13. Neurologi

NEUROSAINS DALAM

APLIKASI KLINIS NEUROLOGIS

Prof BOB SANTOSO WIBOWO SpS(K)

Subdiv. EMG & EVOKED POTENTIALSDept. of NEUROLOGY

FKUI / RSUPN CM

Neuroscience is a field that is devoted to the scientific study of the nervous system. Such studies span the structure, function, evolutionary history, development, genetics, biochemistry, physiology, pharmacology, informatics, computational neuroscience and pathology of the nervous system.

Traditionally it is seen as a branch of biological sciences. However, recently there has been a surge in the convergence of interest from many allied disciplines, including cognitive and neuro-psychology, computer science, statistics, physics, and medicine. http://en.wikipedia.org/wiki/Neuroscience

The scope of neuroscience has now broadened to include any systematic scientific experimental and theoretical investigation of the central and peripheral nervous system of biological organisms.

The methodologies employed by neuroscientists have been enormously expanded, from genetic, biochemical and analysis of dynamics of individual nerve cells and their molecular constituents to imaging representations of perceptual and motor tasks in the brain. http://en.wikipedia.org/wiki/Neuroscience

Neuroscience is at the frontier of investigation of the brain and mind.

The study of the brain is becoming the cornerstone in understanding how we perceive and interact with the external world and, in particular, how human experience and human biology influence each other.

The Neuroscience Program. Amherst College. Retrieved on 2008-04-15. http://en.wikipedia.org/wiki/Neuroscience

Every school has its own way of teaching neuroscience

Consequently, the order in which information is presented , varies inormously

Although taught in logical sequence, the student can enter at any point as a starting point

of any given subject

This is just a brief account of the organization and functions of nervous tissue, with pariticular emphasis on the normal human nervous system

Many abnormalities are also discribedA they provide the only clues indicating the normal functions of some parts of the human brainB the correlation between the functional deficits and the pathological anatomy in some diseases , to illustrate important facts of neuroanatomyC several neurological diseases, are common enough to justify inclusion in any general text of neuroscienceD the intelligent diagnosis and clinical management of these conditions demand a working knowledge of the relevant anatomy and physiology

Neurologi klinikNeurologi klinik

Penerapan ilmu-ilmu neurologiPenerapan ilmu-ilmu neurologi utk mempelajari utk mempelajari fenomena-fenomena perubahan fenomena-fenomena perubahan

berbagai aspek susunan sarafberbagai aspek susunan saraf dalam kaitannya dng berbagai dalam kaitannya dng berbagai gangguan terhadap gangguan terhadap susunan saraf pusat dan perifersusunan saraf pusat dan perifer baik secara baik secara primerprimer maupun maupun sekunder.sekunder.

Overview Overview Sistim Saraf Pusat Sistim Saraf Pusat

dan dan PeriferPerifer

Sistem saraf pusat otak dan medulla spinalis

Sistem saraf perifer

- Serabut saraf (dan ganglia) membawa informasi dari kulit dan tingkai (afferen)

- Serabut saraf membawa informasi ke otot-otot untuk mengontrol gerakan (efferen)

- Serabut saraf dan ganglia sistem saraf otonom

- Serabut saraf dan ganglia dari sistem persarafan enteric untuk mengontrol fungsi usus

Organisasi Sistem Persarafan

Susunan Saraf Susunan Saraf PusatPusat

Susunan Saraf Susunan Saraf PusatPusat

OtakOtak Medula SpinalisMedula Spinalis

Brain Brain OverviewOverview

Brain Brain OverviewOverview

Serebrum - Bagian dari SSP yang mengatur dan mengisi kesadaran

Diencephalon - Pintu gerbang informasi sensorik menuju serebrum.

Serebellum - berfungsi mengontrol fungsi motorik.

Batang otak – membawa informasi ke dan dari medula spinalis serta

berfungsi sebagai kontrol motorik kepala dan leher.

