Trauma kapitis

Prof.DR.Dr.Hasan Sjahrir SpS(K)

Departemen Neurologi FK USU
definisi
Trauma kapitis : adalah trauma mekanik
terhadap kepala baik secara langsung
ataupun tidak langsung yang
menyebabkan gangguan fungsi neurologis
yaitu gangguan fisik, kognitif, fungsi
psikososial baik temporer maupun
permanen.

Sinonim: cedera kepala= head injury
=trauma kranioserebral=traumatic brain
injury
75% KLL
epidemiology
Incidence head trauma
350 per 100.000 in Europe, 200 per
100.000 in North America,
US hospitalization rates due to traumatic
brain injury (TBI) are on the rise,
85% mild head injury,
15% moderate - severe Head injury
Severe head injury intracranial
haemorrhagic lesion 10-27%
Less than 2% require neurosurgery
1.Baandrup L & Jensen R. Cephalalgia 2005; 25:132138.
2.National Institute of Health Traumatic Coma Data Bank
3.Ropper AH, Gorson KC. N Engl J Med 2007;356:166-72
4.Thomas & Kegler. Morb Mortal Wkly Rep. 2007;56:167-170
Berat ringan cedera otak tgt:
Besar & kekuatan benturan
Arah & tempat
Posisi/keadaan kepala

Lesi yang terjadi:
Lesi bentur(coup)
Lesi media/antara
Lesi kontra(counter coup)
Akibat lesi bentur thd otak
Blockade ARAS
Retensi cairan & elektrolit
TIK meninggi
Perdarahan
Kerusakan otak primer
Kerusakan otak sekunder
Pemeriksaan neurologis
Monitor batang otak
Besar & reaksi pupil, refleks kornea
Dolls eye phenomen
Monitor pernafasan
Cheyne stokes lesi hemisfer
Centr neuro hyperventilation lesi mesensefalon-pons
Apneustic breathing : lesi pons
Ataxic breathing lesi medula oblongata
Monitor fungsi motorik
Brills hematon, likuorrhea,battles sign
Funduskopi
Radiologi
EEG
TBI (Traumatic Brain Injury)
Closed head injury
Primary injury
Concussion
Contusion
Hematoma epidural, subdural, intraventricular,
subarachnoid
Secondary
Hypotension, hypoxia, acidosis, edema, ischaemia or
other subsequent factors that can secondary damage
brain tissue
Penetrating head injury
Eye Opening
Score 1 Year 0-1 Year
4 Spontaneously Spontaneously
3 To verbal command To shout
2 To pain To pain
1 No response No response
Best Motor Response
Score 1 Year 0-1 Year
6 Obeys command
5 Localizes pain Localizes pain
4 Flexion withdrawal Flexion withdrawal
3 Flexion abnormal (decorticate)
Flexion abnormal
(decorticate)
2 Extension (decerebrate) Extension (decerebrate)
1 No response No response
Best Verbal Response
Score >5 Years 2-5 Years 0-2 Years
5 Oriented and converses Appropriate words Cries appropriately
4
Disoriented and
converses
Inappropriate words Cries
3
Inappropriate words;
cries
Screams
Inappropriate
crying/screaming
2
Incomprehensible
sounds
Grunts Grunts
1 No response No response No response
Normal Skor
pada anak:
< 6 bulan : 12
6-12 bulan : 12
1-2 thn : 13
2-5 thn : 14
> 5 thn : 14
Normal skor
Dewasa
4+5+6=15
klasifikasi
TK non Operatif
Komosio cerebri
Kontusio c
Impresio fraktur non neurologik (< 1 cm)
Fraktur basis kranii
Fraktur kranii tertutup
TK operatif
Hematoma intrakranial > 75 cc
Epidural, subdural, intraserebral/serebellar
Fraktur kranii terbuka ( + laserasio)
Impresi frk dengan kelainan neurologik (> 1 cm)
Likuorrhoe yang tidak berhenti


Klasifikasi trauma kapitis
berdasarkan WHO: (......ICD)
Patologi:
Komosio serebri
Kontusio serebri
Laserasio serebri
Lokasi lesi
Lesi diffus
Lesi kerusakan vaskuler otak
Lesi fokal
Kontusio dan laserasi serebri
Hematoma intrakranial
hematoma ekstradural(hematoma epidural)
hematoma subdural
hematoma intraparenkhimal
hematoma subarakhnoid
hematoma intraserebral
hematoma intraserebellar
Kategori SKG Gambaran Klinik CT Sken otak
minimal 15 Pingsan (-),defisit
neurologi(-)
Normal
Ringan 13-
15
Pingsan < 10 men,
defisit neurologik (-)
Normal
Sedang 9-12 Pingsan >10 men s/d 6
jam
Defisit neurologik (+)
Abnormal
Berat 3-8 Pingsan>6 jam, defisit
neurologik (+)
abnormal
Catatan: Jika abnormalitas CT Sken berupa perdarahan intrakranial,
penderita dimasukkan klasifikasi trauma kapitis berat

