Cedera Kranio Serebral (Traumatic Brain Injury)

Oleh Dr. Amsar AT, SpS

SMF Neurologi RSUD Arifin Achmad Pekanbaru

SINONIM
trauma kapitis cedera kepala head injury trauma kranio serebral traumatic brain injury

Rhoads & Pflanzer (1996) Human Physiology p. 211

Liquor Cerebrospinal

Layers of the Cranial Vault

Anatomy of the Brain www.neurosurgery.org/pubpgages/patres/anatofbrain. html#micro

Cedera kranio serebral

trauma pada kepala, langsung / tidak langsung,

gangguan fungsi neurologis, fungsi fisik, kognitif, psikososial, temporer atau permanen.

Cedera yg terjadi
kulit kepala ; luka tulang tengkorak ; fraktur selaput otak ; robek pembuluh darah ; pecah jaringan otak ; rusak

Cedera kranio serebral

primary injury, secondary injury

Patofisiologi

Primary injury
at the moment of trauma :
skull fractures auditory/vestibular dysfunction intracranial hemorrhages contusion, concussions axonal injury disruption of the BBB cranial neuropathies

Skull fracture
vault fractures basilar fractures

Vault fractures
linear , extend into the sinuses.
closed, or open fractures. depressed or nondepressed a simple or a compound fracture

Depressed fractures

Penetrating injuries

Penetrating injuries

Basal skull fractures

by dissipated force

injuries to the cranial nerves

discharges from the ear, nose

FRAKTUR BASIS KRANII

1. ANTERIOR rhinorea, anosmia periorbital ecchymosis (raccoon eye) 2. MEDIA otorrhea, gangguan n.VII & VIII 3. POSTERIOR mastoid ecchymosis (Battles sign)

Auditory/vestibular dysfunction
Conductive hearing loss ;

tympanic perforation, hemotympanum, or ossicular disruption. Sensorineural hearing loss ; defect in the inner ear Benign paroxysmal positional vertigo

Intracranial hemorrhages
Epidural hematoma Subdural hematoma Intracerebral hemorrhages Intraventricular hemorrhage Subarachnoid hemorrhage

EPIDURAL HEMATOMA
Bleeding between skull and duramater Usually from an artery Bleeding is applies pressure to the brain Damage from pressure. Usually rapid onset of symptoms Lucid interval classic presentation Can complete recovery with no damage

Epidural hematoma

Epidural hematoma

Subdural hematoma and Intracerebral hemorrhage

direct bleeding into brain tissue almost always result in permanent brain damage. can be rapid or slow

Subdural hematoma

Subdural hematoma

Subdural hematoma

Intracerebral hemorrhages

Coup and contrecoup contusions

Coup contusions
occur at the area of direct impact

Contrecoup contusions
located opposite the site of direct impact

Coup and contrecoup contusion

Concussions
deformity of the deep structures, widespread neurologic dysfunction, impaired consciousness or coma,

a mild form of diffuse axonal injury.

Diffuse Axonal Injury

shaking or strong rotation of the head, tearing of nerve tissue throughout the brain extensive generalized damage to white matter disrupts the brains communication and chemical processes. temporary or permanent brain damage present a variety of functional impairments

Secondary injury
immediately, post primary injury
a period of hours or days

cell damage from primary injuries.

may continue for a long time result of cerebral ischaemia, edema , hypotension, acidosis, inflammatory and cytotoxic processes.

Cytotoxic and inflammatory processes

release of excitatory amino acids (e.g. glutamate), influx of excessive calcium injury mediated by oxygen-free radicals, accumulation of neutrophils, lymphocytes and macrophages, and the deposition of amyloid protein.

Cytotoxic and inflammatory processes

Increase in brain glucose metabolism initially Cerebral blood flow reduction Oxidative metabolism reduction (lactic acid build-up) Cerebral blood vessels unresponsive to energy demands disconnection of blood flow and glucose utilization uncoupling

Cerebral ischaemia
formation of brain oedema, microvascular pathology, focal compression cerebral vasospasm impairment of autoregulation. systemic hypoxaemia systemic arterial hypotension.

Brain oedema
as cytotoxic or vasogenic the breakdown of ATPase pumps. the disruption of the BBB brain hyperaemia. impairment of autoregulation

SOME of the SECONDARY EVENTS IN TRAUMATIC BRAIN INJURY

diffuse axonal injury apoptosis

inflammation
BBB disruption

necrosis edema formation

Brain trauma

ischemia

energy failure cytokines Calcium Eicosanoids endocannabinoids

Acetyl Choline

ROS

Polyamines

Monro-Kellie doctrine
the total intracranial volume is fixed. The intracranial volume (V i/c) is equal to the sum of its components :

V i/c = V (brain) + V (csf) + V (blood)

MONRO-KELLIE DOCTRINE

Vintracranial vault=Vbrain+Vblood +Vcsf

- cranial vault is fixed - noncompressible fluid - compressible brain tissue

TBI

edema and hemorrhage

TTIK

Increased intracranial pressure

cerebral hypoxia, cerebral ischemia, cerebral edema, hydrocephalus, brain herniation.

