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• SUDIHARTO

• NEUROSURGERY DIVISION• SURGERY DEPARTMENT

BRAIN INJURY

INTRUCTIONAL OBJECTIVE• Departement of Neurosurgery• Lecturer : DR. dr. P. Sudiharto• Topic of Lecture :I. Head injury

1. Mechanism of head injury2. Pathophysiology of head injury

a. Primary brain injury b. Secondary brain injury

3. Diagnosisa. History, physical and neurological examinationb. Laboratory tests c. Imaging studies

4. Principles of head injury managementa. Initial managementb. Early management of increased intracranial

pressurec. Surgical management

INTRUCTIONAL OBJECTIVE• Departement of Neurosurgery• Lecturer : DR. dr. P. Sudiharto• Topic of Lecture :I. Head injury

1. Mechanism of head injury2. Pathophysiology of head injury

a. Primary brain injury b. Secondary brain injury

3. Diagnosisa. History, physical and neurological examinationb. Laboratory tests c. Imaging studies

4. Principles of head injury managementa. Initial managementb. Early management of increased intracranial

pressurec. Surgical management

Head injury is defined an injury to any part of the head (e,g, face, skull)Brain injury denotes damage to the brain. That head and brain injuries can occur in combination (Ruff, R, 2005)Craniocerebral injury can involve scalp. Skull or brain in any combination (Pitts & Nockels, 1994)

DEFINITION

Mechanism of Head Injury• Skull molding occurs at site of impact

• A : pre injury contour

• B : subdural veins (bridging vein) torn as brain rotates forward

• C : contour after impact with inbending at point A and outbending at vertex

• D : direct trauma to inferior temporal and frontal lobes

• S : shearing strains throughout brain

MECHANISTIC CAUSES OF HEAD INJURIES

Head injuries are due to one of two basic mechanisms, contact or acceleration injuries

PROCESSES AND FACTORS LEADING TO SECONDARY BRAIN INJURY

• Mass lesion, brain shift and herniation- Intracranial hematoma (EDH, SDH,ICH)Focal brain Swelling, edema

• Cerebral ischemia- Reduced cerebral perfusion pressure- Hypotension- Intracranial hypertension- Cerebral vasospasm- Hypoxaemia- Seizures- Hyperthermia- Infection

PRIMARY HEAD INJURY(Gennarelli, TA, 1990)

Skull Fracture Focal Injuries Diffus Injuries- Linear - Contusions - Concussion- Depressed * Coup * mild- Basilar * Centre – coup * classic

* Intermediate - Diffus axonal injury- Hematomas * Mild

* Extradural/epidural * Moderate* Subdural * severe* Intracerebral

DIAGNOSIS OF BRAIN INJURY IS BASED UPON :

A. HISTORYB. PHYSICAL EXAMINATIONC. NEUROLOGIC EXAMINATIOND. LABORATORY TESTSE. IMAGING STUDIES

The clinical history is a most important factor in head injury and should include :

• The cause of the injury• Severity of the blow• The time, place and details of the accident• The presence of early neurologic abnormalities

(weakness, speech deorder, seizures, loss of consciousness)

• The past medical history (diabetes, hypertension)• A history of alcohol or any drugs consume

A. HISTORY

B. PHYSICAL EXAMINATION

• Initial examination should be rapid and systematic• Attention must be directed to assesment of other mayor

injuries (spinal, chest, abdominalm extremities)• Inspect and feel the entire scalp• Note any injuries to the aye• Inspect the face for evidence of maxillary and mandibular

fractures• Basal skull fractures maybe recognized by the presence of :

- fresh bleeding from an ear- cerebrospinal fluid otorrhea or rinorrhea- bilateral ecchymoses confined to the orbits

C. INITIAL NEUROLOGIC EXAMINATION

Glasgow Coma Score- eye opening- motor response- verbal responsePupillary size and response to light, and symmetryEye movementMotor power, symmetry of limb movementGross sensory examinationReflex activityCranial nerve deficit

D. LABORATORY TESTS

• Complete blood count• Blood urea nitrogen, creatinin• Blood sugar• Blood gas analysis• urinalysis

E. IMAGING STUDIES

• Skull X-rays• Computerized tomography scan

(CT Scan)• Magnetic Resonance Imaging

(MRI)

TATALAKSANA

AAIRWAY & C-SPINE CONTROL

BBREATHING

CCIRCULATION

PRIMARY

SURVEY

KONSEPNYARESPONSIBILITAS TERPENTING

MANAJEMEN ABC : CEGAHHIPOVENTILASI DAN HIPOVOLEMIA

POTENSIAL TERJADINYASECONDARY BRAIN DAMAGE

SCALP

SKULL

MENINGES

BRAIN

LCS

TENTORIUM

GCS

ICP

MENINGESTiga lapis : duramater, arachnoid, piamater

Arteri Meningea Media, potensial terlibat pada kasus EDH

CAIRAN SEREBROSPINAL

Diproduksi oleh pleksus koroideusRata-rata 30 ml per jamBersirkulasi

TENTORIUMMembagi 2 ruangan intrakranialSupratentorial dan Infratentorial

CEREBRAL PERFUSION PRESSURE ( CPP )

Merupakan PRIORITAS UTAMA

Rumus : CPP = Mean Arterial Pressure - ICP

CEREBRAL BLOOD FLOW ( CBF )

Normal : 50 ml/100 gram otak/ menitBila mencapai 5 ml/ menit :

cell death & irreversible damage

TEKANAN INTRAKRANIAL

Normal : 10 mmHg ( 136 mm air )Makin tinggi TIK makin jelek prognosis

HUKUM MONRO-KELLIE

Prinsip : total volume intrakranial bersifat TETAP,Oleh karena kranium merupakan NON EXPANSILE BOX

Vk = V darah + V likwor + V parenkim

60

50

40

30

20

10

0

Fatal

DisfungsiOtak

Obati

Normal

mmHg

Volume Intrakranial

100

50

TekananIntrakranial

Monro Kellie

KOMPONEN MATA

KOMPONEN MOTORIK

KOMPONEN VERBAL

Fraktur Impresi

CT scan Impresi Fraktur

TINDAKAN OPERATIF FRAKTUR DEPPRESI

BASILAR SKULL FRACTURES

Epidural

EPIDURALHEMATOM

PERJALANAN KLINIK EDH

ACUTE EPIDURAL HEMATOMA

Subdural hematom

Intraserebralhematom

Pre operasi Pasca Operasi

KorpusAlienum

FUNGSI OTAK• Sisi dominan untuk yang tidak kidal adl yg

sebelah kiri

• Orang kidal, 75 % sisi dominan adalah kiri

• Fungsi sisi dominan adalah untuk bahasa

dan memori yang berdasarkan bahasa

• Sisi kanan untuk memori visual

LOBUS FRONTALIS

1. PRE-SENTRAL GIRUS

Pusat motorik untuk muka, tangan, kaki, badan, dsb.

2. AREA BROCA

Pada sisi dominan adalah pusat bicara ekspresif motorik

3. AREA MOTOR TAMBAHAN

Untuk gerakan mata dan kepala sisi yang berlawanan

4. AREA PRE-FRONTAL

Untuk inisiatif dan personalitas

5. PARASENTRAL LOBUS

Pusat penahan BAK dan BAB