INITIAL ASSESMENT AND TREATMENT OF

ALTERED MENTAL STATUS

NEUROSURGERY PERSPECTIVE

ROHADI, MD. FICS. FINPS.

NEUROSURGEON

DEPARTMENT OF NEUROSURGERY
WEST NUSA TENGGARA PROV. HOSPITAL, FACULTY OF MEDICINE, MATARAM UNIVERSITY
MATARAM CITY - WEST NUSA TENGGARA – INDONESIA
Jele Pansay, et Dien le querit

“Saya yang merawat lukanya,

Tuhan yang menyembuhkan”

Ambroise Pare
Abad 16
 Basis Neural Kesadaran

• Kesadaran tidak dapat dengan mudah

didefinisikan dalam hal apa pun

• Suatu keadaan terjadi kesadaran terhadap diri

dan sekitarnya
 Anatomi dari Status Mental

• Ascending reticular activating system (ARAS)

• Activating system dari brainstem superior, hypothalamus,
thalamus
• Menentukan tingkat kesadaran atau arousal
• Cerebral hemispheres dan interaksi antara area fungsional di
cerebral hemispheres
• Menentukan fungsi intelektual dan emosional
• Interaksi antara cerebral hemispheres dan ARAS
 Kesadaran (arousal)

• Ascending RAS, Dari batas bawah pons ke Thalamus Ventromedial

• Sel-sel inti dari system ini berasal dari area paramedian area di
Batang Otak
 KESADARAN (CONSCIOUSNESS)

Kesadaran dapat dibagi dua:

1. Derajat (kuantitas, arousal, wakefulness) kesadaran
2. Kualitas (awareness, alertness) kesadaran

Aferen/input Korteks serebri Eferen/output

Arousal Alertness
 AROUSAL

• Tergantung dari jumlah/kuantitas impuls aferen yang sampai ke korteks

serebri

• Bila terjadi gangguan derajat kesadaran akibat gangguan input aferen maka
akan selalu disertai gangguan kwalitas kesadaran.
 AWARENESS

• Merupakan pengelolaan impuls aferen sehingga menghasilkan eferen (output) berupa

pola-pola pemikiran.

• Hal ini yang akan mendasari kata-kata yang diucapkan dan hal-hal yang dikerjakan.

• Bila terjadi gangguan kwalitas kesadaran maka belum tentu juga disertai gangguan
derajat kesadaran.
 Proses Timbulnya Kesadaran
Jaras ascending primer spesifik
Input Panca Indera •Spinothalamicus lat & med
•Trigemino-thalamicus

Neuron lap - 2 & 3

korteks asosiasi / Neuron lap - 4
Neuron lap 2 & 4
persepsi sekunder korteks somatosensorik primer
korteks asosiasi tersier area 5 & 7 lob. area 1,2,3 lob parietalis
parietalis

Modalitas sensoris Persepsi tahu/kenal

Integrasi & asosiasi sadar, mengetahui dan terhadap
mengenal rangsangan rangsangan
 Lesi di upper brainstem

Lesi di Midbrain dan

hipothalamus

Lesi di Diensefalon

Lesi bilateral cortex cerebri

Lesi yang dapat menyebabkan koma atau

kehilangan kesadaran
Penyebab Perubahan Kesadaran secara Struktur :

1.Trauma : EDH, ICH, SDH, SAH, IVH dll

2.Penyakit Vascular : CVA Infark, CVA ICH, CVA SAH, CVA IVH, AVM,
DAVF, dll
3.Infeksi : Meningitis, Encephalitis, Abses Cerebri, dll
4.Tumor : Tumor Primer Cerebri, Tumor Metastase

11
GAWAT - DARURAT

•Gawat : Kritis (mengkhawatirkan),

genting(bahaya), sulit (terancam)

•Darurat : keadaan sulit yang terjadi mendadak,

membutuhkan pertolongan segera.
Gejala Utama

• Gejala peningkatan tekanan intrakranial (TIK)

• Defisit neurologis bersifat progresif maupun akut / tiba-tiba

Intracranial Pressure Monro Kellie
Tekanan
V parenkim Intrakranial

mmHg
Fatal 60
100
50
Disfungsi
40
Otak
50
30
Obati
20

Volume Intrakranial Normal

10

1 mmHG = 1,36 cm H2O 0

 Tanda peningkatan TIK

• Trias : Nyeri Kepala, Mual,

Muntah proyektil
• Palsy Saraf Kranial
• Papil Edema
• Cushing Triad :
– Hipertensi sistolik
– Bradikardi
– Perubahan Respirasi
 TIK  : Bayi