Klasifikasi berdasarkan SKG di triase
Diagnostik :
Trauma kapitis ringan(TKR) Mild Head injury:
SKG 13-15,
CT Sken normal,
pingsan < 30 menit,
tidak ada lesi operatif,
rawat Rumah sakit < 48 jam,
amnesia pasca trauma (APT) < 1 jam
TKS=Moderate Head Injury
SKG 9-12 dan dirawat > 48 jam,
atau SKG > 12 akan tetapi ada lesi operatif intrakranial
atau abnormal CT Sken,
pingsan >30 menit- 24 jam, APT 1-24 jam
TKB=Severe Head injury:
SKG < 9 yang menetap dalam 48 jam sesudah trauma,
pingsan > 24 jam, APT > 7 hari.
Komosio serebri (80%)
Definisi: disfungsi neuron otak sementara,
makroskopis normal
Gejala:
Pening/sakit kepala
Tidak sadar < 30 menit
Amnesia retrograde (AR) ,Amnesia anterograde (PTA)
Mual muntah

Pasien harus opname minimal 48 jam
Kontusio serebri (15-19%)
Definisi: perdarahan interstitiil parenchym
otak,tanpa putusnya kontinuinitas jaringan.
=/= laserasio serebri
Gejala gangguan neurologi fokal (+/-)
Gejala
Tidak sadar > 30 menit
FASE I :Fase shock
FASE II : FAse hiperaktif sentral
FASE III : serebral oedem
FASE IV: fase regenerasi/rekovalesens

Kontusi serebri pada anak2
Fase latent
Fase akut serebral (II)
Fase regenerasi
Epidural hematom
Def : antara tabula interna- duramater
Lucid interval pendek
Jarang pada anak2
Hematom massif:
Arteri meningea media
Sinus venosus
Dx: Brain ct scan
X foto polos
Gejala epidural H