Spinal CordSpinal CordOrganizationOrganizationSpinal CordSpinal Cord

OrganizationOrganization

Gray matterGray matter: mostly : mostly cell bodiescell bodies Dendrites & terminDendrites & terminalsals Spinal reflex integrating centerSpinal reflex integrating center

White matterWhite matter Bundles of Bundles of myelinated axonsmyelinated axons

Ascending tracts – sensoryAscending tracts – sensory Descending tracts – motorDescending tracts – motor

Dorsal rootsDorsal roots Ventral rootsVentral roots

Neuron Numbers and TypesNeuron Numbers and Types

TheThe Brain Brain has enormous numbers of has enormous numbers of “computing” elements“computing” elements ( (neuronsneurons) that ) that accomplish accomplish sophisticated computationsophisticated computation because of their because of their

large numberslarge numbers, , extensive inter-connectionsextensive inter-connections, and their , and their high degree of specializationhigh degree of specialization into into different types of neuronsdifferent types of neurons

((Jan S. Purba MD, PhD)Jan S. Purba MD, PhD)

The Basic Action of the NeuronThe Basic Action of the Neuron

Neurons Neurons have have direct actionsdirect actions and and indirect actionsindirect actions Direct actionsDirect actions take only one of two take only one of two

forms: to forms: to excite or to inhibitexcite or to inhibit Indirect actionsIndirect actions can occur in can occur in several several

waysways, but the important , but the important consequence is that they consequence is that they modulatemodulate excitatory or inhibitory activityexcitatory or inhibitory activity

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

Action potentialsAction potentials

A resting neuronA resting neuron

maintains a maintains a resting electrical chargeresting electrical charge, ,

relative to the outside fluidsrelative to the outside fluids When a neuronal membrane is When a neuronal membrane is destabilizeddestabilized, ,

either by an appropriate electrical field or either by an appropriate electrical field or reaction with neurotransmitter chemical, reaction with neurotransmitter chemical, the the resting membrane potential reverses polarityresting membrane potential reverses polarity

This polarity reversalThis polarity reversal propagates from point propagates from point along the membrane surfacealong the membrane surface

(Jan S. Purba MD, (Jan S. Purba MD, PhD)PhD)

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

Calcium and Calcium and Transmitter ReleaseTransmitter Release

Calcium entryCalcium entry couples couples action potentialsaction potentials to to neurotransmitter releaseneurotransmitter release In many synapses, In many synapses, depolarization of presynaptic terminalsdepolarization of presynaptic terminals opens opens the the membrane gate membrane gate for for calcium channels influxcalcium channels influx, , which in turn which in turn triggers the release of certain transmitterstriggers the release of certain transmitters These channels are These channels are voltage sensitivevoltage sensitive, , unlikeunlike the classes of membrane channels that are the classes of membrane channels that are ligand sensitiveligand sensitive

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

Neurochemical Neurochemical TransmissionTransmission

Neurons release “transmitter” Neurons release “transmitter” chemical secretionschemical secretions from their terminals into from their terminals into

synapsessynapses, which serve , which serve to to excite or to inhibitexcite or to inhibit postsynaptic cells postsynaptic cells Synaptic transmissionSynaptic transmission is ultimately associated is ultimately associated

with with altered conductancealtered conductance across the across the membrane of specific ionsmembrane of specific ions

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

Neurochemical TransmissionNeurochemical Transmission

The The conformational changes and channels conformational changes and channels openingopening are regulated by membrane potential are regulated by membrane potential changes in some ion channel systems and by changes in some ion channel systems and by specific neurotransmitter-receptor specific neurotransmitter-receptor interactions in other systems (ACh and GABA, interactions in other systems (ACh and GABA, for example)for example)

NeurotransmittersNeurotransmitters affectaffect virtually all virtually all physiological processes in the brain and all physiological processes in the brain and all behaviorsbehaviors, and , and any given process or behavior any given process or behavior is generally influenced by more than one is generally influenced by more than one neurotransmitter or neuromodulator neurotransmitter or neuromodulator

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

lanjutan

Neuronal TransportNeuronal Transport

Neurons transport metabolic productsNeurons transport metabolic products,, sometimes sometimes over over relatively great distances, relatively great distances, through small cytoplasmic extensions through small cytoplasmic extensions of the cell bodyof the cell body