• Rewel, gelisah, nangis melengking

• Nafsu makan minum , muntah proyektil
• Fontanela bulging, FOC 
• Frontal bossing, vena prominen
• Pupil: nonreaktif; anisokor
• Kaku kuduk dan kejang (tanda lanjut)
 TIK : tanda awal pada anak-anak
• Gelisah, lesu, perubahan mood tiba-tiba
• Sefalgi
• Vertigo
• Gangguan visus – diplopia
• Ataxia, spastisitas tungkai
• Kaku kuduk
• Penurunan kognisi
TIK : tanda lanjut pada anak-anak

• Perubahan vital sign

• Kejang
• Fotofobia
• Kernig’s sign + Brudzinski’s sign: +
• Posturing: dekortikasi, deserebrasi
 Manifestasi TIK berat
• Pulse pressure melebar
• Bradycardia
• Irama respirasi tdk
teratur
• Abnormal Posturing

◼ Decorticate
(rigid flexion-upper arms
extension of legs)

◼ Decerebrate
(rigid extension- arms with
internal rotation of arms
and wrists)
Gejala Utama

• Gangguan fungsi kesadaran

• Gangguan fungsi saraf baik kranial maupun spinal
• Gangguan motorik
• Gangguan sensorik
• Gangguan otonom
Gangguan saraf cranial dan spinal
• Lesi saraf cranial I-XII

• Gangguan pembauan, visus, gerak mata, pendengaran,

keseimbangan, gerak motorik wajah, etc
Gangguan Otonom

• Pemeriksaan reflek fisiologis dan patologis

• Pemeriksaan fungsi bladder dan bowel
• Colok dubur menjadi hal yang rutin dilakukan bila
curiga ada lesi otonom
IMAGING IN
NEUROEMERGENCY
Imaging Modality

• Plain skull X ray

• CT Scan
• MRI
• Angiography
Plain Skull X ray

• Provides little information

• For evaluation of facial injury-----
nowadays we use MDCT
• The presence of skull fracture places
the patient at a higher risk of
intracranial hemorrhage (Not always)
SKULL FRACTURE : 3D REFORMAT
CT Scan
• Readily available in the emergency setting.
• Rapid and non invasive
• Good delineation of skull fractures, paranasal sinuses
and soft tissue changes
• Accurate localization of foreign metalic bodies and
bony fragments
• Easy identification of intraaxial, extraaxial
hemorrhage, pneumocephalus and brain herniation
• Possibility of CTA of the neck and intracranial vessels
• Easy evaluation of concomitant injuries in other body
regions
MRI
• Accurate detection of traumatic vascular lesions
• Adequate identification of DAI
• Easy identification of all herniations
• Accurate prediction of patient’s outcome with
functional studies
• Less available in the acute setting because of its
length of examination and high costs
• Poor delineation of bony fractures.
• Contraindicated for patients with suspected
metalic foreign bodies (metalic bullets in gun shot
trauma, aneurysmal clips, pace maker)
Kasus Vascular

• Stroke Hemorrhage
• Stroke Infark
• Ruptur Aneurisma
• Ruptur AVM
TYPE OF STROKE (IMAGING)

Perdarahan Intraserebral (ICH) Lacunar Infarction

Perdarahan Subarakhnoid (SAH)

Perdarahan Intraventrikular (IVH)

Malignant Cerebral Infarction
ICH BASAL GANGLIA
Neurosurgical Management of Stroke Hemorrhage

• Emergency Management : Airway, Breathing and

Circulation, complete laboratory and radiological
examinations
• Management of blood pressure
• Management of Increased ICP :
• Mechanical : head position, hyperventilation, sedation
• Medical th/ : osmotic agent, anti convulsant,
neuroprotector
• Surgery : craniotomy and hematoma evacuation,
endoscopic hematoma evacuation, ventriculostomy,
decompressive hemicraniectomy, ICP monitor,
intraventricular thrombolysis
Neurosurgical Indication (AHA 2015)
• Supratentorial hematoma evacuation in deteriorating patients might be
considered as a life-saving measure (Class IIb; Level of Evidence C)

• DC with or without hematoma evacuation might reduce mortality for

patients with supratentorial ICH who are in a coma, have large
hematomas with significant midline shift, or have elevated ICP
refractory to medical management (Class IIb; Level of Evidence C)

• Patients with cerebellar hemorrhage who are deteriorating

neurologically or who have brainstem compression and/or
hydrocephalus from ventricular obstruction should undergo surgical
removal of the hemorrhage as soon as possible (Class I; Level of
Evidence B).
 Hypertensive Stroke

Pre Op

Post Op
 Stroke ICH : On Going Process!!!

