CENTRAL NERVOUS SYSTEM

NERVOUS SYSTEMChairil Amin Batubara

Neurology Department, Medical FacultyUniversity of Sumatera Utara, Adam Malik General HospitalNervous SystemAnatomically Central Nervous System (CNS) Peripheral Nervous System (PNS)Functionally Somatic Nervous System (SNS) Autonomic (Viceral) Nervous System (ANS)23Brain(encephalon)Cerebrum(forebrain)Telencephalon Cerebral cortex Subcortical white matter Basal gangliaDiencephalon Thalamus Hypothalamus Epithalamus SubthalamusCerebellum Cerebellar cortex & nuclei Two lateral lobes ; vermisBrain stem Midbrain (mesencephalon) Pons (metencephalon) Medula oblongata (myelencephalon)Spinal cord(medula spinalis) White matter Gray matter Dorsal column Lateral column Anterior columnCNS4

5

6

7Cerebral circulation :Carotid / anterior system==> Carotid arteries internal carotid arteries opthalmic arteries ant. choroid arteries ant. serebral arteries midlle cerebral arteriesVertebrobasilar / posterior system ==> Vertebral arteries basilar artery post cerebral arteries 8

9EXTRACRANIUMINTRACRANIUMAortic arch Innomate artery( L ) Subclavian artery( L ) Common carotid artery( L ) External carotid artery( L ) Internal carotid artery( L ) Vertebral arteryBasilar artery( R ) Post cerebral artery( R ) Middle cerebral artery( R ) Post cerebral artery( L ) Post communicating artery( L ) Ant communicating artery( L ) Opthalmic artery( R ) Ant choroid artery Circle of Willis 10

Circle of Willis

SISTEM MOTORIK= kelumpuhan =Chairil Amin Batubara

Neurology Department, Medical FacultyUniversity of Sumatera Utara, Adam Malik General HospitalSistem motorik ==> mengurus pergerakan ==> rangkaian neuron dan otot :Upper motor neuron (supra-nuklear)PiramidalisEkstrapiramidalisLower motor neuron (nuklear dan infra-nuklear)Neuro-muscular juncton / Paut saraf-ototOtot

12

15

Sistem ektrapiramidalis: suatu kelompok struktur gray matter yang terletak dalam cerebral hemispheres ==> tdd komponen :Kortikal: area 4s, 6 dan 8Striatal (basal ganglia): nukleus kaudatus, putamen, globus palidus dan talamusnukleus kaudatus + putamen ==> korpus striatum/ neostriatumputamen + globus palidus ==> nukleus lentikularisBatang otak: nukleus subtalamikus, substansia nigra dan bagian dari formasio-retikularis Serebellum1617

Medula spinalisC1 C4C5 Th1T2 Th12L1 L418

Hemiseksi medula spinalis==> sindroma Brown Sequard :kelumpuhan LMN, ipsilateral setinggi lesikelumpuhan UMN ipsilateral di bawah lesianestesi kulit ipsilateral setinggi lesihyperestesi ipsilateral di bawah zona anestetikhilangnya sensasi proprioseptif ipsilateral di bawah lesihilangnya sensasi nyeri & suhu kontralateral di bawah lesi

1920

Pain &Temperature

Proprioception &Stereognosis

S T R O K EChairil Amin Batubara

Neurology Department, Medical FacultyUniversity of Sumatera Utara, Adam Malik General HospitalDEFINISI:MANIFESTASI KLINIS YG BERLANGSUNG CEPATAKIBAT GGN OTAK FOKAL/GLOBALBERLANGSUNG SELAMA 24 JAM A/ LEBIH A/ MENYEBABKAN KEMATIANTANPA PESBB LAIN YG JLS SELAIN VASKULARKLASIFIKASISTROKE ISKEMIK => TOASTSTROKE HEMORAGIKPISPSA

TIA (TRANSIENT ISCHEMIC ATTACK) TOASTATEROSKLEROSIS ARTERI BESAROKLUSI PEMBULUH DARAH KECILLAKUNAR INFARKSTROKE DG PENYEBAB TERIDENTIFIKASISTROKE DG PENYEBAB TAK TERIDENTIFIKASI:EVALUASI KOMPLETTAK KOMPLETSTROKE ISKEMIKALIRAN DRH KE OTAK BERKURANGPENYEBAB:HIPOPERFUSITROMBUSEMBOLITH/: rtPA, ANTIPLATELET, ANTIKOAGULAN