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

Neuronal TargetsNeuronal Targets

The The growing processes of neurons are growing processes of neurons are guided to guided to their targetstheir targets by by physical forcesphysical forces in their in their

environment and environment and chemical signalschemical signals “emitted” “emitted” by the targetsby the targets

Depriving a neuron of contactDepriving a neuron of contact with its normal with its normal contact contact may cause may cause

the neuron to the neuron to degenerate or diedegenerate or die and and its targets to become supersensitiveits targets to become supersensitive to the to the

chemical secretions of the missing neuronchemical secretions of the missing neuron (Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

Ending Ending NeurotransmissionNeurotransmission

The The action of released transmitteraction of released transmitter is is terminatedterminated by several mechanisms by several mechanisms::

enzymatic destructionenzymatic destruction diffusiondiffusion away from receptors away from receptors and and active transport processesactive transport processes that take that take

the transmitter or its precursors back into the transmitter or its precursors back into nerve terminals or into adjacent glia cellsnerve terminals or into adjacent glia cells

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

SynapticVesicles

DADA DA DADADA

NENENENE NE NE

5-HT5-HT 5-HT 5-HT5-HT5-HT

MAOMAO

MAOMAO

Receptors

Postsynaptic NeuronPresynaptic Neuron

DADA

NENE

5-HT5-HT

NE = norepinehrine5-HT = 5 hydroxytryptamine (serotonin)DA = dopamineMAO = monoamine oxidase

NE = norepinehrine5-HT = 5 hydroxytryptamine (serotonin)DA = dopamineMAO = monoamine oxidase

Adapted from Richelson E. Mayo Clinic Proceedings 1994

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

Membrane ReceptorsMembrane Receptors Neural membranesNeural membranes, , both both presynapticpresynaptic and and postsynapticpostsynaptic, contain , contain

embedded proteins that act as embedded proteins that act as receptors for receptors for specific ligandsspecific ligands

These ligandsThese ligands are normally are normally neurotransmitters neurotransmitters and hormonesand hormones, but they can also be , but they can also be drugsdrugs

The ligands must The ligands must “fit”“fit” the the conformationconformation and and electric charge propertieselectric charge properties of of their receptorstheir receptors (Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

Membrane ReceptorsMembrane Receptors

This means that This means that the ordering of amino acids the ordering of amino acids in the receptor proteinin the receptor protein is very important, is very important, along with the along with the ordering of constituent atoms ordering of constituent atoms in the transmitterin the transmitter and the and the arrangement of arrangement of atoms in spaceatoms in space (i.e., the “handedness” of (i.e., the “handedness” of certain key atoms)certain key atoms)

When a ligand binds a receptorWhen a ligand binds a receptor, the receptor , the receptor molecule molecule changes conformationchanges conformation, which may in , which may in turn turn changes the “channels”changes the “channels” in receptor in receptor protein that protein that allow ions to flow across the cell allow ions to flow across the cell membranemembrane

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

lanjutan

Receptor BindingReceptor Binding Neurotransmitters bind receptors temporarilyNeurotransmitters bind receptors temporarily, ,

because the interactions do not lead to covalent bonds because the interactions do not lead to covalent bonds but rather are a but rather are a combination of weaker forces involving combination of weaker forces involving hydrogen bonding, electrostatic attraction and Van der hydrogen bonding, electrostatic attraction and Van der Waals forcesWaals forces

Such binding is Such binding is stereo specificstereo specific and and confers a confers a particular conformation on the membrane particular conformation on the membrane receptorreceptor

This receptor conformationThis receptor conformation determines whether determines whether the aqueous channels within the protein are the aqueous channels within the protein are open or closed to ionic fluxopen or closed to ionic flux

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

Ion ChannelsIon Channels

Neuronal membranesNeuronal membranes have have coiled proteinscoiled proteins that are that are embedded in the embedded in the hydrophobic lipid bilayerhydrophobic lipid bilayer

Some of the amino acidsSome of the amino acids surround a variable-size pore, which surround a variable-size pore, which constitutes a constitutes a channel channel through which ions can flowthrough which ions can flow according to the according to the electrostatic and concentration gradientselectrostatic and concentration gradients

