REVIEW OF HEAD INJURY

PATHOPHYSIOLOGY AND STRUCTURAL DAMAGES

Prof.Dr. Abdul Gofar Sastrodiningrat,SpBS(K)

Ketua Program Studi Pendidikan Dokter Spesialis Bedah Saraf
Fakultas Kedokteran Universitas Sumatera Utara

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

 DEFINISI :
Cedera Kepala adalah suatu trauma
pada kepala yang dapat menimbulkan
gangguan struktural kepala dan atau
gangguan fungsional jaringan otak

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

 PATHOPHYSIOLOGY

CONTACT INJURY
Epidural Hemorrhag
 Laserasi / avulsi scalp
 Fraktur tulang tengkorak
 Epidural hematoma

CONTACT INJURY

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

 PATOFISIOLOGI
INERTIAL INJURY

 1. Akselerasi
2. Deselerasi
 Akselerasi – deselerasi :
1. membentuk sudut dalam bidang
datar : Rotasi
2. membentuk sudut dalam ruang :
Angulasi
 Bentuk lesi : Primary Brain Damage
1. Cerebral contusion
2. Cerebral laceration INERTIAL INJURY
3. Diffuse Axonal Injury

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

 PATOFISIOLOGI
INERTIAL INJURY CONTACT INJURY

FRACTURES EDH
1. Acceleration Injury PRIMARY BRAIN DAMAGE SDH
2. Deceleration Injury 1. Cerebral laceration
2. Cerebral contusion ICH
Rotation / Angular 3. Diffuse Axonal Injury IVH

SAH
1. Systemic Insult
2. Intracranial Insult

APOPTOSIS SECONDARY BRAIN

DAMAGE
Programmed cell death
Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012
 INTRACRANIAL INSULT

 CEREBRAL EDEMA  INCREASED ICP

Kerusakan jaringan otak traumatik
 SEIZURES
kerusakan Blood-brain barrier
Vasogenic edema.  INFECTION

Ggn CBF  kegagalan cellular

energy metabolism  kerusakan
pompa Na-K  Ca influx 
Citotoxic edema

Cerebral edema  peningkatan ICP

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

  SYSTEMIC INSULT

 HYPOXIA  HYPERTHERMIA  39⁰C

Airway obstruction  Hypoxia (peningkatam excitotoxic
( PO2 < 60 mmHg) neurotransmitter  merubah
 HYPOTENSION (sist < 90 mmHg) aktivitas protein kinase C) 
 CPP turun  Ischemia ischemic brain damage
(keadaan akan menjadi lebih buruk bila ada
: peningkatan ICP, ggn AUTOREGULASI,  HYPERGLYCEMIA
VASOSPAME, perubahan CBF  HYPOGLYCEMIA
 HYPERCAPNIA (PCO2> normal)  ANEMIA
 vasodilatasi cerebral  peningkatan ICP.
 ELECTROLYTE IMBALANCE
 HYPOCAPNIA (PCO2< 24 mmHg) 
vasokonstriksi  penurunan CBV 
penurunan CBF

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

 PATHOPHYSIOLOGY
Reaksi extracranial

PRIMARY BRAIN DAMAGE

1. Cerebral laceration
2. Cerebral contusion
3. Diffuse Axonal Injury
SECONDARY BRAIN
1. Systemic Insult
DAMAGE
2. Intracranial Insult proses biomolekular abnormal

Reaksi intracranial

PRO ANTI
APOPTOSIS APOPTOSIS

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

 ...within 1 one our after TBI

Pro APOPTOSIS Anti APOPTOSIS

 CASPASE FAMILIES  IAP (Inhibitor of Apoptosis) FAMILIES

cysteine-aspartic acid protease
(caspase) family (Bcl2 – Family)

Caspase 1 and Caspase 3 Bcl2 inhibits caspase activity

producing cell death with
morphological features of apoptosis either by preventing the release
of cytochrome c from the
mitochondria and/or by binding
 It is the predominant caspase involved in to the apoptosis-activating
the cleavage of amyloid-beta 4A
precursor protein, which is associated factor (APAF-1).
with neuronal death in Alzheimer's
disease
Bcl2 bekerja pada mitochondria

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

CASPASE 3 BCL2

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

Clark RS, Kochanek PM, Chen M, Watkins SC, Marion DW, Chen J, Hamilton RL, Loeffert JE,
Graham SH.
Source
Departments of Anesthesiology and Critical Care Medicine, Safar Center for Resuscitation
Reseach, Pittsburgh, PA 15260, USA. clark@smtp.anes.upmc.edu

 The bcl-2 and caspase families are important regulators of programmed

cell death in experimental models of ischemic, excitotoxic, and
traumatic brain injury.
 The Bcl-2 family members Bcl-2 and Bcl-xL suppress programmed cell
death, whereas Bax promotes programmed cell death.
 Activated caspase-1 (interleukin-1beta converting enzyme) and caspase-3
(Yama/Apopain/Cpp32) cleave proteins that are important in maintaining
cytoskeletal integrity and DNA repair, and activate deoxyribonucleases,
producing cell death with morphological features of apoptosis

