fisiologi patofisiologi dan terapi peningkatan tekanan
TRANSCRIPT
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FISIOLOGI, PATOFISIOLOGI, dan TERAPI Peningkatan Tekanan
Intrakranial
Pembimbing:dr. Robert Sinurat, Sp.BS
Dibuat oleh:Patrick Hiskia Hasiholan Situmeang
04 – 142
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Anatomi Otak
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Vaskularisasi
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Aliran LCS Ventrikel Lateralis 1 & 2
Foramen Monroe
Ventrikel 3
Aquaductus Sylvii
Ventrikel 4
F. MagendieF. Luschka
Sinus Sagitalis Superior
Subarachnoid Vili Arachnoidales
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Embriologi
http://rosswikijan2008.pbworks.com/f/1214972537/Brain%20Development.jpg
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Embriologi
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Fisiologi TTIK
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Monroe – Kellie Doctrine
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Cerebral Perfusion Pressure (CPP)– Tekanan minimal untuk mencegah keadaan
iskemia• Dewasa CPP > 70 mmHg• Anak CPP > 50 – 60 mmHg• Infant CPP > 40 – 50 mmHg
Intra Cranial Pressure (ICP)– Dewasa: 0 – 15 mmHg– Anak: 3 – 7 mmHg– Infant: 2 – 6 mmHg
Mean Arterial Pressure (MAP)
CPP = MAP - ICP
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CBF Global Cortical Subcortical 1400g brain
~ 45-55 ml/100g/min~ 75-80 ml/100g/min~ 20 ml/100g/min~ 700 ml/min~ 12-15% CO
CMRO2 ~ 3-3.5 ml/100g/min~ 50 ml/min~ 20% basal MRO2
Cerebral PvO2 ~ 35-40 mmHg
ICP (supine) ~ 8-12 mmHg~ 10-16 cmH2O
NB: a large proportion of the brains energy consumption (~ 60%) is used to supportelectrophysiological function & the maintenance of ion gradients
local CBF & CMRO2 are heterogeneous throughout the brain,both are ~ 4x greater in grey matter
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Skema Aliran Darah pada TTIK
http://www.nda.ox.ac.uk/wfsa/html/u08/u08b_t1b.gif
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Kemoregulasi & Autoregulasi
• Mekanisme kompensasi otak
• Perubahan CPP tanpa perubahan CBF
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Kemoregulasi & Autoregulasi
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Etiologi TekananTinggi Intrakranial
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Skema Peningkatan TIK
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Silbernagl/Lang, Color Atlas of Pathophysiology © 2000 Thieme
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Silbernagl/Lang, Color Atlas of Pathophysiology © 2000 Thieme
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Edema Cerebri
• Vasogenic Edema• Cytotoxic Edema• Interstitial Edema
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Gejala Klinis
Silbernagl/Lang, Color Atlas of Pathophysiology © 2000 Thieme
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Anamnesis
• Etiologi• Usia • Perjalanan penyakit
Gejala Klinis
• Pusing• Muntah• Papilledema• Kesadaran menurun• Gejala Herniasi
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Papilledema
• Terjadi akibat penekanan n. Opticus
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Herniasi Otak
• Transtentorial• Subfalcine• For. Magnum
(tonsiler)
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Cushing Triad
• Peningkatan tekanan sistolik dan pelebaran rentang sistolik – diastolik
• Bradikardia• Pernapasan Cheyne-Stokes
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Cushing Reaction (respon iskemia)
Peningkatan tekanan Cairan Serebro Spinalis
TTIK
Kompresi otak dan pembuluh darah
Aliran darah ke otak terhambat
Inisiasi respon iskemiaaliran darah kembali meningkat (drastis)
Iskemia Otak Terkompensasi
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Gejala Herniasi
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Monitor TTIK
• Indikasi – Dicurigai ada
peningkatan TIK– Pasien kesadaran comatose (GCS ≤ 8)
– Prognosis buruk
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• Intraventricular catheters– Transduser tekanan setinggi foramen Monroe (meatus
auditorius externa)– Diagnostik dan terapeutik– Resiko infeksi dikurangi dengan antibiotik profilaksis
• Intraparenchymal Pressure Transducer– Kabel serat optik (Camino device)– Mikrosensor di ujung kateter fleksibel (Codman device)– Dimasukkan ke parenkim otak atau ventrikel– Resiko infeksi lebih kecil
•
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• Subarachnoid Bolt– Masuk melalui duramater dengan jarum spinal– LCS di subarachnoid mengisi bolt– Kurang begitu akurat
• Epidural Transducer– Gaeltec device, dimasukkan ke dalam tabula
interna cranium dan superficial duramater– Dapat memberikan penyimpangan nilai lebih dari
5 – 10 mmHg pada penggunaan lebih dari beberapa hari.
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Tatalaksana
• Mekanik– Elevasi kepala (head-up) 30°– Hiperventilasi
• Medikamentosa– Mannitol 20 % dosis 0.5 – 1 g/kgBB dalam
waktu 15 menit– Maintance: ½ dosis awal 4 – 6 jam sekali
perhatikan osmolalitas darah
• Operatif
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