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

Ion ChannelsIon Channels

The degreeThe degree to which these ion channels are to which these ion channels are openopen can be regulated by voltage fields can be regulated by voltage fields ((voltage-gated channelsvoltage-gated channels))

Voltage-gated channelsVoltage-gated channels, at least those for , at least those for sodium sodium in mammalian brainin mammalian brain, ,

are also regulated by are also regulated by phosphorylation of protein kinase C and phosphorylation of protein kinase C and

cAMP-dependent protein kinasecAMP-dependent protein kinase

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

lanjutan

Discovered or characterized in the neurodegenerative disease program that can betargeted to prevent neuronal apoptosis and thus treat various neurological disease. Drug or molecular therapies are being developed to :

(1) antagonize NMDA receptors (NMDA-Rc),

(2) modulate activation of the p38 mitogen activated kinase (MAPK)-MEF2C (transcription factor) pathway,

(3) prevent toxic reactions of free radicals such as nitric oxide (NO) and reactive oxygen species (ROS), and

(4) inhibit apoptosis-inducing enzymes including caspases

Schematic illustration of the signaling pathways

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

apoptosis

Second MessengersSecond Messengers

Activation (opening) of an ion channelActivation (opening) of an ion channel creates a creates a cascade of intracellular biochemical reaction that cascade of intracellular biochemical reaction that leads ultimately to leads ultimately to phosphorylation of intracellular phosphorylation of intracellular proteinsproteins

This cascade of reactionsThis cascade of reactions constitutes a constitutes a biochemical biochemical signal transduction mechanism signal transduction mechanism that converts that converts biochemical signals at membrane surface to biochemical signals at membrane surface to biochemical signal inside the cellbiochemical signal inside the cell

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

The roles of calcium and cytochrome C

as interorganellar messenger in apoptosis

Cytochrome c released from mitochondria functions ina positive feedback loop by binding to InsP3 receptorson the endoplasmic reticulum, triggering calcium releaseand thus amplifying calcium-dependent apoptosis (Jan S. Purba MD, (Jan S. Purba MD,

PhD)PhD)

PlasticityPlasticity

The nervous system can exhibit The nervous system can exhibit considerable plasticityconsiderable plasticity

Neurons can growNeurons can grow new axonal and dendritic new axonal and dendritic processes, and new synapses can be processes, and new synapses can be formedformed

Moreover, Moreover, neural circuits can be recruitedneural circuits can be recruited into existence and exiting circuits can be re-into existence and exiting circuits can be re-organizedorganized

Even Even certain topographical mapscertain topographical maps can be can be “sculpted” by the nature of their input“sculpted” by the nature of their input

(Jan S. Purba MD, PhD)(Jan S. Purba MD, PhD)

Metodologi Metodologi dalam dalam

Neurologi KlinikNeurologi Klinik

MengaplikasikanMengaplikasikan neuroanatomi, neuroanatomi, neurofisiologi, neuropatologi, neurokimia, neurofisiologi, neuropatologi, neurokimia, neuroimaging dan fungsi susunan saraf neuroimaging dan fungsi susunan saraf pusat dan periferpusat dan perifer baik dalam baik dalam

keadaan sehat maupun sakitkeadaan sehat maupun sakit untuk untuk menegakkan diagnosis danmenegakkan diagnosis dan

mengaplikasikan mengaplikasikan penemuan penemuan neurofarmakologi, neurofarmakologi, neurobehaviour, neurorehabilitasineurobehaviour, neurorehabilitasi dalam dalam rangka pengobatan/penyembuhan penderitarangka pengobatan/penyembuhan penderita..

1.1. AnamnesisAnamnesis Menggunakan metode Menggunakan metode wawancarawawancara

baik dengan penderita (baik dengan penderita (autoauto) maupun ) maupun dengan orang-orang yang “dekat” dengan orang-orang yang “dekat” dengan penderita (dengan penderita (alloallo))

Wawancara ini sangat penting dan Wawancara ini sangat penting dan utamautama kelihaian seorang dokter kelihaian seorang dokter terlihat dari terlihat dari penguasaan komunikasipenguasaan komunikasi dan dan ketajaman naluriketajaman naluri dalam mencari dalam mencari penyakit penderitapenyakit penderita

