kuliah brain injury unmuh

8/10/2019 Kuliah Brain Injury Unmuh

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Brain Injury

Dr. Krisna Murti SpBSDepartemen Bedah dan Anestesi

RST Soepraoen


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Curriculum Vitae

Nama : Krisna Murti , dr, Sp BSPangkat : Mayor CKM

Jabatan : - Ka Instal Kamar Bedah RST Soepraoen

- Konsultan Bedah saraf RS PantiNirmala dan RKZ

Tempat/ Tgl Lahir : Surakarta , 25 Juli 1970

Agama : Islam

Status : K2

Alamat : Perum Dokter RST Supraun Jl. S.

Supriyadi no. 22


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DIKUM : FK UNDIP 1996 ( Dokter umum)

FK UNPAD 2006 ( Spes Bedah Saraf)

National Neuroscience Institute Singapore 2003Nagoya University Japan, advance training 2006

Berbagai kursus dan seminar DN dan LN

DIKMIL : Sepamilsuk 1993

Sussarcab Kes 1998Sussar selam militer 1998

Selapa TNIAD 2008

Penugasan : Ops Timtim 1998 ,

Maluku 2000Contact : HP 081219040088

EM : [email protected]


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Welcome to Trauma!

First and ForemostABCs!

airway

breathing

circulation

disability

exposure


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Head Injuries:

Account for about one half of all trauma

deaths

Survivors range from baseline function to

severe morbidity

As with most trauma, broken down into

blunt and penetrating


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Anatomy for Head Injuries

Scalp may result in significant bleeding

Skull

well placed fractures place vessels and nerves at risk for injury

protective, but a rigid, fixed space

Dura

Falx separates hemispheres

Tentorium separates cerebrum

Brain

Direct (Primary)

Indirect (secondary)


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Direct (Primary) Brain Injuries

Direct damage done to brain parenchyma

Damage is already done

Irreversible

Damage control (debridement)


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Linear fracture
http://images.google.co.id/imgres?imgurl=http://www.netmedicine.com/xray/img_xr/skul10ax.jpg&imgrefurl=http://xraytamin.blogfa.com/8612.aspx&usg=__PlHU2xmRXdXz5cnNUaagnJdlkHU=&h=379&w=450&sz=14&hl=id&start=48&tbnid=gFoMuAjdeKb9mM:&tbnh=107&tbnw=127&prev=/images%3Fq%3Dlinear%2Bskull%2B%2Bfracture%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D40http://images.google.co.id/imgres?imgurl=http://www.medicalfinals.co.uk/joomla/images/stories/medical_finals/headct/skull-case7.jpg&imgrefurl=http://www.medicalfinals.co.uk/joomla/content/view/92/39/&usg=__PE3CFwVBlm9S5Mt4oG2iBZ8ie1I=&h=512&w=512&sz=12&hl=id&start=16&tbnid=4a25UaYvCUD2kM:&tbnh=131&tbnw=131&prev=/images%3Fq%3Dlinear%2Bskull%2B%2Bfracture%26gbv%3D2%26hl%3Did%26sa%3DGhttp://images.google.co.id/imgres?imgurl=http://radiographics.rsnajnls.org/content/vol23/issue4/images/large/g03jl18g18a.jpeg&imgrefurl=http://radiographics.rsnajnls.org/cgi/content-nw/full/23/4/811/F18A&usg=__F-uEfDleITJyFSl0B4ddC-kA2Gs=&h=1800&w=1789&sz=286&hl=id&start=10&tbnid=YtAe9NzRFjO3xM:&tbnh=150&tbnw=149&prev=/images%3Fq%3Dlinear%2Bfracture%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DGhttp://images.google.co.id/imgres?imgurl=http://medicalimages.allrefer.com/large/infant-skull-fracture.jpg&imgrefurl=http://health.allrefer.com/health/skull-fracture-infant-skull-fracture.html&usg=__murPA2CntLBvAd5Y3q9QTwozxFA=&h=320&w=400&sz=17&hl=id&start=3&tbnid=oTmZelzepsTDWM:&tbnh=99&tbnw=124&prev=/images%3Fq%3Dlinear%2Bfracture%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DG