STROKE HEMORAGIKPIS = PERDARAHAN INTRA SEREBRALHIPERTENSI = ANEURISMA CHARCHOAT BOUCHARTNON HIPERTENSI

PSA = PERDARAHAN SUBARAKHNOIDBERRY ANEURYSM

TH/:KONSERVATIFOPERATIF = SESUAI INDIKASI

JARAK AB X CD X JUMLAH SLICE / 212345

Acute subarachnoid hemorrhage. A noncontrasted axial computed tomography (CT) scan shows the blood as areas of increased density. A transverse view (A) near the base of the brain shows blood in the Texaco star pattern, formed by blood radiating from the suprasellar cistern into the sylvian fissures and the anterior interhemispheric fissure. A higher cut (B) shows blood as an area of increased density in the anterior and posterior interhemispheric fissures, as well as in the sulci on the right. SH: OPERATIFPERDARAHAN CEREBELLAR:DIAMETER >/= 3 CMPERBURUKAN KLINIS PROGRESIF A/ HIDROSEFALUS

PISVOL: > 30 CCLETAK 1 CM DARI PERMUKAANSH SIPE KESADARANTIK USIA MUDAFR: HIPERTENSI(-) (-)(-)TUAHIPERTENSI, DM, CV( 2,5 x tingkat kesadaran ) + ( 2 x muntah ) + ( 2 x nyeri kepala ) + ( 0,1 x tek. diastolik ) + ( 3 x pertanda ateroma ) - 12Siriraj Stroke Score Score > 1 = Stroke haemorrhagic Score < -1 = Stroke non haemorrhagic (stroke iskemik akut atau infark) Akurasi prediksi : 90 %34DENGAN ATAU TANPA Penurunan kesadaran, Nyeri kepala, dan Refleks BabinskiAlgoritme Stroke Gadja MadaPENDERITA STROKE AKUTKetiganya atau 2 dari ketiganya ada ( + ) Penurunan kesadaran ( + ), Nyeri kepala ( - ), dan Refleks Babinski ( - )YaTidakTidakSTROKE PERDARAHAN INTRASEREBRALYaSTROKE PERDARAHAN INTRASEREBRAL35YaYaTidak Penurunan kesadaran ( - ), Nyeri kepala ( + ), dan Refleks Babinski ( - ) Penurunan kesadaran ( -), Nyeri kepala ( - ), dan Refleks Babinski ( + ) Penurunan kesadaran ( - ), Nyeri kepala ( - ), dan Refleks Babinski ( - )STROKE ISKEMIK AKUT ATAU STROKE INFARKSTROKE PERDARAHAN INTRASEREBRALSTROKE ISKEMIK AKUT ATAU STROKE INFARKYaTidak

HEADACHEChairil Amin Batubara

Neurology Department, Medical FacultyUniversity of Sumatera Utara, Adam Malik General Hospital37HeadacheSefalgia = NYERI KEPALA definition: pain / unpleasant sensation of the head as long as chin until cervicooccipital

38Headache Verbal Scale0 = no headache1 : mild headache, ADL normal2 : moderate headache, ADL a mild disturbed (no need take a rest)3 : severe headache : ADL very disturbed (need take a rest/ admitted to hospital).39HEADACHE CLASSIFICATIONPRIMARY HEADACHEMigraineTension Type HeadacheCluster Headache & other trigeminal autonomic chephalalgiasOther primary headacheSECONDARY HEADACHEOther headache, cranial neuralgia, central or primary facial painInternational Headache Classification (IHS)20041. Migraine1.1 Migraine without aura1.2 Migraine with aura1.2.1 Typical aura with migraine headache1.2.2 Typical aura with non-migraine headache1.2.3 Typical aura without headache1.2.4 Familial hemiplegic migraine(FHM)1.2.5 Sporadic hemiplegic migraine1.2.6 Basilar type migraine1.3 Childhood periodic syndromes that are commonly precursors of migraine1.4 Retinal migraine1.5 Complications of migraine1.6 Probable migraineIHS classification of MIGRAINE 20041.MIGRAINE WITHOUT AURA2. MIGRAINE WITH AURA3. CHILDHOOD PERIODIC SYNDROME4. RETINAL MIGRAINE5. COMPLICATIONS OF MIGRAINE6. PROBABLE MIGRAINETypical auraHemiplegic migraineBasilar migraineCyclical vomitingAbdominal migraineBenign paroxysmal vertigo childhoodChronic migraineStatus migrainosusPersistent aura without infarctionMigrainous infarctionMigraine-triggered seizuresMigraine without aura ( IHS 2004)At least 5 attacksHx attacks lasting 4-72 hrsHx has 2 following characteristics:UnilateralPulsatingModerate or severe painAgravation by physical activityDuring Hx 1 of the followingNausea and/or vomitingPhonophobia and photophobiaNot attributed to another disorderAura :visual,sensoris,speech,5- 1 hrAt least 2 attack, 4- 72 hoursUnilateralThrobbingModerate/severe intensityNausea/vomiting or/andPhonopobia/photopobiaWithout motor weaknessMigraine Hx with Typical auraFamilial Hemiplegic MigraineGenetik, chromosome 1 & 19Headache fulfilling criteria migraine with typical auraAura hemiparese 60 mntsCerebellar ataxia (20%)Onset suddenly60% patients FHM have symptom of basilar type44Sporadic hemiplegic migraineCriteria idem FHMNo family historyNormal CT Scan & EEG

