NERVOUS SYSTEM

Chairil Amin Batubara

Neurology Department, Medical Faculty

University of Sumatera Utara, Adam Malik
General Hospital

Nervous System
Anatomically

Functionally

Central Nervous System (CNS)

Peripheral Nervous System (PNS)

Somatic Nervous System (SNS)

Autonomic (Viceral) Nervous System (ANS)

Telencephalon
Cerebrum
(forebrain)
Diencephalon
Brain
(encephalon)

CNS
Spinal cord
(medula spinalis)

Cerebral cortex
Subcortical white matter
Basal ganglia

Thalamus
Hypothalamus
Epithalamus
Subthalamus

Cerebellum

Cerebellar cortex & nuclei

Two lateral lobes ; vermis

Brain stem

Midbrain (mesencephalon)
Pons (metencephalon)
Medula oblongata (myelencephalon)

White matter
Gray matter

Dorsal column
Lateral column
Anterior column

Cerebral circulation :

Carotid / anterior system

==> Carotid arteries internal carotid arteries

opthalmic arteries ant. choroid arteries

ant. serebral arteries midlle cerebral

arteries

Vertebrobasilar / posterior system

==> Vertebral arteries basilar artery post
cerebral arteries

( R ) Post cerebral artery

( R ) Ant choroid artery

R ) Middle cerebral artery

R ) Post cerebral artery
Basilar artery

INTRACRANIUM
EXTRACRANIUM
Circle of Willis

( L ) Ant communicating artery

( L ) Opthalmic artery

( L ) Post communicating arte

( L ) Vertebral artery
( L ) Internal carotid artery
( L ) External carotid artery

( L ) Subclavian artery

( L ) Common carotid artery

Innomate artery

Aortic arch

 Circle of Willis

10

SISTEM MOTORIK
= kelumpuhan =
Chairil Amin Batubara

Neurology Department, Medical Faculty

University of Sumatera Utara, Adam Malik
General Hospital

 Sistem

motorik ==> mengurus

pergerakan ==> rangkaian neuron
dan otot :
Upper motor neuron (supra-nuklear)
Piramidalis
Ekstrapiramidalis
Lower motor neuron (nuklear dan infranuklear)
Neuro-muscular juncton / Paut saraf-otot
Otot
12

15

 Sistem

ektrapiramidalis: suatu kelompok

struktur gray matter yang terletak dalam
cerebral hemispheres ==> tdd komponen :
Kortikal: area 4s, 6 dan 8
Striatal (basal ganglia): nukleus kaudatus,
putamen, globus palidus dan talamus
nukleus kaudatus + putamen
==> korpus striatum/ neostriatum
putamen + globus palidus ==> nukleus lentikularis

Batang otak: nukleus subtalamikus, substansia

nigra dan bagian dari formasio-retikularis
Serebellum
16

17

 Medula

spinalis

C1 C4
C5 Th1
T2 Th12
L1 L4

18

 Hemiseksi

medula spinalis
==> sindroma Brown Sequard :
kelumpuhan LMN, ipsilateral setinggi lesi
kelumpuhan UMN ipsilateral di bawah lesi
anestesi kulit ipsilateral setinggi lesi
hyperestesi ipsilateral di bawah zona anestetik
hilangnya sensasi proprioseptif ipsilateral di
bawah lesi
hilangnya sensasi nyeri & suhu kontralateral di
bawah lesi

19

Pain &
Temperature

20

Proprioception &
Stereognosis

STROKE
Chairil Amin Batubara

Neurology Department, Medical Faculty

University of Sumatera Utara, Adam Malik
General Hospital

DEFINISI:
MANIFESTASI

KLINIS YG
BERLANGSUNG CEPAT
AKIBAT GGN OTAK FOKAL/GLOBAL
BERLANGSUNG SELAMA 24 JAM A/
LEBIH A/ MENYEBABKAN KEMATIAN
TANPA PESBB LAIN YG JLS SELAIN
VASKULAR

KLASIFIKASI
STROKE

ISKEMIK => TOAST

STROKE HEMORAGIK
PIS
PSA
TIA

(TRANSIENT ISCHEMIC ATTACK)