Anamnesis yang akuratAnamnesis yang akurat gambaran gambaran diagnosis atau diagnosis banding diagnosis atau diagnosis banding dapat ditemukandapat ditemukan

Metode

2.2. Pemeriksaan/status neurologi klinikPemeriksaan/status neurologi klinik

A.A. Pemeriksaan umumPemeriksaan umum, meliputi , meliputi pemeriksaan pemeriksaan fungsi vitalfungsi vital dan dan gambaran umumgambaran umum dari dari kepala, dada dan perut serta ekstremitaskepala, dada dan perut serta ekstremitas

A.Pemeriksaan NeurologiMeliputi:• Pemeriksaan Kesadaran

I. Kuantitas; dapat digunakan Skala Koma Glasgow dengan menilai respon mata, motorik, verbal.

II. Kualitas - Meningkatnya tingkat

kesadaran/eksitasi serebral: tremor, euforia, mania

- Menurunnya tingkat kesadaran: delirium, somnolen, sopor, soporo-koma, koma

GLASGOW COMA SCALEGLASGOW COMA SCALE

VerbalVerbal MotorMotor EyesEyes

VerbalVerbal

Orientasi baik (5)Orientasi baik (5) Bingung (confused) (4)Bingung (confused) (4) Bicara tidak sesuai (inappropriate) Bicara tidak sesuai (inappropriate)

(3)(3) Suara tidak dimengerti (2)Suara tidak dimengerti (2) Tidak ada suara (1)Tidak ada suara (1) (T=intubasi)(T=intubasi)

MotorMotor

Bergerak sesuai perintah (6)Bergerak sesuai perintah (6) Melokalisai nyeri (5)Melokalisai nyeri (5) Fleksi terhadap nyeri (withdrawal) (4)Fleksi terhadap nyeri (withdrawal) (4) Fleksi abnormal (3)Fleksi abnormal (3) Respons ekstensi (2)Respons ekstensi (2) Tidak ada respon (1)Tidak ada respon (1)

EyesEyes

Buka mata spontan (4)Buka mata spontan (4) Buka mata dengan perintah (3)Buka mata dengan perintah (3) Buka mata dengan rangsangan nyeri Buka mata dengan rangsangan nyeri

(2)(2) Tidak ada respon (1)Tidak ada respon (1)

• Pemeriksaan Rangsang Meningeal

- - Kaku Kuduk- Tanda Lasegue- Tanda Kernig- Tanda Brudzinski I- Tanda Brudzinski II

Saraf KranialisSaraf Kranialis

• Pemeriksaan fungsi Pemeriksaan fungsi saraf kranialissaraf kranialis

Pemeriksaan fungsi saraf Pemeriksaan fungsi saraf kranialiskranialis

Homunculus MotorikHomunculus MotorikPemeriksaan Motorik

Traktus Traktus KortikospinalKortikospinal

Voluntary Movement: “Conscious”

• MeliputiMeliputi- Kekuatan motorikKekuatan motorik- Tonus (hiper, normo dan hipo)Tonus (hiper, normo dan hipo)- Trofik (hiper, normo dan hipo)Trofik (hiper, normo dan hipo)- Gerakan-gerakan involunterGerakan-gerakan involunter

Pemeriksaan Sistem Motorik

Kekuatan motorikKekuatan motorik

MeliputiMeliputi::- Pemeriksaan sensorikPemeriksaan sensorik- EksteroseptifEksteroseptif (nyeri, raba/tekan, (nyeri, raba/tekan,

suhu)suhu)- ProprioseptifProprioseptif- Enteroseptif Enteroseptif

Pemeriksaan Sistem Sensorik

General Properties of Sensory Systems

Homunculus SensorikHomunculus Sensorik

Jaras sensorikJaras sensorik

Refleks-Refleks :Refleks-Refleks :- Refleks FisiologisRefleks Fisiologis (Biseps, Triseps, (Biseps, Triseps,

KPR, APR)KPR, APR)- Refleks PatologisRefleks Patologis (Babinsky, (Babinsky,

Chaddock, dll)Chaddock, dll)

• Pemeriksaan fungsi vestibuler dan serebelumPemeriksaan fungsi vestibuler dan serebelum