3 jam Pasca operasi

Pre op

24 jam

48 jam
ICH - IVH
Craniotomy Evakuasi ICH
Hypertensive Stroke ICH – Open Microsurgery

Pre Op

Post Op
STROKE ICH – ENDOSCOPIC EVACUATION

Post op
THE EFFECTIVENESS OF MINIMALLY INVASIVE CLOT
EVACUATION WITH STEREOTACTIC OR ENDOSCOPIC
ASPIRATION WITH OR WITHOUT THROMBOLYTIC USAGE
IS UNCERTAIN (CLASS IIB; LEVEL OF EVIDENCE B).
(REVISED FROM THE PREVIOUS GUIDELINE)
CVA SAH-Hydrocephalus

41
SUBARACHNOID HEMMORHAGE &
ANEURYSMAL RUPTURED

Ruptured MCA Aneurysm

43
AVM
KASUS DARURAT NEUROPEDIATRIK-INFEKSI
• Trauma kraniospinal dan saraf perifer
• Peningkatan TIK:
• SOP dengan perdarahan
• ICH spontan
• disfungsi shunt
• kraniostenosis
• hidrosefalus komunikan

• NTD: ensefalokel / mielokel pecah

• Sindrom tethered cord
• Infeksi: infeksi shunt, abses otak, meningitis
KASUS-KASUS
NTD pecah
49
Hydrocephalus : VP Shunt
ETV

51
Meningitis TB + Hydrocephalus

52
Cerebral Abcess

53
Pediatric Tumor
Kapan Tumor Otak menjadi Emergency

• Kenaikan mendadak tekanan otak

• Perdarahan intratumoral
• Hidrosefalus
• Edema berat
• Defisit neurologis progresif: papil edema, paresis
• Kejang
TUMOR : DECREASED OF CONSCIOUSNESS
MENINGIOMA
58
EARLY DIAGNOSTICS TESTS
All Patients : Selected Patients :

• Full blood count • Blood alcohol level

• Blood Glucose • Toxicology screen
• RFT • Pregnancy test
• Electrolytes • Chest radiography
• ECG • EEG (seizure?)
• PTT, APTT, INR • Cardiac enzymes
• O2 saturation • LFT
 GENERAL
MANAGEMENT
‘Time is Brain’

60
Emergency Investigations :
• To establish the diagnosis of disease ?
• To determine the underlying cause of the event ?
 INITIAL MANAGEMENT
1. Head positioning
• Head up 30 0 in line position
2. A : Airway
• Clearance of respiratory tract
• The tongue drops?
3. B : Breathing
• Inspection on the chest
• Oxygenation is given
• Mouth breathing /artificial respiration
4. C : Circulation
• Signs : + Pale?
+ pulse rate?
+ Arterial pulse unpalpable?
• Tx : * Stop bleeding
* Infusion
Daftar Pustaka
• Guideline Tatalaksana Cedera Otak RS. Dr. Soetomo. Edisi 2. 2014
• Orlando Regional Medical Center . 2014. Severe Traumatic Brain Injury Management Guideline
• Greenberg, M.S; 2016. Head Trauma in Handbook of Neurosurgery. Chapter 27. Sevent Edition. Thieme.
USA. Page 850-919
• Schmidek & Sweet. 2013. Trauma in Operative Neurosurgical Tehnique. Indication,Methods and Result.
Section Seven. Vol 2. Elsiever Sounder USA.
• Reilly P, Selladurai B, 2007, Initial Management of Head Injury a Comprehensive Guide, McGraw Hill
Australia, 177-205
• Bullock, M.R; et al. 2011. Trauma in Youman Nerological Surgery. Vol 4. Sixth edition. Elsiever Sounder USA
• Brain Trauma Foundation Guideline. 2006.
• Gerber, L.M. et al. 2013. Marked reduction in mortality in patients with severe traumatic brain injury. J
Neurosurg 119:1583–1590
• Dinsmore, J. 2013. Traumatic brain injury: an evidence-based review of management. Continuing Education
in Anaesthesia, Critical Care & Pain. Page 1-7. the British Journal of Anaesthesia.
• Rohadi, Alfauzi, A. 2012. Surgical Outcome of Traumatic Epidural Hematoma. MABI. Bali.
• Rohadi, Saderi, A.T, Harahap, H.S. 2009. Pola Cedera Kepala di Kota Mataram. Lemlit Unram.
• Rohadi, et al. 2018. Management of Neurosurgery Cases in Lombok Island earthquake. The 5 th WFNS Spine
Committee Biennial Conference. Nusa Dua Bali.
• Rohadi, Et al. 2019. Early tracheostomy in patient with severe traumatic brain injury clinical experiences in
rural and remote areas. International Journal of Research in Medical Sciences. 2019 Jan;7(1):58-62
• Rohadi. Et al. 2019. Toward zero mortality in acute epidural hematoma: A review in 268 cases problems and
challenges in the developing country . Interdisciplinary Neurosurgery 17 (2019) 12
Daftar Pustaka

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THANK YOU