 TOAST
ATEROSKLEROSIS

ARTERI BESAR
OKLUSI PEMBULUH DARAH KECIL
LAKUNAR INFARK
STROKE DG PENYEBAB
TERIDENTIFIKASI
STROKE DG PENYEBAB TAK
TERIDENTIFIKASI:
EVALUASI KOMPLET
TAK KOMPLET

STROKE ISKEMIK
ALIRAN

DRH KE OTAK BERKURANG

PENYEBAB:
HIPOPERFUSI
TROMBUS
EMBOLI
TH/:

rtPA, ANTIPLATELET,
ANTIKOAGULAN

STROKE HEMORAGIK
PIS

= PERDARAHAN INTRA SEREBRAL

HIPERTENSI = ANEURISMA CHARCHOAT BOUCHART

NON HIPERTENSI
PSA

= PERDARAHAN SUBARAKHNOID

BERRY ANEURYSM
TH/:

KONSERVATIF
OPERATIF = SESUAI INDIKASI

JARAK AB X CD X JUMLAH SLICE / 2

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: OPERATIF
PERDARAHAN

CEREBELLAR:

DIAMETER >/= 3 CM
PERBURUKAN KLINIS PROGRESIF A/
HIDROSEFALUS
PIS

VOL: > 30 CC
LETAK 1 CM DARI PERMUKAAN

SH

SI

PE KESADARAN
TIK
USIA MUDA
(-) (-)
FR: HIPERTENSI
(-)
TUA
HIPERTENSI, DM,
CV

Siriraj Stroke Score

( 2,5 x tingkat kesadaran ) + ( 2 x muntah ) +
( 2 x nyeri kepala ) + ( 0,1 x tek. diastolik ) +
( 3 x pertanda ateroma ) - 12
Score > 1 = Stroke haemorrhagic
Score < -1 = Stroke non haemorrhagic
(stroke iskemik akut atau infark)
Akurasi prediksi : 90 %

Algoritme Stroke Gadja Mada

PENDERITA
STROKE AKUT

Ketiganya atau 2 dari

DENGAN
ATAU TANPA

Penurunan kesadaran,
Nyeri kepala, dan
Refleks Babinski

Ya

ketiganya ada ( + )

STROKE PERDARAHAN
INTRASEREBRAL

Tidak
Penurunan kesadaran ( + ),
Nyeri kepala ( - ), dan
Refleks Babinski ( - )

Tidak

Ya

STROKE PERDARAHAN
INTRASEREBRAL

34

 Penurunan kesadaran ( - ),
Nyeri kepala ( + ), dan
Refleks Babinski ( - )

Ya

STROKE PERDARAHAN
INTRASEREBRAL

Tidak
Penurunan kesadaran ( -),
Nyeri kepala ( - ), dan
Refleks Babinski ( + )

Ya

STROKE ISKEMIK AKUT

ATAU STROKE INFARK

Tidak
Penurunan kesadaran ( - ),
Nyeri kepala ( - ), dan
Refleks Babinski ( - )

Ya

STROKE ISKEMIK AKUT

ATAU STROKE INFARK

35

HEADACHE
Chairil Amin Batubara

Neurology Department, Medical Faculty

University of Sumatera Utara, Adam Malik
General Hospital

Headache

Sefalgia = NYERI KEPALA

definition: pain / unpleasant sensation

of the head as long as chin until
cervicooccipital
37

Headache Verbal Scale

0

= no headache
1 : mild headache, ADL normal
2 : moderate headache, ADL a mild
disturbed (no need take a rest)
3 : severe headache : ADL very
disturbed (need take a rest/ admitted
to hospital).

38

HEADACHE CLASSIFICATION

PRIMARY HEADACHE
1. Migraine
2. Tension Type Headache
3. Cluster Headache & other trigeminal
autonomic chephalalgias
4. Other primary headache

SECONDARY HEADACHE
Other headache, cranial
neuralgia, central or primary
facial pain
39

International Headache
Classification (IHS)2004

1. Migraine
1.1 Migraine without aura
1.2 Migraine with aura

1.2.1
1.2.2
1.2.3
1.2.4
1.2.5
1.2.6

Typical aura with migraine headache

Typical aura with non-migraine headache
Typical aura without headache
Familial hemiplegic migraine(FHM)
Sporadic hemiplegic migraine
Basilar type migraine

