HISTORY TAKING

NEUROLOGICAL EXAMINATION


DIAGNOSIS
FURTHER EXAMINATION : LAB, LP,
EEG, EMG, RADIOLOGIC, BIOPSY

FINAL DIAGNOSIS

PEM. LABORATORIUM
FOTO RONTGEN
SKULL
SERVIKAL : AP, LAT, OBLIQ
THORAKAL: AP, LAT
LUMBOSAKRAL: AP, LAT, OBLIQ
CT SCAN, MRI, MRA, PET, SPECT, DLL
LUMBAL PUNGSI
EEG, EMG. EVOKE POTENSIAL,DLL

SKULL
- FRAKTUR
- MALFORMASI KONGENITAL
- GANGGUAN PERKEMBANGAN

SPINE
- FRAKTUR
- TUMOR TULANG
- PENYAKIT DEGENERATIF
- INFEKSI YANG MELIBATKAN TULANG

STRUKTURAL / ANATOMIS CT SCAN, MRI,
MYELOGRAFI, DLL

FUNGSIONAL EEG, EMG, EVOKE POTENSIAL

METABOLISME PET, SPECT

BLOOD VASCULATURE ANGIOGRAFI, MR
ANGIOGRAFI, TCD

COMPARATIVE INDICATIONS OF CT & MRI
Location and type of pathology CT MRI
Brain atrophy +++ +++
Acute infarct ++ +++
Older infarct ++ +++
Lacunar state +++ +++
Intraparenchymal hemorrhage ++ +++
Subarachnoid hemorrhage +++ +
Aneurysm + ++
Venous thrombosis + +++
Brain tumor (cerebral hemispheres) ++ +++
Pituitary tumor + +++
INDIKASI
Diagnosis meningitis, ensefalitis, dll
Perdarahan sub arachnoid, intra serebral
Meningeal karsinomatosis
Mengukur tekanan intra kranial
Kemoterapi intrathecal
Drainase / reduksi cairan likuor (pada hidrosefalus
communican
Respon terapi
Diduga peninggian intra kranial ok SOL Herniasi
Infeksi lokal dekubitus
Kadar trombosit < 40.000
Protrombin time < 50 %
Penyakit /gang. jantung, pernafasan yg berat
Massa pada spinal kord
(kecuali utk Dx LP yang diikuti myelografi)
Sakit kepala (post lumbal puncture headache)
Hematoma epidural / subdural
Infeksi
Herniasi
Traumatic tap
Pasien dibaringkan dgn posisi miring pada piggir tempat
tidur.
Leher badan badan paha lutut FLEKSI
Lokasi LP L4-L5 (setentang SIAS ), atau L2-L3
Kulit dibersihkan dgn jodium, bilas dengan alkohol, beri
anastesi lokal
Tusukkan jarum sejajar dgn garis tlg belakang dengan
sudut 10 20
0
arah kepala, sampai menembus duramater.

Gambaran aktivitas listrik otak/potensial listrik otak

Grafik Elektroensefalogram

Prosedur pembuatan grafik Elektroensefalografi

Sumber gelombang yang utama Kortek

Electrodes are placed on the scalp according to the
internationally standardized 1020 system

Singkatan dari:
Electroencephalogram
Electroencephalographic
Electroencephalography
CAA/FEB/09
Definisi:
Rekaman listrik otak yang direkam
oleh elektroda yang ditempatkan pada
kulit kepala
CAA/FEB/09
Electro- listrik
Encephalo-otak
Gram(ma)-gambar
Definisi : Rekaman Bioelektrik

ELECTROENCEPHALOGRAPHY

Definisi:
Ilmu yang mempelajari aktivitas listrik otak
Tehnik melakukan rekaman & menginterpretasi -kan
suatu electroencephalogram
CAA/FEB/09
CAA/FEB/09
Neuron pada
korteks otak
Perubahan potensial
listrik
Gelombang
ALPHA (8 -13 Hz)
BETA (>13Hz)
THETA (4 -7 Hz)
DELTA(<4Hz)
Perubahan fokal &
perubahan sel otak di
bagian lain
Diagnosis & klasifikasi kejang
Ensefalopati, Ensefalitis
Brain death
Pengukuran & prognosis kejang
Deteksi lesi otak struktural tumor serebri ,trauma
kapitis
Gangguan metabolik, fisiologik di otak
DLL
EEG BUKAN ALAT DIAGNOSTIK YANG MUTLAK
DAPAT DIJUMPAI
EEG normal --- Klinis abnormal
EEG abnormal --- Klinis normal
YANG PENTING KORELASI DENGAN KLINIS
DASAR-DASAR ANALISA EEG
Umur, keadaan klinis, pemakaian obat, indikasi EEG
Komposisi gelombang EEG & topografinya
Gambaran EEG simetris / asimetris
Perubahan aktivitas EEG selama rekaman dengan
adanya stimulus & perubahan kesadaran (mengantuk,
tidur, PS, HV)
Adanya gelombang abnormal spt, spike, dll
Parameter utama hubungan frekwensi/voltase
Macam-macam gelombang
Alfa : 813 spd, anak lanjut, dewasa, mata tertutup
Beta : > 14 spd, 25 uV, frontal
Teta : 4 7 spd, mengantuk, tidur
Delta : < 4 spd, tidur, sadar abnormal
Spike : 27 70 ms duration
Sharp wave : 70 200 ms
Spike & sharp wave Epileptipform wave
GAMBARAN ABNORMAL SPESIFIK
Spike komplek, 3 spd, diffuse bilateral, sinkron &
simetris ( Petit mal )
Spike wave, bilateral, sinkron & diffuse (Grandmal
idiopatik )

