prognosis ?

PENYEBAB STROKE PENDARAHAN
•Hipertensi

•Kelainan vaskuler: AVM, aneurisma, cavernoma

•Tumor

•Iatrogenik (terapi trombolitik atau antikoagulan)

 PEMBESARAN HEMATOMA

20 % bertambah dalam 6 jam pertama

34,3% bertambah dalam 24 jam

CT Scan ulang dalam 24 jam

PENDARAHAN INTRAKRANIAL
MENGAKIBATKAN:
• massa hematoma
• jaringan otak cedera
• gangguan aliran darah
• kelainan vaskuler otak
• udema otak
INDIKASI TINDAKAN BEDAH:
•GCS
•Usia
•Progresifitas defisit neurologis (GCS, lateralisasi)
•Hasil CT scan:
ukuran hematoma
lokasi
efek massa
perdarahan intraventrikel
hidrosefalus
 KONSERVATIF OPERATIF
CT SCAN

KLINIS •GCS 15 •GCS < 15

•Hemiparesis •Hemiparesis
•Gelisah •Tanda TIK +
 KONSERVATIF OPERATIF
CT SCAN

KLINIS •GCS 15 •GCS < 15

•Hemiparesis •Hemiparesis
•Gelisah •Tanda TIK +
 PROGNOSTIK ???
• Golden periode stroke 6 jam
• Kompleks:
– Hipertensi
– Diabetes
– Geriatri
– Fungsi organ menurun
 KELAINAN KONGENITAL

• Hidrosefalus

• Meningoencepalocele

• Myelocele
Ensefalokel Nasofrontal
Ensefalokel Nasoetmoidal
Ensefalokel Nasoorbital
Ensefalokel Oksipital
Spina Bifida
MRI
Emergency bila ruptur !!!
 Infeksi bilamana…
• Ada tanda-tanda infeksi

• Ada sumber infeksi:

HIV, TBC, OMK, gigi
 Langkah-langkah Tatalaksana
Pasien di UGD
1. General precaution
2. Stabilisasi (Airway, Breathing, Circulation) &
Imobilisasi
3. Survey sekunder
(pemeriksaan status general: anamnesis &
pemeriksaan fisik seluruh sistem organ)
4. Pemeriksaan neurologis
5. Menentukan diagnosis klinis & pemeriksaan
tambahan
6. Menentukan tahapan tatalaksana selanjutnya
Terima Kasih...

Bedah Saraf RSI Sakinah