Elevations in ICP
decreased CPP decreased CBF severe elevations

herniation

cerebral ischemia

FATAL

Brain herniation
Supratentorial herniation
Subfalcine herniation Transtentorial herniation Uncal herniation

Cerebellar herniation

Brain herniation

Hydrocephalus
communicating type
more common, presence of blood products in the subarachnoid space

noncommunicating type
caused by blood clot obstruction at the

Type of TBI

Klasifikasi berdasar GCS

TBI
Minimal

GCS
15

Klinis
Pingsan (-), defisit neurologi(-) Pingsan < 10 mnt,

CT Scan
Normal

Ringan

13 15

defisit neurologik (-)

Normal

Pingsan >10 mnt s/d 6 jam

Sedang 9 12 Defisit neurologik (+) Abnormal

Berat

3-8

Pingsan > 6 jam, defisit neurologik (+)

Abnormal

HEMATOMA EPIDURAL antara tab. interna - duramater hematom massif akibat a.meningea media atau sinus venosus

GEJALA KLINIK
lucid interval (+), pendek kesadaran makin menurun late hemiparese
pupil anisokor

babinsky (+)
fraktur os temporal

Epidural Bleeding Fossa Posterior

- Lucid interval tidak jelas

- Fraktur kranii oksipital

- Kehilangan kesadaran cepat

- Gangguan serebellum
- Pupil isokor

CT Sken Epidural Bleeding

Gambaran ; hiperdens , bikonveks

Lokasi

; antara tulang - dura,

daerah temporal

HEMATOMA SUBDURAL
- duramater - arakhnoid - bridging vein robek

Jenis
1. AKUT : Lucid interval : 0 - 5 hari

2. SUBAKUT : Lucid interval : 5 bbrp minggu

3. KRONIK: Lucid interval

: > 3 bulan

Hematom Subdural Akut

sakit kepala kesadaran menurun + / CT Sken otak : - hiperdense - antara duramater - araknoid, - seperti bulan sabit robekan vena jembatan

Hematoma Intraserebral
perdarahan parenkhim otak

karena
pecah arteri intraserebral

mono atau multiple

PERDARAHAN SUBARAKHNOID
kaku kuduk

nyeri kepala gangguan kesadaran +/ CT Sken otak : perdarahan subaraknoid

FRAKTUR BASIS KRANII

1. ANTERIOR rhinorea, anosmia periorbital ecchymosis (raccoon eye), 2. MEDIA otorrhea, gangguan n.VII & VIII 3. POSTERIOR mastoid ecchymosis (Battles sign)

Diffuse Axonal Injury

shaking or strong rotation of the head, the unmoving brain behind the movement of the skull, tearing of nerve tissue throughout the brain disrupts the brains communication and chemical processes. temporary or permanent brain damage present a variety of functional impairments

Concussion
komosio, mild TBI goncangan otak physiologic injury tak ada kelainan struktur temporarily perbaikan ; jam - minggu

Concussion
Grade
Grade I Grade II

Symptom
confused temporarily, no memory changes brief disorientation, anterograde amnesia < 5

Grade III
Grade IV Grade V

brief disorientation, anterograde amnesia < 5 retrograde amnesia, loss of consciousness < 5,
brief disorientation, anterograde amnesia < 5 retrograde amnesia, loss of consciousness 5-10 brief disorientation, anterograde amnesia < 5 retrograde amnesia, loss of consciousness > 10

Post-concussive syndrome (PCS)

usually lasts 2-4 months. typically, the symptoms peak 4-6 weeks. on occasion, last for a year or longer. 20% will not have returned to full-time work 1 year some are disabled permanently. more severe in children permanent, multidisciplinary approach

Symptoms of PCS
Changes in ability to think, concentrate. Memory loss Headaches or blurry vision. Tinnitus, dizziness. Changes in sleep patterns, Changes in personality Lack of interest in usual activities. Changes in sex drive. Loss of sense of taste or smell. Vertigo, ataxia,

PENATALAKSANAAN

PENATALAKSANAAN
1. Survei Primer ;
menstabilkan kondisi pasien.

2. Survei Sekunder ;
pemeriksaan dan tindakan lanjutan

Survei Primer
A
B

=
=

Airway (Jalan Nafas).

Breathing (Pernafasan).

C
D

=
=

Circulation (Sirkulasi)
Pemeriksaan Umum dan Neurologi

A = Airway (Jalan Nafas)

Bebaskan jalan nafas ; periksa mulut, keluarkan darah,

gigi yang patah, muntahan, dsb.