GAMBARAN ABNORMAL NON SPESIFIK
Tumor otak perlambatan fokal, Delta
Trauma kapitis perlambatan, penurunan voltase
diffuse, sesuai luasnya lesi
Meningitis,ensefalitis,metabolik ensefalopati
Suatu tindakan untuk merangsang timbulnya aktivitas
EEG abnormal, dapat berupa
Stimulus fotik
Hiperventilasi
Rekaman tidur
Aktivitas listrik otot menusukkan elektroda jarum
pada otot

Elektromyogram gambaran khas pada otot istirahat /
aktif dan memberikan gambaran abnormal sesuai
kelainan level motor unit
Prinsip : membedakan lesi
Saraf Motor neuron
Akson
Sambungan saraf otot
Otot
Hasil interpretasi tidak memberikan diagnosa klinis
spesifik, tetapi membantu menegakkan diagnosa,
bersama pemeriksaan klinis,dll

Motor neuron disease
Gangguan saraf tepi & akson ( neuropati )
Gangguan pada neuromuskular junction
(miastenia gravis)
Penyakit otot primer ( DMP )
Membantu menegakkan diagnosis seperti Bells
Palsy
DLL
Motor nerve conduction studies mencatat respon
elektris dari otot terhadap stimulasi saraf motoriknya
pada 2/lebih, sehingga dapat ditentukan kecepatan
penghantaran serabut motorik pd 2 tempat stimulasi
(MCV).

Sensory nerve conduction studies mengukur
kecepatan hantaran saraf & amplitudo action potensial
pada serabut sensorik ( KHS )


By injecting 5-25ml of radiopaque dye
(iopamidol/ isovue) through a lumbar puncture
needle.
The entire spinal subarachnoid space can be
visualized.
Useful in visualizing small areas within the spinal
canal.
CT body scan :
- provides excellent images of the spinal
canal & intervertebral foramina visualizing
spinal & posterior fossa lesions
MRI has largerly replaced contrast myelography
because:
- does not require lumbar puncture
- provides sharper visualization of the spinal
canal & its contents.
- image lesion greater clarity


EVOKED POTENTIALS

Assess the integrity of individual functional
systems (visual, auditory, somatosensory, or
motor).
Activated with a repeatedly delivered stimulus.
Provide evidence of whether impulse conduction
in the system in question is intact from the site of
stimulation all the way to the cerebral cortex.
May reveal subclinical lesions


Visual evoked potentials
Brainstem auditory evoked potentials
Somatosensory evoked potentials
Transcranial motor cortex stimmulation
Endogenous event-related evoked potentials

POSITRON EMISSION TOMOGRAPHY (PET)

Measured the cerebral concentration of
systematically administered radioactive tracers.
Measured local patterns of cerebral blood flow,
oxygen uptake, & glucose utilization.
Noninvasively
Tomographic images are constructed by
techniques similar to those used in CT & MRI.

Proved to be of value in:
- grading primary brain tumors
- distinguishing tumor tissue from radiation
necrosis
- localizing epileptic foci
- differentiating types of dementing diseases.
Has ability to quantitate neurotransmitter & their
receptors importance in the study of
parkinson disease & other degenerative diseases.
PET not available for routine diagnosis because:

- found in relatively few medical centers
- requires costly facilities & support staff.
Single Photon Emission Computed Tomography
(SPECT)

Has evolved from PET
Measure regional blood flow
Demonstrate reduced perfusion of the brain (in
stroke or in Alzheimer disease)
Detect focal pathological processes of other kinds
(epileptogenic foci)


NORMAL ALZHEIMER DISEASE
ANGIOGRAPHY

Has evolved over the last 50 years
Relatively safe & an extremely valuable method
for the diagnosis of :
- aneurysms
- vascular malformations
- narrowed or occluded arteries & veins
- arteria dissections
- angiitis
A needle is placed in the femoral or brachial
artery.

The great advantages of this procedure are:

- The vessels can be visualized with relatively
small amounts of dye & that this can be
accomplished with the smaller catheters than
those used in standard angiography.
- The arterial route is now used exclusively.

Copyright 2004 American
Academy of Neurology 42
Introduction

TCD is a non-invasive ultrasonic technique measuring
local blood flow velocity and direction in the proximal
portions of large intracranial arteries.

TCDs principal use is in the evaluation and
management of patients with cerebrovascular disease.
Copyright 2004 American
Academy of Neurology 43


non-invasive
can be performed at the bedside
easily repeated or used for continuous
monitoring
is generally less expensive than other techniques
contrast agents are not used avoiding allergic
reactions and decreasing risk to the patient
Copyright 2004 American
Academy of Neurology 44
examination of cerebral blood flow velocities in
certain segments of large intracranial vessels

detects indirect effects (abnormal waveform
characteristics) suggesting of proximal
hemodynamic or distal obstructive lesions

more valuable in specific conditions