CURRICULUM VITAE
PENDIDIKAN
• Fakultas Kedokteran Universitas Indonesia 1989
• Spesialisasi Ilmu Kesehatan Anak Fakultas Kedokteran
Universitas Padjadjaran 1999
• Konsultan Neurologi Kolegium Ikatan Dokter Anak Indonesia
2013
• Training of Pediatric Neurology, Child Epilepsy dan Neonatal
Neurophysiolgy, Unversity Medical Centre Utrecht, The
Netherland, 2006
• Training of Assessment and Using Dir/Flooltime, Model to Treat
Children with Developmental Challenges Interdisciplinary dr. Dewi Hawani, Sp.A(K)
Council and Developmental and LearningDisorder (ICDL), USA, Staf Divisi Neuropediatrik
2009
KSM/Departemen Ilmu Kesehatan
Anak
PEKERJAAN RSHS/FK UNPAD
• Staf Divisi Neurologi Pediatri Departemen/KSM Ilmu Kesehatan
Anak Fakultas Kedokteran Universitas Padjadjaran/RSUP Dr.
Hasan Sadikin
Tatalaksana
Peningkatan Tekanan
Intrakranial
dr. Dewi Hawani, Sp.A(K)
Purwasuka Pediatric Update
Karawang, July 2024
Pendahuluan
● Tekanan tinggi intrakranial (TTIK) :
tekanan intrakranial menetap lebih dari 20 mmHg
selama lebih 5 menit
● Peningkatan tekanan intrakranial, meningkatkan
morbiditas dan mortalitas
● Keberhasilan menurunkan TTIK dalam 24 jam pertama,
memperbaiki luaran pasien
Patofisiologi :
Monroe-Kellie doctrine
● Volume within the skull is fixed
● Composed :
brain tissue (~80%)
blood volume (~10%)
CSF volume (10%)
● Any increased in the volume of the
component had to reduction the
volume of one or both the remaining
component
Patofisiologi
CPP = MAP -
ICP
CPP = cerebral Perfusion Pressure
MAP = Mean Arterial Pressure
ICP = intracranial Pressure
Cerebral Autoregulation
Increased intracranial pressure
Decreased cerebral blood flow
Ischemic, Cell Death
Cerebral edema
Etiologi
Gejala klinis
brain herniation
● 1. cingulate
● 2. transtentorial
● 3. uncal
● 4. tonsillar
Clinical symptoms & signs
acute ICP in infants and children
Headache (children) Neurological Examination
Full fontanel (infant) Loss of consciousness (LOC)
Altered mental status Pupillary dilated
Vomiting Cranial nerve palsy (III and VI)
Visual change Papiledema
Blurred/ double vision Meningeal sign
Photofobia
Pathological reflex : Babinski
Altered vital sign :
Hypertension
Bradikardia
Bradipneu
(impending brain herniation)
Diagnosis raised ICP
Physical Exam :
● Loss of Conciousnes (LOC)
GCS<8
● Pupil Dilated
● Motor Posture
Brain imaging (CT/MRI):
● Basal cistern absent or compressed
● Midline shift
Imaging characteristics of raised ICP
● Space Occupying lesion
● Compression of basal cistern
● Midline shift
● Effaced sulci
● Cerebral edema
CT scan: Compression of basal cistern
Brain CT on raised ICP
MRI : hidrocephalus
CT scan : cerebral edema
Brain CT on raised ICP
Basal cistern Midline shift
compressesed
Monitoring TTIK
Direct/invasive
● Intraventricular device
● Parenchymal devices
● Subdural/epidural devices
Point of Care Ultrasound (POCUS)
POCUS (point of care ultra sound)
Optic Nerve Sheath Diameter Evaluation
Diagnosing raised ICP :
ONSD (Optic Nerve Sheath Diameter)
Diameter cut off
Infants 4 mm
Children (1-10 years) 4.71 mm
Older than 10 years 5.43 mm
Management
increased
intracranial pressure
Tujuan :
• Mempertahankan aliran
darah otak
• Mencegah herniasi otak
Step wise protocol
berdasarkan beratnya gejala
Mempertahankan:
• CPP 60-70 mmHg
• Intracranial pressure < 20
mmHG
Management ICP : Step Wise Protocol
TIER 1 TIER 2
● Menurunkan metabolism otak ● Hyperosmolar terapi
Analgesia ● Drainase likuorcerebrospinal (LCS)
Menurunkan hiperpireksia ● Hyerventilasi
Sedasi ● Mild hypotermia
Obat neuromuscular blok
● Kepala : head up 30-45 derajat
● Kontrol gula darah TIER 3
● Profilaksis kejang Barbiturate coma
Decompressive craniectomy
Hyperosmolar Agent for cerebral edema
Mannitol 20% mekanisme :
Dosis 0,25 – 1g/ Kg IV, evaluasi tiap 8 jam
Perbaikan aliran darah
Stop maksimal 48 jam
Osmotic efek
Hindari severe hypernatremia and
hyperchloremia Efek samping:
Hipotensi
Untuk mengurangi resiko Acute Kidney Injury Dehidrasi
(AKI) :
Upper Natrium serum : 155 -160 mEq/L
Serum chloride : 110 – 115 mEq/L
Pantau kadar osmolaritas darah,
dipertahankan dibawah 320 mOsm/L
Periksa fungsi ginjal tiap hari selama pemberian
obat
Hyperosmolar Agent for cerebral edema
Hypertonic Saline (HTS) 3 %
Mekanisme : efek osmotik
Dosis :
Bolus 1 – 6 mL/Kg, intravena
dilanjutkan
Continous 0,1 – 1 mL/Kg/jam dititrasi untuk maintain
ICP < 20 mmHg
Evaluasi perabaikan, stop maksimal 48 jam
Serum osmolality harus dipertahankan < 320 mOsm/L
Hati2 bisa renal insuffisiensi
Key Message
● TTIK harus ditangani segera untuk mencegah
kerusakan otak lebih lanjut
● Penanganan yg tepat akan menurunkan morbiditas
dan mortalitas
● Anamnesis, pemeriksaan fisik/neurologik dan
pencitraan membantu diagnosis
● Hiperosmolar agent diberikan untuk mengatasi edema
serebri
Terima Kasih
Management of raised ICP
● Initial stabilization & resuscitation
● ● Analgesic and sedation
Intubation
● ● Anticonvulsant
Mechanical ventilation
● ● Glucosa & Nutritional modification
Volume resuscitation
● ● Neuromuscular blocade
Brain surgery
● ● Sedation and analgesia for intervention
Head positioning and posture
Hidrocephalus communican
Edema cerebri
Subdural hematoma
Epidural Subdural
hematoma hematoma