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

Target Terapi Cedera Kepala

 TERAPI DASAR
Ditujukan terhadap Primary Brain Damage , Systemic Insults dan
Intracranial Insults
1. Mengatasi cerebral edema dan mengatasi
peningkatan tekanan intrakranial :
a. Larutan hipertonis : Mannitol 20% , Totilac®
b. Tindakan hiperventilasi terbatas
c. Tindakan operasi
2. Mengatasi hipoksia :
a. Saluran pernafasan yang ‘patent’
b. Perawatan dibawah ventilator
c . MAP yang normal
3. Mencegah terjadinya infeksi

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

 TERAPI terhadap SECONDARY BRAIN
DAMAGE :
Bertujuan mengantisipasi proses biomolekular yang
mengarah ke apoptosis

1. Simvastatin (hydroxymethylglutaryl-coenzym A
reductase inhibitor) , inhibits posttraumatic brain
edema, reduces inflammatory cytokine release from
astrocytes after TBI
Cholestatat® 40 – 80 mg perhari oral

2. Glisodin (Gliadin dan SOD – superoxide dismutase)

antioxidant 1 – 3 kapsul perhari oral

3. Semax [Pro8-Gly9-Pro 10 ACTH (4-10)]

anti apoptosis nasal drops , 1 fls perhari

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

 STRUCTURAL DAMAGES

 SKULL FRACTURES

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

FRAKTUR KALVARIUM

 Tindakan kraniotomi elevasi

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

FRAKTUR BASIS KRANIUM
 ANATOMI :

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

 Fraktur Fossa Anterior
pada Atap Orbita

Raccoon’s eyes

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

 Fraktur Fossa Anterior
pada Lamina Cribrosa

1. Rhinorrhea
2. Hyposmia / Anosmia

Kemungkinan terjadi
CSF leakage

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

 FRAKTUR FOSSA MEDIA pada os
petrosum dan mastoid

1
1
2 2

1. Petrosum
2. Mastoid

1. Otorrhea (1)
2
2. Battle’s sign (2)

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

FRAKTUR FOSSA MEDIA
pada SELLA TURSICA

Traumatic Diabetes Insipidus

1. Polyuria > 3000 ml / 24

2. Serum Natrium tingg1

Terapi : Minirin nasal drops

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012
FRAKTUR FOSSA MEDIA
pada SELLA TURSICA

Anterior Pituitary Dysfunction

 Growth hormone
 Gonadotrophin
(LH/FSH)
 ACTH
 TSH

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

Fraktur Fossa Posterior

 Fraktur melintas Foramen Magnum,

menghancurkan Meulla Oblongata

 Sudden death

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

Traumatic Carotid Cavernous Fistula

1. Mata menonjol dan nyeri

2. Vessels congestion
3. Bruit

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

 TINDAKAN :
1. Balooning
2. Coilling
3. Stenting

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

INTRACRANIAL HEMORRHAGE

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

Epidural Hematoma
Hematoma dibawah tulang
tengkorak, diatas duramater
1. Lucid interval
2. Pupil anisokor
3. Refleks cahaya negatif pada pupil yang melebar
4. Refleks cahaya positif pada pupil kontralateral
5. Gambaran CT : hematoma hiperdens cembung
Tindakan : Craniotomy cito

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

OPTIC NERVE (II)

ags 27
Occulomotor (III), Trochlear (IV),
Abduscens (VI) nerves

ags 28
Reflex consensual

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

Subdural Hematoma Akut
Hematoma berasal dari : Hematoma terletak diantara
1. Burst Lobe permukaan otak – dibawah
2. Bridging veins duramater

1. Trauma Kapitis Sedang sampai Berat (GCS 3 – 12)

2. Gambaran CT : Hematoma hiperdens cekung, midline shift
Tindakan : Hemicraniectomy Dekompresi Cito

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

Subdural Hematoma Kronik
1. Riwayat Trauma Kapitis 2 – 3 minggu sebelumnya
2.Gejala neurologik samar : nyeri kepala, dysphasia,
kadang-kadang hemiparesis ringan
3. Gambaran CT : Gambaran hematoma hipodens cekung
4. Bukan berkembang dari Subdural Hematoam Akut

Tindakan : Twin-burr holes drainage

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

Intracerebral Hematoma
Perdarahan pada Basal Ganglia kanan dan Thalamus
kanan

TINDAKAN : Hemicraniectomy Dekompresi dan

Evakuasi Hematoma

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

Intraventricular Hematoma
Perdarahan Thalamus kiri dengan IVH ventrikel lateralis kiri
kanan dan ventrikel III

TINDAKAN :
Extraventricular drainage (EVD)

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

 FUNCTIONAL DAMAGES

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

 Penurunan kesadaran
Secara kwantitatif dicerminkan oleh GCS

 Kelumpuhan

 Gangguan fungsi luhur

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012
 TERIMA KASIH

Sastrodiningrat AG : Neurosurgery Lecture Notes, USU Press, Medan 2012