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Depressed fracture
http://images.google.co.id/imgres?imgurl=http://img.medscape.com/pi/emed/ckb/neurosurgery/247017-248108-4158.jpg&imgrefurl=http://emedicine.medscape.com/article/248108-media&usg=__kHRntoRncEwF0FqSxU1YvUyhlF0=&h=1726&w=1485&sz=881&hl=id&start=82&tbnid=nxeyIFKySHY28M:&tbnh=150&tbnw=129&prev=/images%3Fq%3Ddepressed%2Bfracture%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D80http://images.google.co.id/imgres?imgurl=http://www.neurosurgery.com.sg/images/photos/neurotrauma/Skullfracture3D.jpg&imgrefurl=http://www.neurosurgery.com.sg/index.php%3Fid%3D69&usg=__ERuaztKapy84qBJsCsFMTrw6S_s=&h=512&w=512&sz=21&hl=id&start=70&tbnid=cLNBDvzj_vQyqM:&tbnh=131&tbnw=131&prev=/images%3Fq%3Ddepressed%2Bfracture%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D60http://images.google.co.id/imgres?imgurl=http://anatpat.unicamp.br/minDsc35118%2B.jpg&imgrefurl=http://anatpat.unicamp.br/eradtrauminis.html&usg=__zyxOpJT8lbfkrMFhJEYWYTagghk=&h=219&w=183&sz=12&hl=id&start=63&tbnid=0hQk5djh86TctM:&tbnh=107&tbnw=89&prev=/images%3Fq%3Ddepressed%2Bfracture%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D60http://images.google.co.id/imgres?imgurl=http://eforensicmed.googlepages.com/Depressed_skull_fracture.jpg/Depressed_skull_fracture-full.jpg&imgrefurl=http://eforensicmed.googlepages.com/bluntforcetrauma&usg=__tsjCxu_e8-Y4lToSLG4JEAw-0Mg=&h=797&w=1200&sz=77&hl=id&start=46&tbnid=G5G-dUkbuWNUnM:&tbnh=100&tbnw=150&prev=/images%3Fq%3Ddepressed%2Bfracture%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D40http://images.google.co.id/imgres?imgurl=http://forensicpathcareers.doodlekit.com/media/AA/AA/forensicpathcareers/images/76284/main/Depressed_Skull_Fracture.jpg&imgrefurl=http://forensicpathcareers.doodlekit.com/home&usg=__fsqF91XzXKjEBn6T89iEyLAlPVE=&h=337&w=450&sz=26&hl=id&start=22&tbnid=T7BJXyZ5PDsdrM:&tbnh=95&tbnw=127&prev=/images%3Fq%3Ddepressed%2Bfracture%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D20


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Indirect (Secondary) Brain Injury

Damage that occurs after the initial insult

Expanding mass lesions, swelling or

bleeding quickly overwhelm buffers

End result is increased intracranial pressure

(ICP) and/or herniation

Diagnosis and treatments target minimizing

the effects of these indirect insults


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Intracranial Pressure (ICP)

Intracranial space essentially full ofbrain, blood vessels, and a little CSF

In response to an insult, small amount

of CSF can be displaced, can decreaseblood volume, then increase ICP

At higher ICP, loss of autoregulationoccurs

Cerebral perfusion pressure = (MAP-ICP)

Ischemia and neuronal death


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Mechanism 1: Brain Contusion

A brain contusion is defined by celldeath accompanied by hemorrhage(leakage of blood)

The soft brain tissue is vulnerableto contusion in head trauma

The contusion often occurs at a sitedistant from the point of impact

Gross brain image from

http://neuropathology.neoucom.edu/chapter4/chapter4bContusions_dai_sbs.html#contusion


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ec an sm :- Understanding the Determinants of

Intracranial Pressure - The volume of the intracranial vault =

Intracranial Contents:

80% brain tissue 10% blood

10% cerebrospinal fluid

An increase in the volume of any of these intracranial

contents causes increased intracranial pressure

1. The brain can swell (edema)

2. Excess blood can accumulate due to hemorrhage

3. Cerebrospinal fluid can accumulate due to blockage ofoutflow


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Mechanism 2: ICP Key Concept #1: The intracranial vault is a

fixed volume --> Bone does not expand!