1.3 Childhood periodic syndromes that are commonly

precursors of migraine
1.4 Retinal migraine
1.5 Complications of migraine
1.6 Probable migraine

IHS classification of MIGRAINE 2004

1.MIGRAINE WITHOUT AURA
2. MIGRAINE WITH AURA

3. CHILDHOOD PERIODIC SYNDROME

Typical aura
Hemiplegic migraine
Basilar migraine
Cyclical vomiting
Abdominal migraine
Benign paroxysmal
vertigo childhood

4. RETINAL MIGRAINE
5. COMPLICATIONS OF MIGRAINE

6. PROBABLE MIGRAINE

Chronic migraine
Status migrainosus
Persistent aura without infar
Migrainous infarction
Migraine-triggered seizures

Migraine without aura ( IHS

2004)
A. At least 5 attacks
B. Hx attacks lasting 4-72 hrs
C. Hx has 2 following characteristics:
A.
B.
C.
D.

Unilateral
Pulsating
Moderate or severe pain
Agravation by physical activity

D. During Hx 1 of the following

A. Nausea and/or vomiting
B. Phonophobia and photophobia

E. Not attributed to another disorder

Migraine Hx with Typical aura

1.Aura :visual,sensoris,speech,5- 1 hr
2.At least 2 attack, 4- 72 hours
3.Unilateral
4.Throbbing
5.Moderate/severe intensity
6.Nausea/vomiting or/and
7.Phonopobia/photopobia
8.Without motor weakness

Familial Hemiplegic Migraine

Genetik,

chromosome 1 & 19
Headache fulfilling criteria migraine
with typical aura
Aura hemiparese 60 mnts
Cerebellar ataxia (20%)
Onset suddenly
60% patients FHM have symptom of
basilar type

Sporadic hemiplegic
migraine
Criteria idem FHM
No family history
Normal CT Scan &
EEG

Basilar type migraine

Sign

& symptoms of fossa posterior disorders

Disartria,
Vertigo
Tinnitus, deafness
Diplopia
Ataxia
Bilateral parestesia
unconciousness
Headache fulfilling criteria migraine without
aura

1.3 Childhood periodic syndromes

that are commonly precursors of
migraine
1.3.1 Cyclical vomiting
2.5% schoolchildren
Recurrent unexplained nausea & vomiting 4x
/hours 5 days
No sign of gastrointestinal disease

1.3.2 Abdominal migraine

12% of schoolchildren
Abdominal pain, anorexia, nausea, vomiting

1.3.3 Benign paroxysmal vertigo of

childhood

At least 5 attacks severe vertigo

Resolve within few minutes-hour
no neurological deficit
Normal vestibular function
EEG normal

Retinal migraine
Rare
At

least 2 attacks scintillating,

scotoma, blindness
Unilateral (only one eye)
Follows with migraine with aura
No attributed to another
disorders

1.5 Complications of migraine

1.5.1 Chronic migraine

Migraine without aura

> 15 days
> 3 months
No attributed to another disorders
without Medication over used

1.5.2 Status migrainosus

Severe headache migraine > 72 jam
No attributed to another disorders

1.5.3 Persistent aura without

infarction
1.5.4 Migrainous infarction
1.5.5 Migraine-triggered seizures

The 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%),
Kelman L. Cephalalgia 2007; 27:394402.

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%).

Food as Trigger factor of

migraine

MAYOR
MSG
wine /vodka/bier
Cheese
Chocolate
Yogurt/yeast
citrus fruits
Buttermilk, milk

MINOR
nuts
Fried foods
Popcorn
Chile peppers
Seafoods
Pork / livers
Salty
food/sweety

2.Tension-type headache
2.1

Infrequent episodic tension-type

headache
2.1.1 Infrequent episodic tension-type
headache associated with pericranial
tenderness
2.1.2 Infrequent episodic tension-type
headache not associated with pericranial
tenderness

2.2

Frequent episodic tension-type

headache
2.2.1 Frequent episodic tension-type headache
associated with pericranial tenderness

2.1 Infrequent episodic

TTH

2.2 Frequent episodic tensiontype headache

At

least 10 attacks/episodes occuring

on 1- 15 days/month, for < 3 months
Headaches lasting from 30 minutes
7days

2.3 Chronic tension-type headache

2.3.1 Chronic tension-type headache
Associated with pericranial tenderness
2.3.2 Chronic tension-type headache Not
associated with pericranial tenderness
2.4 Probable tension-type headache
2.4.1 Probable infrequent episodic tensiontype headache
2.4.2. Probable frequent episodic tensiontype headache
2.4.3.Probable chronic tension-type
headache