45Basilar type migraineSign & symptoms of fossa posterior disordersDisartria,VertigoTinnitus, deafnessDiplopiaAtaxiaBilateral parestesiaunconciousnessHeadache fulfilling criteria migraine without aura461.3 Childhood periodic syndromes that are commonly precursors of migraine1.3.1 Cyclical vomiting2.5% schoolchildrenRecurrent unexplained nausea & vomiting 4x /hours 5 daysNo sign of gastrointestinal disease1.3.2 Abdominal migraine12% of schoolchildrenAbdominal pain, anorexia, nausea, vomiting1.3.3 Benign paroxysmal vertigo of childhoodAt least 5 attacks severe vertigoResolve within few minutes-hourno neurological deficitNormal vestibular functionEEG normalRetinal migraineRareAt least 2 attacks scintillating, scotoma, blindnessUnilateral (only one eye) Follows with migraine with auraNo attributed to another disorders1.5 Complications of migraine1.5.1 Chronic migraineMigraine without aura> 15 days> 3 monthsNo attributed to another disorderswithout Medication over used1.5.2 Status migrainosusSevere headache migraine > 72 jamNo attributed to another disorders1.5.3 Persistent aura without infarction1.5.4 Migrainous infarction1.5.5 Migraine-triggered seizuresThe triggers or precipitants of the acute migraine attack.1207 pts migraine of whom 75.9% reported triggers.Stress (79.7%), hormones in women (65.1%), not eating (57.3%), weather (53.2%), sleep disturbance (49.8%), perfume or odour (43.7%), neck pain (38.4%),light(s)(38.1%), alcohol (37.8%), smoke (35.7%), sleeping late (32.0%), heat (30.3%), food(26.9%), exercise (22.1%) sexual activity (5.2%).

Kelman L. Cephalalgia 2007; 27:394402.Food as Trigger factor of migraineMAYORMSGwine /vodka/bierCheeseChocolateYogurt/yeastcitrus fruitsButtermilk, milk

MINORnutsFried foodsPopcornChile peppersSeafoodsPork / liversSalty food/sweety512.Tension-type headache2.1 Infrequent episodic tension-type headache2.1.1 Infrequent episodic tension-type headache associated with pericranial tenderness2.1.2 Infrequent episodic tension-type headache not associated with pericranial tenderness2.2 Frequent episodic tension-type headache2.2.1 Frequent episodic tension-type headache associated with pericranial tenderness2.2.2 Frequent episodic tension-type headache not associated with pericranial tenderness2.1 Infrequent episodic TTH

532.2 Frequent episodic tension-type headacheAt least 10 attacks/episodes occuring on 1- 15 days/month, for < 3 monthsHeadaches lasting from 30 minutes 7days2.3 Chronic tension-type headache2.3.1 Chronic tension-type headache Associated with pericranial tenderness2.3.2 Chronic tension-type headache Not associated with pericranial tenderness2.4 Probable tension-type headache2.4.1 Probable infrequent episodic tension-type headache2.4.2. Probable frequent episodic tension-type headache2.4.3.Probable chronic tension-type headache2.3 Chronic TTH

564. Other primary headaches4.1 Primary stabbing headache4.2 Primary cough headache4.3 Primary exertional headache4.4 Primary headache associated with sexual activity4.4.1 Preorgasmic headache4.4.2 Orgasmic headache4.5 Hypnic headache4.6 Primary thunderclap headache4.7 Hemicrania continua4.8. New daily-persistent headache (NDPH)58Indication for Prophylaxis Migraine Migraine duration is greater than 48 hoursAcute medications are ineffective/failure, contraindicated, have side effect of drug or likely to be overused medicationsAttacks produce profound disability (occurs > 2 days per month) prolonged aura, or true migrainous infarctionAttacks occur > 2 more times per week, even with adequate acute care treatment with the risk of developing rebound headache Patient preference for preventive therapy US Headache Consortium Guidelines, Bigal, 2006, Loder, 200559

