Trauma kapitis

Dr. Luhu A. Tapiheru

Fakultas Kedokteran Universitas
Muhammadiyah Sumatera Utara

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

Klasifikasi
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

Pemeriksaan neurologis
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
1 Year

Score

0-1 Year

Spontaneously

Spontaneously

To verbal command

To shout

To pain

To pain

No response

No response
Best Motor Response
1 Year

Score

0-1 Year

Obeys command

Localizes pain

Localizes pain

Flexion withdrawal

Flexion withdrawal

Flexion abnormal (decorticate)

Flexion abnormal
(decorticate)

Extension (decerebrate)

Extension (decerebrate)

No response

No response
Best Verbal Response

Score

>5 Years

2-5 Years

0-2 Years

Oriented and converses

Appropriate words

Cries appropriately

Disoriented and
converses

Inappropriate words

Cries

Inappropriate words;
cries

Screams

Inappropriate
crying/screaming

Incomprehensible
sounds

Grunts

Grunts

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

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

Klasifikasi berdasarkan SKG di triase

Kategori

SKG Gambaran Klinik

CT Sken otak

minimal

15

Normal

Ringan

13- Pingsan < 10 men,

15
defisit neurologik (-)

Normal

Sedang

9-12 Pingsan >10 men s/d 6

jam
Defisit neurologik (+)

Abnormal

Berat

3-8

abnormal

Pingsan (-),defisit
neurologi(-)

Pingsan>6 jam, defisit

neurologik (+)

Catatan: Jika abnormalitas CT Sken berupa perdarahan intrakranial,

penderita dimasukkan klasifikasi trauma kapitis berat

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 Hematoma

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

Subdural hematom

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%(+)

Foto Rontgen

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

Oedema serebri

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

Obat anti oedema

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 (subdural hematoma)

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 PENDERITA

TRAUMA KRANIOSEREBRAL

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.

Low-level responsive states

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
Jose Leon-Carrion et al. Brain Injury Treatment.2006

Low-level responsive states

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.20

PARAMETER OF POOR PROGNOSIS IN PATIENTS IN PROLONGED STATE OF

COMA
Brain Injury Treatment,
2006

CHARACTERISTIC

without
with recovery recovery

significance

SIGN OF
HYPOTHALAMIC
Fever

30%

57%

p<0.03

perspiration diffuse

16%

54%

p<0.005

8%

92%

Decerebrate

49%

51%

Decorticate

73%

30%

MOTOR REACTIVITY
No answer

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)

Duration of PTA
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

Neurobehavioural symptoms
post TBI
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

Terimakasih