Pemicu 1 : Dua Pasienku Sayang

Sugiarto Kamarudy Lay / 405140208

Blok Sistem Saraf dan Kejiwaan

Fakultas Kedokteran Universitas Tarumanagara
Jakarta 2018
 Learning Issues
• Anatomi, Histologi, Fisiologi Sistem Saraf
• Kejang dan Penyakit Degeneratif
Circle of Willis
ACA, MCA, PCA, and Basilar Vasculature
Ventricles of Brain
Neuroglial Cells
Cortical pathway for speaking a word seen or heard
 Seizures
The New Basic Classification

• The basic classification is a simple version of the

major categories of seizures. The new basic
seizure classification is based on 3 key features.

 Where seizures begin in the brain

 Level of awareness during a seizure
 Other features of seizures

https://www.epilepsy.com/article/2016/12/2017-revised-classification-seizures
 ILAE 2017 Classification of Seizure Types Basic Version 1

Focal Onset Generalized Onset Unknown Onset

Impaired Motor Motor

Aware
Awareness Tonic-clonic Tonic-clonic
Other motor
Other motor
Motor Non-Motor (Absence) Non-Motor
Non-Motor

Unclassified 2
focal to bilateral tonic-clonic

1 Definitions, other seizure types and descriptors are listed in the accompanying paper & glossary of terms

2 Due to inadequate information or inability to place in other categories

From Fisher et al. Instruction manual for the ILAE 2017 operational
classification of seizure types. Epilepsia doi: 10.1111/epi.13671
 Defining Where Seizures Begin
• Focal seizures: Previously called partial seizures, these start in an
area or network of cells on one side of the brain.
• Generalized seizures: Previously called primary generalized, these
engage or involve networks on both sides of the brain at the onset.
• Unknown onset: If the onset of a seizure is not known, the seizure
falls into the unknown onset category. Later on, the seizure type
can be changed if the beginning of a person’s seizures becomes
clear.
• Focal to bilateral seizure: A seizure that starts in one side or part of
the brain and spreads to both sides has been called a secondary
generalized seizures. Now the term generalized refers only to the
start of a seizure. The new term for secondary generalized seizure
would be a focal to bilateral seizure.

https://www.epilepsy.com/article/2016/12/2017-revised-classification-seizures
 ILAE 2017 Classification of Seizure Types Expanded Version1

Focal Onset Generalized Onset Unknown Onset

Aware
Impaired Motor Motor
Awareness tonic-clonic tonic-clonic
clonic epileptic spasms
Motor Onset tonic Non-Motor
automatisms myoclonic
myoclonic-tonic-clonic behavior arrest
atonic2
clonic myoclonic-atonic
epileptic spasms2 atonic
hyperkinetic epileptic spasms2
Non-Motor (absence) Unclassified3
myoclonic
tonic typical
Non-Motor Onset atypical
myoclonic
autonomic
eyelid myoclonia
behavior arrest
cognitive
emotional 1 Definitions, other seizure types and descriptors are listed in the
sensory accompanying paper and glossary of terms.
2 These could be focal or generalized, with or without alteration of awareness
focal to bilateral tonic-clonic 3 Due to inadequate information or inability to place in other categories

From Fisher et al. Instruction manual for the ILAE 2017 operational
classification of seizure types. Epilepsia doi: 10.1111/epi.13671
 Wording Changes

OLD TE RM NEW TERM

Unconscious (still used, not in name) Impaired awareness (surrogate)

Partial Focal
Simple partial Focal aware
Complex partial Focal impaired awareness
Dyscognitive (word discontinued) Focal impaired awareness
Psychic Cognitive
Secondarily generalized tonic-clonic Focal to bilateral tonic-clonic
Arrest, freeze, pause, interruption Behavior arrest
 Rules for Classifying Seizures (2 of 2)

Optional terms: Terms such as motor or non-motor

may be omitted when the seizure type is otherwise
unambiguous.

Additional descriptors: It is encouraged to add

descriptions of other signs and symptoms, suggested
descriptors or free text. These do not alter the seizure
type. Example: focal emotional seizure with tonic right
arm activity and hyperventilation.

Bilateral vs. generalized: Use the term “bilateral” for

tonic-clonic seizures that propagate to both
hemispheres and “generalized” for seizures that
apparently originate simultaneously in both.

Atypical absence: Absence is atypical if it has slow onset or offset, marked changes in tone or EEG spike-waves at
less than 3 per second.

Clonic vs. myoclonic: Clonic refers to sustain rhythmical jerking and myoclonic to a regular unsustained jerking.

Eyelid myoclonia: Absence with eyelid myoclonia refers to forced upward jerking of the eyelids during an absence
seizure.
 EPILEPSY
• Epilepsi adalah suatu penyakit otak yg ditandai dengan
gejala sbb:
– Minimal tdp 2 bangkitan tanpa provokasi atau 2
bangkitan refleks dengan jarak waktu antar bangkitan
pertama dan dan kedua lebih dari 24 jam.
– Satu bangkitan tanpa provokasi atau 1 bangkitan refleks
dg kemungkinan tjdnya bangkitan berulang dalam 10 thn
ke depan (min 60%) sama dengan bila tdp 2 bangkitan
tanpa provokasi/bangkitan refleks. Cth :  bangkitan
pertama yg tjd setelah 1 bln kejadian stroke, bangkitan
pertama pd anak yg disertai lesi struktural dan epileptiform
discharges.
– Sudah ditegakkan diagnosis sindrom epilepsi

Pedoman Tatalaksana Epilepsi PERDOSSI 2014 Edisi ke 5

 EPILEPSY ETIOLOGY
1. Idiopatik : tdk terdapat lesi structural di otak atau deficit
neurologis. Predisposisi genetik dan usia.
2. Kriptogenik : dianggap simtomatis TAPI penyebabnya belum
diketahui. Contohnya sindrom West, sindrom Lennox-
Gastaut, dan epilepsi mioklonik.
3. Simtomatis : bangkitan epilepsi yg disebabkan oleh
kelainan/lesi structural pada otak misalnya cedera kepala, inf
SSP, kelainan congenital, gangguan peredaran darah otak,
toksik, metabolik, kelainan neurodegeneratif.