Skull image from www.mnsu.edu


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ec an sm :- Understanding the Physics of Intracranial

Pressure -

Volume (mL)

Pressure

(mmHg)

Intracranial Pressure Rises as Brain+Bood+CSFvolume Increases

ICP > 20 mmHg


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ec an sm :- Understanding the Physics of Intracranial

Pressure -

ICP

CPP

This patient has dangerously high intracranial pressures, which

increase the likelihood of morbidity and mortality


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Mechanism 2: ICP Key Concept #3:

When the brain issqueezed through the

foramen magnum(herniation), the

brainstem is compressed,the patient stops

breathing, and thepatient dies

Herniation schematic from Robbins and Cotran. Pathologic Basis of Disease. 7th ed. Philadelphia: Elselvier; 2005.


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Normal CT
http://images.google.co.id/imgres?imgurl=http://www.southernhealth.com.au/imaging/images/13.jpg&imgrefurl=http://www.southernhealth.com.au/imaging/ct_dh_preps.htm&usg=__JaUzPU7jopDrxzWpY5HbhM7q-pM=&h=483&w=485&sz=24&hl=id&start=3&tbnid=2QhXH8vWjFTIlM:&tbnh=128&tbnw=129&prev=/images%3Fq%3Dnormal%2Bbrain%2BCT%26gbv%3D2%26hl%3Did%26sa%3DGhttp://images.google.co.id/imgres?imgurl=http://neurosun.googlepages.com/headct.jpg/headct-full%3Bcrop:0.12,0.02,0.88,0.94.jpg&imgrefurl=http://neurosun.googlepages.com/normalctbrainfindings&usg=__3fzdhrsRfLHYNsoEhQkIdHmyEwk=&h=444&w=369&sz=35&hl=id&start=15&tbnid=x0PBOv5Mic1w-M:&tbnh=127&tbnw=106&prev=/images%3Fq%3Dnormal%2Bbrain%2BCT%26gbv%3D2%26hl%3Did%26sa%3DGhttp://images.google.co.id/imgres?imgurl=http://thebrain.mcgill.ca/flash/capsules/images/outil_bleu13_img03.jpg&imgrefurl=http://thebrain.mcgill.ca/flash/capsules/outil_bleu13.html&usg=__btDmJWJpzqO74NJ0ynQNH81QFMY=&h=213&w=200&sz=9&hl=id&start=10&tbnid=ETDc9YhrYjUmmM:&tbnh=106&tbnw=100&prev=/images%3Fq%3Dnormal%2Bbrain%2BCT%26gbv%3D2%26hl%3Did%26sa%3DG


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EDEMA
http://images.google.co.id/imgres?imgurl=http://bestpractice.bmj.com/best-practice/images/bp/688-3_default.jpg&imgrefurl=http://bestpractice.bmj.com/best-practice/monograph/688/resources/image/bp/2.html&usg=__dCvSE3ggciNO-yTUn6u2GP_dAUs=&h=433&w=416&sz=58&hl=id&start=5&tbnid=OK3PAquMv07ibM:&tbnh=126&tbnw=121&prev=/images%3Fq%3Dtraumatic%2B%2Bbrain%2Bedema%26gbv%3D2%26hl%3Did%26sa%3DGhttp://images.google.co.id/imgres?imgurl=http://download.imaging.consult.com/ic/images/S1933033208808749/gr14-midi.jpg&imgrefurl=http://imaging.consult.com/image/chapter/Brain%2520and%2520Spine%3Ftitle%3DVascular%2520Injury%2520and%2520Parenchymal%2520Changes%26image%3Dfig14%26locator%3Dgr14%26pii%3DS1933-0332(08)80874-9&usg=__gQnxDPrYge3kGeNM7sBqRo6QoYo=&h=200&w=173&sz=5&hl=id&start=10&tbnid=Vry757h7BNpQ-M:&tbnh=104&tbnw=90&prev=/images%3Fq%3Dtraumatic%2B%2Bbrain%2Bedema%26gbv%3D2%26hl%3Did%26sa%3DG


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Categories of Brain Injuries

Diffuse

Concussion (movement to TBI!)