TETANUSChairil Amin Batubara

Neurology Department, Medical FacultyUniversity of Sumatera Utara, Adam Malik General HospitalDEFINISIPenyakit infeksi yang ditandai dengan peninggian tonus dan spasme otot disebabkan lepasnya neurotoksin tetanospasmin oleh bakteri batang gram positif Clostridium tetani di dalam jaringan yang low oxidation-reduction potential (dead or devitalized tissue)KLASIFIKASIA. Bedasarkan Klinis:1. Generalized2. Cephalic3. Localized4. Neonatorum

B. Berdasarkan Derajat Keparahan:1. Ringan2. Sedang3. Berat4. Sangat berat

A.1. Generalized TetanusPaling seringMasa inkubasi 7 21 hari (tergantung jarak luka dengan SSP)TrismusIrritable RestlestnessDiaphoresisDisphagiaHydrophobiaDroolingOphisthotonusA.2. Cephalic Tetanus Masa inkubasi 1 2 hariLuka di kepalaDisfungsi saraf kranialisPrognosis jelekA.3. Localized TetanusHanya terbatas pada ekstrimitas di mana ada lukaA.4. Tetanus NeonatorumMasa inkubasi 3 10 hari post partumIrritableSulit menelanRigiditasFacial grimacing

Derajat Keparahan TetanusTetanus sangat berat sama gejala gejalanya dengan tetanus berat, namun telah terjadi gangguan otonom dan kardiovaskular.RINGAN SEDANGBERAT Trismus3 2 jari1 jariJari (-) Spasme(-)(+)Lama SpastisitasUmum?Umum Rigiditas(-)(+)(+) PernafasanBaik> 30 x/i> 40 x/i Disfagia(-)RinganBeratPATOFISIOLOGILuka tetanospasmin retrograde intraneuronal/ axon terminal motor neuron perifer/ med. spinalis/ batang otak memblokade pelepasan inhibitory neurotransmitter glycine & GABA di terminal presinaptik akibatnya eksitasi firing rate motor neuron meningkat tanpa ada inhibisi sehingga otot lebih meningkat tonus dan spasmenya jika blokade di neuromuscular junction maka toksin menginhibisi pelepasan acethilcholine presinaptic bisa menjadi paralisisTERAPIDebridement luka.Human Tetanus Immunoglobuline (HTIG):Dewasa & anak: 3000 UI single dose IMNeonatus: 500 UI atau 150 UI/ kgBB IM Kalau bisa disuntikan di sekitar luka dgn dosis terbagi dan single doseKalau HTIG tidak ada maka bisa diberikan Anti Tetanus Serum (ATS):Harus dites sensitifitas/ alergi dahulu (skin test)Dosis: 30.000 UI 20.000 UI diberikan IM, sisanya 10.000 UI lagi diberikan IV sesudah 48 jam pemberian pertama.Metronidazole 500 mg/ 8 jam/ IV, dapat ditambah antibiotik lain seperti Clindamycine, Erytromycine, Tetracycline atau Vancomycine.Pemberian Penicilline sudah ditinggalkan krn:Bersifat sinergis dgn tetanospasmin (central GABA agonist) shg pasien menjadi lebih spasme lagi.Mencetuskan adanya kolonisasi bakteri resisten shg meningkatkan morbiditas infeksi nasokomial.Diazepam 0,1 mg/ kgBB/ IV atau IM/ 4 jam (dewasa bisa sampai 500 mg/hari sedang neonatus bisa sampai 15 40 mg/ hari)Atau Midazolam 0,1 mg/ kgBB IV atau IM/ 4 jam atau 2 10 mg/ jam IV, atau Propofol infus 1 10 mg/ kgBB IV.Blokade neuromuskular jangka lama dgn muscle relaxant Verocuronium ( 0,1 mg/ kgBB IV atau 6 8 mg/ jam) atau Atracurium (0,5 mg/ kgBB IV) dirawat di ICU (dengan ventilator)Jika memang diprediksikan perawatan dgn ventilator lebih dari 10 hari, maka dipertimbangkan tracheostomy.

Thanx71