Bila perlu intubasi ;

waspadai fraktur tulang leher

B = Breathing (Pernafasan)
Pastikan pernafasan adekuat. Perhatikan frekuensi, pola nafas, tipe nafas dan simetrisitas. Bila ada gangguan, cari penyebab, - sentral atau - perifer Bila perlu, berikan oksigen dg target saturasi O2 > 92%.

C = Circulation (Sirkulasi)
Pertahankan TD Sistolik > 90 mmHg.
Pasang sulur intravena. Berikan cairan iv ;

- NaCl 0,9% atau Ringer,

- hindari cairan hipotonis. Bila perlu ; - obat vasopresor dan / inotropik.

D = Pemeriksaan
Tanda Vital :
tekanan darah, nadi, nafas, suhu

Glasgow Coma Scale ( GCS ) Pupil :

ukuran, bentuk, reflek cahaya

Pemeriksaan neurologi

Survei Sekunder
E : Laboratorium
Darah Hb, Al, Trombosit, Ureum, Kreatinin, Gula darah, Analisa Gas Darah, Urine : perdarahan (+) / (-) Radiologi : - Ro kepala ; AP, Lat - CT sken kepala. - Foto lain :

Pemeriksaan

Pemeriksaan tanda vital Pemeriksaan luka, fraktur, dislokasi Otorrhea, Rhinorrhea PeriorbitalEcchymosis/RacoonEyes MastoidEcchymosis/BattlesSign

Pemeriksaan Tingkat Kesadaran

GCS ( Glasgow Coma Scale )

Glasgow Coma Scale ( GCS )

Eye Opening ( E )
Spontaneous To speech To painful stimulation No response Follows commands Localizing movements to pain 4 3 2 1 6 5 4 3 2 1

Motor response ( M )

Withdrawal movements to pain Flexor posturing to pain Extensor posturing to pain No response Oriented to person, place, date

5
4 3 2 1

Verbal response ( V )

Converses but is disoriented Says inappropriate words Says incomprehensible sounds No response

Jumlah

Pola pernafasan
Pola
Cheyne stoke CNH Apneustic breath Ataxic Hemisfer Mesencephalon - pons Pons Medulla oblongata

Lesi

Pemeriksaan Pupil
bentuk ukuran simetris reaksi

Pemeriksaan neurologi
1. Brainstem examination 2. Motor examination 3. Sensory examination 4. Reflex examination

Brainstem examination
pupillary examination ocular movement corneal reflex gag reflex

Pemeriksaan motorik
kekuatan otot lateralisasi tonus refleks tendon refleks patologis

Funduskopi
papil oedem

papil atrofi batas papil warna papil gambaran arteri

Gangguan otonom
miksi
defaekasi

ereksi
heart rate

hydrosis

Pemeriksaan Ro foto
- Ro foto kepala - Ro foto servikal - Ro foto lain

CT Sken Kepala
Gambaran Kontusio
Gambaran Edema Otak Gambaran Perdarahan Gambaran fraktur Midline shifting Hidrosefalus

F : Manajemen Terapi
1. Medikamentosa /simptomatis ; untuk perdarahan neuroprotektor untuk TTIK anti kejang penenang

2. Operasi

Terapi non operatif

mencegah ttik mengatasi edem otak minimalisasi kerusakan otak sekunder mengatasi gejala akibat cedera. mencegah komplikasi.

INDIKASI OPERASI

EDH (epidural hematoma)

> 40 cc dg midline shifting, temporal / frontal / parietal, fungsi batang otak baik.

> 30 cc pada fossa posterior, hidrosefalus, penekanan batang otak, fungsi batang otak baik.
perdarahan progresif

SDH (subdural hematoma)

SDH luas (> 40 cc / > 5 mm),
GCS > 6,

edema/kontusio serebri,
midline shifting, fungsi batang otak baik

Indikasi lain
Fraktur impresi > 1 diploe.
Fraktur kranii dg laserasi serebri. Fraktur kranii terbuka Edema serebri berat dg TTIK

MANAGEMEN
DI RUANG RAWAT

Kritikal
Rawat di Unit Intensif Neurologi

(Neurological ICU)

TBI Sedang dan Berat

1. Lanjutkan penanganan ABC 2. Pantau tanda vital, pupil, GCS, - tiap 4 jam - sampai GCS 15

Hindari !!!!
1. TD Sistolik < 90 mm Hg,
2. Suhu > 380Celcius,

3. Frek. nafas > 20 x / menit

Cegah TTIK
a. Posisi kepala 30 derajat.

b. Pemberian Manitol 20%. - dosis awal 1 gr / kg BB, guyur, - lanjutkan dg dosis - 0,5 gr / kg BB, guyur, (stlh 6 jam pemberian I), - 0,25 gr / kg BB, guyur, (stlh 12 jam pemberian I)

Komplikasi
kejang infeksi hidrosefalus stress ulcer demam

Terima kasih