Diffuse Axonal Injury Focal

Laceration (blunt) and penetrating

Contusions

Intracerebral hematomas

Epidural and subdural

Subarachnoid hemorrhage


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Diffuse Brain Injuries

Concussion

Mild traumatic brain injury

No significant imaging findingsDoes not mean no injury

Diffuse Axonal Injury

Severe injury globally caused by sheering ofaxons

Often neurologically devastated


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http://images.google.co.id/imgres?imgurl=http://www.learningradiology.com/caseofweek/caseoftheweekpix2008-2/cow315-1arr.jpg&imgrefurl=http://www.learningradiology.com/archives2008/COW%2520315-Diffuse%2520Axonal%2520Injury/daicorrect.htm&usg=__l47i9x1D8gCJ_ak5cSqacON7dYg=&h=522&w=400&sz=57&hl=id&start=98&tbnid=gCg1_WOail1dEM:&tbnh=131&tbnw=100&prev=/images%3Fq%3Ddiffuse%2Binjury%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D80http://images.google.co.id/imgres?imgurl=http://img.medscape.com/pi/emed/ckb/emergency_medicine/756148-810904-784.jpg&imgrefurl=http://emedicine.medscape.com/article/810904-overview&usg=__LawVYAt__XGDbX7dBodgSpxj2zE=&h=504&w=410&sz=29&hl=id&start=14&tbnid=9sjWJA-Yv9yRqM:&tbnh=130&tbnw=106&prev=/images%3Fq%3Ddiffuse%2Binjury%26gbv%3D2%26hl%3Did%26sa%3DG


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Mechanism : Diffuse Axonal Injury

A microscopic view of axonal degeneration


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Focal Brain Injuries

Penetrating injuries often intuitively

obvious

Contusions (including contrecoup)

Hematomas

Epidural

Subdural



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Contusions

Focal areas ofhemorrhage within the

parenchyma

Contrecoup injuriesoccur from awhiplash effect ofthe brain against theskull on the oppositeside of the initial pointof impact or injury


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Subarachnoid blood vessels ruptured

May be the most common finding on

moderate to severe brain injuries


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Penetrating Brain Injury (GSW)


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Epidural Hematoma

Blood between inner

table of the skull and the

dura

Usually a tear of the

MMA Lens shaped hematomas

that do not cross suture

lines on CT

Rare in elderly


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Epidural hematoma (EDH)
http://images.google.co.id/imgres?imgurl=http://www.med.mun.ca/anatomyts/radioanat/radiology/ken/epidural02.JPG&imgrefurl=http://www.med.mun.ca/anatomyts/radioanat/radiology/ken/bonk.htm&usg=__MRw-SmYsp6IJ53bUpZCpQVT5bI8=&h=421&w=360&sz=50&hl=id&start=1&tbnid=s3yLOTdWnVmTSM:&tbnh=125&tbnw=107&prev=/images%3Fq%3Depidural%2Bhematoma%26gbv%3D2%26hl%3Didhttp://images.google.co.id/imgres?imgurl=http://www.nebraskabraininjurylawyer.com/images/brainoverviews/hematomas/hematoma.subdural2.JPG&imgrefurl=http://www.nebraskabraininjurylawyer.com/how.html&usg=__gX6J29X21xpAVoaWEalxFLlO740=&h=272&w=300&sz=25&hl=id&start=172&tbnid=unIAWtcEWhU2OM:&tbnh=105&tbnw=116&prev=/images%3Fq%3Depidural%2Bhematoma%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D160http://images.google.co.id/imgres?imgurl=http://www.binglixue.com/image/images/cns/CNS020.jpg&imgrefurl=http://www.binglixue.com/image/cns/cns1.htm&usg=__Z3PP-eRh2bR6-kI7aBzAqU12Kmo=&h=330&w=504&sz=41&hl=id&start=60&tbnid=8eN-ERaMIlS6KM:&tbnh=85&tbnw=130&prev=/images%3Fq%3Depidural%2Bhematoma%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D40http://images.google.co.id/imgres?imgurl=http://www.uth.tmc.edu/radiology/test/er_primer/skull_brain/brct/b15.JPG&imgrefurl=http://www.uth.tmc.edu/radiology/test/er_primer/skull_brain/brct/brct15.html&usg=__AsAyqlV233gxodoF8UYm794Z8C4=&h=288&w=296&sz=20&hl=id&start=8&tbnid=ZmunD1Vn18RCxM:&tbnh=113&tbnw=116&prev=/images%3Fq%3Depidural%2Bhematoma%26gbv%3D2%26hl%3Didhttp://images.google.co.id/imgres?imgurl=http://www.med.mun.ca/anatomyts/radioanat/radiology/ken/epidural02.JPG&imgrefurl=http://www.med.mun.ca/anatomyts/radioanat/radiology/ken/bonk.htm&usg=__MRw-SmYsp6IJ53bUpZCpQVT5bI8=&h=421&w=360&sz=50&hl=id&start=1&tbnid=s3yLOTdWnVmTSM:&tbnh=125&tbnw=107&prev=/images%3Fq%3Depidural%2Bhematoma%26gbv%3D2%26hl%3Did