• Pemeriksaan fungsi kortikal luhurPemeriksaan fungsi kortikal luhur jika diindikasikan jika diindikasikan seperti:seperti:- TOAGTOAG (Test Orientation and Attention of Galvaston) (Test Orientation and Attention of Galvaston)- MMSEMMSE (Mini Mental Status Examination), penilaian (Mini Mental Status Examination), penilaian

awal fungsi kognitifawal fungsi kognitif

Kesimpulan dari semua pemeriksaan Kesimpulan dari semua pemeriksaan adalah adalah diagnosadiagnosa atau atau diagnosa diagnosa bandingbanding (jika belum jelas kesimpulan (jika belum jelas kesimpulan pemeriksaan tsb).pemeriksaan tsb).

Dan berdasar diagnosis tersebut disusun Dan berdasar diagnosis tersebut disusun rancangan rancangan pemeriksaan pemeriksaan tambahan/penunjangtambahan/penunjang untuk lebih untuk lebih memastikan diagnosis sekaligus memastikan diagnosis sekaligus menyingkirkan diagnosis banding.menyingkirkan diagnosis banding.

Diagnosis dan Diagnosis Banding

Meliputi :Meliputi :• Pemeriksaan laboratoriumPemeriksaan laboratorium

umum/khusus/LPumum/khusus/LP• Pemeriksaan neuroimagingPemeriksaan neuroimaging

konvensional CT scan, MRI, MRS, PET, konvensional CT scan, MRI, MRS, PET, SPECTSPECT

• Pemeriksaan khusus atas indikasiPemeriksaan khusus atas indikasi EEG-Brain Mapping, EMG, Evoked EEG-Brain Mapping, EMG, Evoked potential, Doppler, Neurooftalmologi, potential, Doppler, Neurooftalmologi, NeurootologiNeurootologi

Pemeriksaan Tambahan/Penunjang

BABINSKI TELESCOPING REFLEX HAMMER

Tromner reflex hammer

This is not a reflex hammer

EEG

http://www.polysomnograph.com/images/mapping.png

TOP VIEW

INTEGRATED MAPS

Human Brain Mapping and Neuroimaging Research are new multidisciplinary fields that demand * novel statistical models and * analytic tools for quantifying disease, * temporal, age, genotypic and neurophysiological variation in the brain anatomy and function. www.stat.ucla.edu

The future of quantitative EEG for clinical applications lies, undoubtedly, in the coupling of digital methods of signal analysis and of image processing. In this picture, what you see is the combination of two remarkable devices:

the magnetic resonance scanner (MRI), which produces anatomical or functional images of the brain with great detail and

clarity, and the magnetoencephalograph (MEG). The MEG is capable of recording minute alterations in the electromagnetic field, generated by the electrical activity of neurons deep within the brain. In order to do this, it uses a magnetic pick-up coil immersed into liquid helium, named SQUID, thus achieving the phenomenon of electrical superconductivity. The resulting record is superimposed upon the anatomical image generated by the MRI scanner. In this figure, points of altered electrical activity (epileptic areas) are shown as colored circles, placed over the areas where the MEG apparatus was able to determine its location.The increased sophistication and number of resources available on computerized EEG systems and of medical imaging processing will continue to evolve. Quantitative, high resolution EEG has a bright future as a tool in the medical diagnostic work-up.

http://www.tc.umn.edu/~binhe/cit.htm

http://splweb.bwh.harvard.edu:8000/~hjpark/Snapshots/PET_MRI_EEG.jpg

EMG

MeliputiMeliputi• Pengobatan kausalPengobatan kausal• Pengobatan simptomatikPengobatan simptomatik• Pengobatan kognitif dan Pengobatan kognitif dan

neurorehabilitasineurorehabilitasi

Terapi / Pengobatan

Ilustrasi kasus aplikasi Ilustrasi kasus aplikasi neurologi klinisneurologi klinis

Seorang Seorang laki-laki berusia 60 tahunlaki-laki berusia 60 tahun datang ke datang ke dokter dg keluhan utama dokter dg keluhan utama nyeri kepala dan nyeri kepala dan sempoyongan yang muncul tiba-tiba.sempoyongan yang muncul tiba-tiba.