Lucid interval (+) pendek :
yaitu periode sadar diantara 2 fase penurunan
kesadaran
Kesadaran makin menurun
Hemiparese terlambat
Pupil anisokor
Babinsky (+)
Fraktur menyilang di temporal
Kejang
bradikardi
Gejala EDH fossa posterior
Lucid interval tidak jelas
Fraktur krainii oksipital
Kehilangan kesadaran cepat
Gangguan serebellum, batang otak,
pernafasan
Pupil isokor
Prognosa jelek
Subdural hematom
Def : duramater arakhnoid
=/= hygroma subdural
Hematom:
Bridging vein robek
Kausa: Tr.Kapitis, keheksi, ggan darah
Lokasi frontal ,parietal, temporal
Gejala/klasifikasi
Akut : Lucid interval 0-5 hari
Subakut : 5-15 hari
Kronik : 15 hari - tahun
Intraserebral hematom
Dwf: pecahnya arteri
intraserebral/serebellar
Mono- multiple
Fraktur basis kranii
Anterior
Media
Posterior
Diagnosa tgt gejala ,sebab x
foto hanya 50%(+)
X foto
X foto tengkorak 30% , fraktur
(+)
3-5% kelainan intrakranial
kepentingan:
Kematian 80% fraktur (+)
Medikolegal
kepentingan pengawasan klinik
Penanggulangan trauma
kapitis akut
Atasi shock
Air way
Evaluasi kesadaran
Amati jejas kepala & tubuh
Awas fraktur servikalis
Klinik neurologi & X ray
Atasi oedema serebri
Keseimbangan cairan & elektrolit, kalori
Monitor tek intra kranial
Pengobatan konservatif
Refer bedah satraf atas dasar indikasi
Def: peninggian cairan intra/ekstra sel
otak o.k. proses lokal atau umum
Jenis
Vasogenik
Sitotoksik
Osmotik
hidrostatik
VASO SITO OSMO HIDRO
pato BBB sod pump osmotik gga LCS
lokalisasi subs alba alb+grisea alb+grisea alba
permeable meninggi normal normal normal
histologis ekstrasel intra eks+intra ekstrasel
unsur plasma plasma air air+Na
Vasogenik : Tr kapitis, stroke,
meningitis, ensefalitis, SOL, hipertensi
malignan, konvulsi
Sitotoksik: asfiksia, cardiac arrent, zat
toksik
Osmotik: water intoxication, hemodialisis
Hidrostatik: hidrosefalus
Hipertonik sol: manitol ,gliserol
Kortikosteroid
Barbiturat
Hipothermi
Hiperventilasi artifisiil
INDIKASI OPERASI PENDERITA
TRAUMA KRANIOSEREBRAL
EDH (epidural hematoma) ;
> 40 cc dengan midline shifting pada daerah
temporal / frontal / parietal dengan fungsi
batang otak masih baik.
> 30 cc pada daerah fossa posterior dengan
tanda-tanda penekanan batang otak atau
hidrosefalus dengan fungsi batang otak masih
baik.
EDH progresif.
EDH tipis dengan penurunan kesadaran bukan
indikasi operasi.
SDH luas (> 40 cc / > 5 mm) dengan
GCS > 6, fungsi batang otak masih
baik.
SDH tipis dengan penurunan
kesadaran bukan indikasi operasi.
SDH dengan edema serebri / kontusio
serebri disertai midline shifting dengan
fungsi batang otak masih baik.
Indikasi operasi ICH pasca trauma sama
seperti stroke hemoragis.
Fraktur impresi melebihi 1 (satu) diploe.
Fraktur kranii dengan laserasi serebri.
Fraktur kranii terbuka (pencegahan infeksi
intra-kranial).
Edema serebri berat (disertai tanda
peningkatan TIK) ------ pertimbangan
dekompresi.
INDIKASI OPERASI PENDERITA
TRAUMA KRANIOSEREBRAL
Coma acute brain functioning failurebrain stem and/or
cerebral hemisphere lesion
Persistent vegetative state ( coma vigile)eye are
open(respons to sounds) but not respond to any kind of
stimulation(total lack of cognitive function)=apallic state
absence of neocortical functions
Locked-in syndrome (LIS)quadriplegia, lateral gaze
palsy, paralytic mutism, fully conscious and aware of
environment ventral of pons lesion
Minimally responsive state
Akinetic mutismlack of movement (not completely
paralyzed) & speech, can eye open lesion frontal basal
and posterior region of mid brain
Jose Leon-Carrion et al. Brain Injury Treatment.2006
PARAMETER OF POOR PROGNOSIS IN PATIENTS IN PROLONGED STATE
OF COMA
Brain Injury Treatment,
2006
CHARACTERISTIC
with
recovery
without
recovery significance
SIGN OF
HYPOTHALAMIC
Fever 30% 57% p<0.03
perspiration diffuse 16% 54% p<0.005
MOTOR REACTIVITY
No answer 8% 92%
Decerebrate 49% 51%
Decorticate 73% 30%
5 factors that correlated
with poor outcome
Age older than 60 years
Initial GCS score of less than 5
Fixed dilated pupil
Prlonged hypotension or hypoxia
Presence of surgical intracranial mass
lesion
The traumatic coma data bank
The temporal lobes & frontal
lobe are commonly injury



Physiologic disruption of hippocampal
function



Disturbing memory storage and retrieval



Post Traumatic Amnesia (PTA)
(Retrograde and Anterograde Amnesia)





the duration of PTA is related to the
degree of residual memory deficit ,
disability and a higher probability of
personality change after TBI





Amnesia from Head Injury
British boxer Nigel Benn lands a punch to the head of American boxer Gerald
McClellan during a 1995 fight in London.
McClellan suffered severe brain damage in the fight that left him blind and that
impaired his ability to form new memories and access long-term memories.

Neuro behavioural
problems of TBI
Behavioral and emotional problems
cognitive impairmentcontribute more to
persistent disability than do physical
impairment sequelae in 72% of patients
surviving head trauma

Kewman DG, Siegerman C,et al,1985
Brooks N,McKinlay W et al.Brain Inj 1987

Neurobehavioural
symptoms post TBI
Poor sleep patern
Poor drive and motivation
Tiredness
Socially withdrawn
Headache
Impulsive
Aggressive
Anxiety
depression
Aggressive behaviour is a frequent
sequela of TBI
A 70% incidence of postraumatic
irritability of which 20% was defined
as violent behaviour
patient who display aggresion
postraumatic exhibit significantly
more verbal & executive deficits.
Wood RL,Liossi C. J.Neuropsychiatry Clin Neurosci 2006;18:333-341
The locus of TBI is the key
predicator of behavioral
problems
Frontal lobe : changes in emotional control,
initiation, motivation, inhibition
Temporal lobe:agression, memory loss,
aphasia
Limbic system:distorts emotion, difficulty
perception/organization
Parietal lobe : apraxia, neglect, agnosia
Occipital lobe : acalculia, agnosia, alexia