Pedoman Tatalaksana Epilepsi PERDOSSI 2014 Edisi ke 5

 Selected Generalized Epilepsy Syndrome
• Infantile Spasms (West Syndrome) :
– unique age specific form of generalized epilepsy that may be either
idiopathic/symptomatic.
– Characterized by sudden flexor or extensor spasms that simultaneously
involve the head, trunk and limbs (before 6 months of age).
– EEG  hypsarrhytmia.
• Childhood Absence (petit mal) (staring spells during which the child is not
aware or responsive)
– Begins most often ages 4-12 yrs
– Charcterized by recurrent absence seizures!
– EEG  3Hz spike wave discharges !!!!
• Lennox-Gastaut Syndrome (tonic-atonic)
– Chilhood epilepetic encephalopathies that are characterized by mental
retardation , uncontrolled seizures and a distinctive EEG pattern
• Juvenile Myoclonic Epilepsy (most frequent and common)
– Idiopathic, often begins in otherwise healthy individuals between ages 8-20
yrs
– EEG  4-6 Hz spike waves

Louis ED, Mayer SA, Rowland LP. Merritt’s Neurology 13th Edition 2016
Epilepsy Foundation at www.epilepsy.com
3Hz generalized spike wave

Epilepsy Foundation at www.epilepsy.com

4-5 Hz polyspike wave

Epilepsy Foundation at www.epilepsy.com

 Selected Localization-Related Epilepsy Syndromes

• Benign Rolandic Epilepsy of Childhood

– involves twitching, numbness or tingling of the child's face or tongue (a
partial seizure) (< 2min). Fully conscious.
– infrequent and usually occur at night, most cases seizures stop when child
reach 15 yrs of age.
– EEG  spikes in motor area and temporal lobes.
• Temporal Lobe Epilepsy
– most common form of partial or localization related epilepsy.
– Virtually all patients have complex partial seizures. Auras are frequent,
behavior changes (motionless stare, loss of awareness, automatisms)
• Frontal Lobe Epilepsy
– Brief seizures that begin and end abruptly with little, if any postictal period.
– A tendency for seizures to cluster and occur at night
– Prominent, but often bizzare, motor manifestations s.a asynchronous
thrashing or flailing of arms and legs; pedaling leg movements, etc.
– Minimal abnormality on scalp EEG recordings
– A history of status epilepticus.

Louis ED, Mayer SA, Rowland LP. Merritt’s Neurology 13th Edition 2016
Epilepsy Foundation at www.epilepsy.com
Konsensus Kejang Demam UKK
Neurologi; IDI 2006
Konsensus Kejang Demam UKK Neurologi; IDI 2006
 Pemeriksaan Penunjang
• Pemeriksaan Laboratorium : tdk dikerjakan scr rutin, tp u/ evaluasi sumber
infeksi penyebab demam atau keadaan lain seperti gastroenteritis disertai
demam. (darah perifer, elektrolit, gula darah).
• Pungsi Lumbal : pd bayi kecil sulit sekali u/ menyingkirkan atau
menegakkan diagnosis meningitis karena manifestasi klinisnya tidak jelas.
– Bayi < 12 bulan sangat dianjurkan.
– Bayi 12-18 bulan  dianjurkan.
– Bayi > 18 bulan  tidak rutin.
• EEG
• Pencitraan (CT-scan, MRI)

Konsensus Kejang Demam UKK Neurologi; IDI 2006

 Kemungkinan Berulangnya Kejang

• Riwayat kejang demam atau epilepsi dalam

keluarga
• Usia kurang dari 12 bulan
• Suhu tubuh kurang dari 39 derajat Celsius saat
kejang
• Interval waktu yang singkat antara awitan
demam dengan terjadinya kejang.
• Apabila kejang demam pertama merupakan
kejang demam kompleks.

Konsensus Kejang Demam UKK Neurologi; IDI 2006

 Penatalaksanaan Saat Kejang
• Diazepam IV 0,3-0,5 mg/kg perlahan-lahan dengan
kecepatan 1-2 mg/menit atau dalam waktu 3-5 menit, dgn
dosis maksimal 20 mg.
• Obat praktis  diazepam rektal
– BB < 10 kg : 0,5-0,75 mg/kg atau 5 mg.
– BB > 10 kg : 10 mg
• Bila setelah pemberian diazepam rektal, kejang blm
berhenti  diulang lagi dengan cara dan dosis yang sama
dengan interval waktu 5 menit.
• Fenitoin IV dosis awal 10-20 mg/kg/kali dgn kecepatan 1
mg/kg/menit atau < 50mg/menit. Bila kejang berhenti
dosis selanjutnya 4-8 mg/kg/hari dimulai 12 jam setelah
dosis awal.

Konsensus Kejang Demam UKK Neurologi; IDI 2006

Konsensus Kejang Demam UKK Neurologi; IDI 2006
 Status Epilepticus (SE)

• Status epilepticus is when a seizure lasts

longer than 5 minutes or when seizures occur
close together and the person doesn't
recover between seizures.
• Status Epilepticus is a medical emergency!
 Dementia

LANGE Clinical Neurology

Parkinson
Parkinson
Parkinson