Sebelumnya ia merasakan Sebelumnya ia merasakan kelopak mata kelopak mata kanannya jatuh dan sukar menelankanannya jatuh dan sukar menelan makanan. makanan. Selain itu suaranya juga menjadi Selain itu suaranya juga menjadi serakserak..

Pasien memiliki kebiasaan Pasien memiliki kebiasaan merokok sejak lama merokok sejak lama dan konsumsi alkohol > 3 botol setiap haridan konsumsi alkohol > 3 botol setiap hari

RPD: RPD: Hipertensi. Minum obat tidak teraturHipertensi. Minum obat tidak teratur

PF: PF: Tekanan darah meningkatTekanan darah meningkat, ,

RR & HR dbn. RR & HR dbn.

Ptosis mata kanan, Ptosis mata kanan,

pupil anisokor kiri<kananpupil anisokor kiri<kanan, ,

refleks cornea (-)refleks cornea (-) mata kanan, mata kanan,

sensasi nyeri sensasi nyeri ↓ pada sisi kanan wajah,↓ pada sisi kanan wajah, anhidrosis anhidrosis sisi wajah kanan, sisi wajah kanan,

uvula deviasi ke kiri, uvula deviasi ke kiri,

palatum kanan jatuhpalatum kanan jatuh, ,

motorik kekuatan normal, motorik kekuatan normal,

sensasi tajam ↓ pada sisi tubuh kirisensasi tajam ↓ pada sisi tubuh kiri

KEGAGALANELEKTRIK

KEGAGALANENERGI JARINGAN

KEGAGALANHOMEOSTASIS KATION

SHIFT NEUROTRANSMITTER& KALSIUM

INTRASELTOKSISITAS Ca

INFARK&

NEKROSIS

KEGAGALANMETABOLIK

KEGAGALAN ELEKTRIK

KEGAGALANENERGI

JARINGAN

MENURUNNYAHOMEOSTASIS

KATION

PERGESERANNEUROTRANSMITTER

& Ca2+

OKSIGEN & GLUKOSA JAR.

ATP & PCr

ASIDOSIS LAKTAT JAR.

KALIUM SELULAR

Na,Ca2+, Cr, H2O SELULAR

TERJADI EDEMA SITOTOKSIK

PELEPASAN GLUTAMAT & NEUROTRANSMITTER LAIN INFLUX KALSIUM

KEGAGALANMETABOLIK

TOKSISITASCALSIUMEKSTRASELULAR

FOSFOLIPASE AS. ARAKHIDONAT LEUKOTRIN & PG

RADIKAL OKSIGEN MERUSAK MEMBRAN PROTEIN & DNA

PROTEASE MEMECAH PROTEINARGININ CITRULIN & NO

INFARKDAN NEKROSIS

KERUSAKAN BBB

EDEMA VASOGENIK(INTRASEL EDEMA)

AKTIVITAS & RECRUITMENTLEKOSIT

The Molecular Events Initiated in Brain Tissue by Acute Cerebral Ischemia

ProteinProteinsintesissintesis

AnaerobicGlycolysis

EnergyMetabolismis damaged

Anoxic Depolarization of membrane

cell

CMRG=CerebralMetabolic rate of

Glucose

Kelainan Medulla SpinalisKelainan Medulla Spinalis

Gejala & Tanda Klinis Lesi Gejala & Tanda Klinis Lesi Medulla Spinalis:Medulla Spinalis:1.1. Tanda motorikTanda motorik

A.A. Tanda Tanda LMNLMN : atrofi, hipotoni, : atrofi, hipotoni, hiporefleks, refleks patologik (-), hiporefleks, refleks patologik (-), klonus (-).klonus (-).

B.B. Tanda Tanda UMNUMN : hipertoni, hiperefleks, : hipertoni, hiperefleks, klonus (+), refleks patologik (+).klonus (+), refleks patologik (+).