2.3 Chronic TTH

A. Headache occurring on 15 d/mo (180 d/y) for >3 mo
and fulfilling criteria B-D
B. Headache lasts hours or may be continuous
C. Headache has 2 of the following characteristics:
1. bilateral location
2. pressing/tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity
D. Both of the following:
1. not >1 of photophobia, phonophobia, mild nausea
2. neither moderate or severe nausea nor vomiting
E. Not attributed to another disorder

2.3 Chronic TTH

ICHD-II. Cephalalgia 2004; 24 (Suppl 1)

International Headache Society 2003/4

4. Other primary
headaches
4.1 Primary stabbing headache
4.2

Primary cough headache

4.3 Primary exertional headache
4.4 Primary headache associated with
sexual activity
4.4.1 Preorgasmic headache
4.4.2 Orgasmic headache
4.5 Hypnic headache
4.6 Primary thunderclap headache
4.7 Hemicrania continua
4.8. New daily-persistent headache
(NDPH)

Indication for Prophylaxis

Migraine
US Headache Consortium Guidelines, Bigal, 2006, Loder,
2005

1. Migraine duration is greater than 48 hours

2. Acute medications are ineffective/failure,
contraindicated, have side effect of drug
or likely to be overused medications
3. Attacks produce profound disability
(occurs > 2 days per month) prolonged
aura, or true migrainous infarction
4. Attacks occur > 2 more times per week,
even with adequate acute care treatment
with the risk of developing rebound
headache
58
5. Patient preference for preventive
therapy

TETANUS
Chairil Amin Batubara

Neurology Department, Medical Faculty

University of Sumatera Utara, Adam Malik
General Hospital
59

Penyakit
dengan

DEFINISI

infeksi

yang

peninggian

ditandai

tonus

dan

spasme otot disebabkan lepasnya

neurotoksin
bakteri

tetanospasmin

batang

gram

oleh
positif

Clostridium tetani di dalam jaringan

yang

low

oxidation-reduction

potential (dead or devitalized tissue)

KLASIFIKASI
B. Berdasarkan
A. Bedasarkan Klinis:

Derajat Keparahan:

1. Generalized

1. Ringan

2. Cephalic

2. Sedang

3. Localized

3. Berat

4. Neonatorum

4. Sangat berat

A.1. Generalized Tetanus

Paling

sering

Restlestness

Masa

inkubasi 7

Diaphoresis

21 hari (tergantung

Disphagia

jarak luka dengan

Hydrophobia

SSP)

Drooling

Trismus
Irritable

Ophisthotonu

A.2. Cephalic Tetanus

Masa

inkubasi 1 2 hari

Luka
Disfungsi

di kepala
saraf kranialis

Prognosis

jelek

A.3. Localized Tetanus

Hanya terbatas pada
ekstrimitas di mana ada
luka

A.4. Tetanus Neonatorum

Masa

inkubasi 3 10 hari post partum

Sulit menelan

Irritable

Rigiditas

Facial grimacing

Derajat Keparahan Tetanus

RINGAN

SEDANG

BERAT

Trismus

3 2 jari

1 jari

Jari (-)

Spasme

(-)

(+)

Lama

Spastisitas

Umum

Umum

Rigiditas

(-)

(+)

(+)

Pernafasan

Baik

> 30 x/i

> 40 x/i

Disfagia

(-)

Ringan

Berat

Tetanus sangat berat sama gejala gejalanya dengan tetanus berat,

namun telah terjadi gangguan otonom dan kardiovaskular.

PATOFISIOLOGI
Luka 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 paralisis

TERAPI
1.
2.

Debridement luka.
Human Tetanus Immunoglobuline (HTIG):

Dewasa & anak: 3000 UI single dose IM

Neonatus: 500 UI atau 150 UI/ kgBB IM
Kalau bisa disuntikan di sekitar luka dgn dosis
terbagi dan single dose

3.

Kalau 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.

4.

5.

6.

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)

7.

8.

9.

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.

Thanx

71