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Subdural Hematoma

Blood beneath the dura,

overlying the brain and

arachnoid, resulting from

tears to bridging vesselsCrescent shaped density that

may run length of skull

Very common in the elderly


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Subdural hematoma(SDH)

h i l f d j d
http://images.google.co.id/imgres?imgurl=http://wpcontent.answers.com/wikipedia/commons/thumb/3/38/Trauma_subdural_arrow.jpg/190px-Trauma_subdural_arrow.jpg&imgrefurl=http://www.answers.com/topic/subdural-hematoma&usg=__58WRTdd_lyTFsQ8WPj9tdZ8Qi3g=&h=232&w=190&sz=11&hl=id&start=91&tbnid=4m0Xz3PiuDA_cM:&tbnh=109&tbnw=89&prev=/images%3Fq%3Dsubdural%2Bhematoma%26gbv%3D2%26ndsp%3D20%26hl%3Did%26sa%3DN%26start%3D80http://images.google.co.id/imgres?imgurl=http://www.neurosurgery.com.sg/images/photos/neurotrauma/LtSDHpre2.jpg&imgrefurl=http://www.neurosurgery.com.sg/index.php%3Fid%3D72&usg=__V-uRrpZV6WUnVCvSnCkxXz3IcPc=&h=512&w=512&sz=32&hl=id&start=6&tbnid=o5gxLHlV1M0-LM:&tbnh=131&tbnw=131&prev=/images%3Fq%3Dsubdural%2Bhematoma%26gbv%3D2%26hl%3Did%26sa%3DGhttp://images.google.co.id/imgres?imgurl=http://brighamrad.harvard.edu/Cases/bwh/images/15/DR25Arrow74.GIF&imgrefurl=http://brighamrad.harvard.edu/Cases/bwh/hcache/15/full.html&usg=__ZjaGSxZDHI0RSOOE6UB69WPSfWk=&h=365&w=288&sz=90&hl=id&start=4&tbnid=O3As6o6-5T59GM:&tbnh=121&tbnw=95&prev=/images%3Fq%3Dsubdural%2Bhematoma%26gbv%3D2%26hl%3Did%26sa%3DG


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Prehospital Care of Head Injured

Patient

Historically, most patients were

hyperventilated (bad!)

ABCs

Spinal immobilization

Initial resuscitation

Rapid transport


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Head Injury Management

Management overall goal is to prevent or

minimize secondary injuries to the brain

Prevent hypoxia

Prevent hypotension

Prevent hemorrhage (anemia)

Prevent or limit increasing pressure


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ED Assessment of Head Injured

Patient

ABCs (again)

History (think alternate sources)

Clues to brain injury (examples: Cushings

reflex, raccoon eyes, etc)

Physical examtreat prioritized life threats

first

The D of the ABCs (neuro exam)


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Glasgow Coma Scale (GCS)MOTOR VERBAL EYES

6 follow commands 5 conversant +

oriented

4 open

spontaneously

5 localizes 4 conversant +

disoriented

3 open to

command4 flexion/withdrawal 3 inappropriate

words

2 open to pain

3 decorticate post 2 incomprehensible

sounds

1 doesnt open

2 decerebrate post 1 no sounds

1 no movement


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GCS Scores

GCS 13-15 Mild head injury

GCS 9-12 Moderate head

injury

GCS < 8 Severe head injury


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Management Principles

ABCs (Get used to it)

Protect spine as well (C spine injury

assumed until proved otherwise)

Stop blood loss elsewhere

Maintain perfusion (why hyperventilation is

detrimental!)


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Thank You !


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kuliah brain injury unmuh

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