2.2. Gejala nyeriGejala nyeriA.A. Nyeri RadikularNyeri Radikular: nyeri seperti ditusuk, : nyeri seperti ditusuk,

pada distribusi dermatom saraf bagian pada distribusi dermatom saraf bagian dorsal dorsal inflamasi atau kompresi saraf inflamasi atau kompresi saraf dorsal yang disebabkan lesi dorsal yang disebabkan lesi ekstramedular - medula spinalis.ekstramedular - medula spinalis.

B.B. MenyebarMenyebar, nyeri menetap, nyeri menetap lesi lesi intramedular. intramedular.

3.3. Gejala sensorikGejala sensorikA.A. Nyeri & suhuNyeri & suhu: lesi pada traktus : lesi pada traktus

spinothalamikus spinothalamikus defisit pada tubuh defisit pada tubuh kontralateral dibawah lesi. kontralateral dibawah lesi.

B.B. Posisi & rasa getarPosisi & rasa getar defisit ipsilateral defisit ipsilateral dan dibawah level lesi.dan dibawah level lesi.

Sindroma klinis medula spinalisSindroma klinis medula spinalis1.1. Mielopati transversaMielopati transversa : tanda LMN & UMN : tanda LMN & UMN

trauma, mielitis viral, MS trauma, mielitis viral, MS. . 2.2. Hemiseksi medula spinalisHemiseksi medula spinalis sindroma sindroma

Brown-Sequard Brown-Sequard gangguan nyeri & suhu gangguan nyeri & suhu kontralateral, kelemahan ipsilateral serta kontralateral, kelemahan ipsilateral serta gangguan getar dan posisi gangguan getar dan posisi trauma, trauma, tumor.tumor.

3.3. Siringomielia Siringomielia gejala LMN setinggi lesi , gejala LMN setinggi lesi , paraparesis paraparesis kongenital. kongenital.

4.4. Oklusi arteri spinalis anteriorOklusi arteri spinalis anterior hiperefleks, paraparesis spastis, hiperefleks, paraparesis spastis, hilangnya rasa nyeri & suhu dibawah lesi hilangnya rasa nyeri & suhu dibawah lesi aterosklerotik aorta. aterosklerotik aorta.

5.5. Subacute combined degenerationSubacute combined degeneration (sklerosis posterolateral) (sklerosis posterolateral) hilangnya rasa getar & posisi pada hilangnya rasa getar & posisi pada tungkai bilateral berhubungan tungkai bilateral berhubungan dengan tanda UMN dengan tanda UMN defisiensi vit defisiensi vit B 12. B 12.

6.6. Amyotrophic Lateral SclerosisAmyotrophic Lateral Sclerosis (ALS): (ALS): LMN & UMN LMN & UMN etiologi belum etiologi belum diketahui.diketahui.

7.7. Tabes DorsalisTabes Dorsalis: nyeri, parestesia, : nyeri, parestesia, hilangnya rasa getar & posisi hilangnya rasa getar & posisi NeurosifilisNeurosifilis. .

Lesi Saraf PeriferLesi Saraf Perifer

Gejala sensorik Gejala sensorik lesi saraf perifer. lesi saraf perifer. Gangguan: - distal dng pola Gangguan: - distal dng pola

glove - stockingglove - stocking polineuropati. polineuropati. Klasifikasi:Klasifikasi:

A.A. Mononeuropathy simplexMononeuropathy simplex

B.B. Mononeuropathy multiplexMononeuropathy multiplex

C.C. PolyneuropathyPolyneuropathy GBS, CIDP, metabolik GBS, CIDP, metabolik (DM).(DM).

Lesi pada Lesi pada rootroot & & plexusplexus::A.A. Lesi trauma & kompresiLesi trauma & kompresi

B.B. Tabes dorsalisTabes dorsalis

C.C. Penyakit Lyme Penyakit Lyme

Mielopati:Mielopati:A.A. SiringomieliaSiringomielia

B.B. Subacute combined degenerationSubacute combined degeneration (defisiensi Vit B12)(defisiensi Vit B12)

Neuroscience is at the frontier of investigation of the brain and mind.

The study of the brain is becoming the cornerstone in understanding how we perceive and interact with the external world and, in particular, how human experience and human biology influence each other.

The Neuroscience Program. Amherst College. Retrieved on 2008-04-15. http://en.wikipedia.org/wiki/Neuroscience