BRAINSTEM

Dr. Ahmad Muzayyin, Sp.S., M.Kes.

Major Regions and Landmarks

Figure 141

Embryology of the Brain

Table 14-1

Regions of the Adult Brain

Telencephalon (cerebrum) cortex, white matter, and basal nuclei Diencephalon thalamus, hypothalamus, and epithalamus Mesencephalon midbrain (brain stem) Metencephalon pons (brain stem), cerebellum Myelencephalon medulla oblongata (brain stem)

Basic Pattern of the Central Nervous System

Spinal Cord
Central cavity surrounded by a gray matter core External to which is white matter composed of myelinated fiber tracts

Brain
Similar to spinal cord but with additional areas of gray matter Cerebellum has gray matter in nuclei Cerebrum has nuclei and additional gray matter in the cortex

Figure 12.4

Some terms
nucleus: collection of neuron cell bodies in the CNS tract: collection of axons in the CNS ganglia: collection of neuron cell bodies in the PNS nerve: collection of axons in the PNS
Cranial nerves Spinal nerves

The Brain Stem

Processes information between spinal cord and cerebrum or cerebellum Controls automatic behaviors necessary for survival Associated with 10 of the 12 pairs of cranial nerves (covered later) Includes:
mesencephalon (midbrain) pons medulla oblongata Note: some consider the diencephalon part of the brain stem as well

Brain Stem

Figure 12.15a

Anatomy: Brain stem

Most cranial nerves are located in the brain stem

Brain Stem

Figure 12.15b

Posterior view

Medulla Oblongata
Most inferior part of brain, connects brain to spinal cord Relays information Pyramids two longitudinal ridges formed by corticospinal tracts Regulates autonomic functions:
regulates arousal, heart rate, blood pressure, pace for respiration and digestion

Cranial nerves IX, X, XI, XII come off or go into

Medulla Oblongata

Figure 12.16c

Medulla Oblongata

Medulla Nuclei
Cardiovascular control center adjusts force and rate of heart contraction Respiratory centers control rate and depth of breathing Additional centers regulate vomiting, hiccuping, swallowing, coughing, and sneezing

Lesi di Medula oblongata

Sindrom Pra- Olivar : (Hemiplegi alternans) Hemiplegi kontralateral Paralisis N.XII homolateral Hemihipestesia kontralateral Sindrom Retro-Olivar : Lesi pd N.IX, X, XI, XII & Trakt. Spinotalamikus Sindrom Lateralis (Wallenberg) : Hemihipalgesia & hemitermestesia alternans Lesi N.IX, X homolateral Gangguan vestibuler Ataxia homolateral Horner tidak lengkap homolateral

Pons

Pons
Involved in somatic and visceral motor control Contain the nuclei for cranial nerves V, VI, VII, VIII Contains nuclei of the reticular formation Control of respiration that modifies the info from the medulla Nuclei and tracts passing through to the cerebellum (motor and somatosensory info) Nuclei and tracts to other portions of the CNS (just passing through)

Lesi di Pons
Sindrom Foville : (Hemiplegi alternans okulomotori) Hemiplegi kontralateral Deviation conjugate pontin Dapat pula tampak hemihipestesia kontralateral Sindrom Raymond-Cestan : Ataxia cerebellar homolateral Hemihipestesia kontralateral Dapat pula terdapat deviation conjugate pontin Sindrom Millard-Gubler : Paralisis N.VI, VII homolateral Hemiplegi kontralateral

Mesencephalon

Mesencephalon
Also called midbrain Processes sight, sound, and associated reflexes Maintains consciousness Cranial nerve nuclei III and IV 2 basic divisions
tectum (roof) tegmentum

Mesencephalon
Process of visual and auditory sensations
corpora quadrigemina (in tectum) = superior colliculi (visual reflex) and inferior colliculi (auditory reflex)

Substantia nigra (in tegmentum)

Neurons inhibit activity of cerebral nuclei by releasing dopamine If damaged, results in less dopamine released and muscle tone increases: muscle rigidity, difficulty initiating movement = Parkinsons Disease

Reticular formation: maintain consciousness

Midbrain Nuclei

Figure 12.16a

Mesencephalon

Lesi di Mesensefalon
Sindrom Weber : (Hemiplegi alternans) Hemiplegi kontralateral Paralisis N. III homolateral Sindrom Benedict : Paralisis N. III homolateral Di sisi kontralateral dapat tampak : hemikhorea, hemiatetosis Kadang dapat pula hemiparkinson Sindrom Claude : Paralisis N.III homolateral Hemiataxia kontralateral Kadang dapat pula hemihipestesia kontralateral

MATI
Mati adalah proses yg berlangsung secara berangsur. Tiap sel dalam tubuh manusia mempunyai daya tahan yg berbeda-beda terhadap tidak adanya oksigen & oleh karenanya, mempunyai saat kematian yg berbeda pula. Bagi dokter, kepentingan bukan terletak pada tiap butir sel tersebut, tetapi pada kepentingan manusia itu sebagai kesatuan yg utuh.

MATI
Ada 3 organ penting dlm penentuan kematian: jantung, paru-paru & otak (khususnya batang otak). Kerusakan permanen pada batang otak, merupakan tanda bahwa manusia itu secara keseluruhan tidak dapat dinyatakan hidup lagi.

MATI
Definisi mati: Seseorang dinyatakan mati bilamana: a. fungsi spontan pernapasan & jantung telah berhenti secara pasti atau irreversibel, atau b. bila terbukti telah terjadi kematian batang otak.

Diagnosis Mati Batang Otak (MBO)

Ada tiga langkah untuk menegakkan diagnosis MBO: a) meyakini bahwa telah terdapat pra kondisi tertentu, b) menyingkirkan penyebab koma dengan henti napas yg irreversibel, c) memastikan a-refleksia batang otak & henti napas yg menetap. Bila setiap kasus didekati secara sistematis, tak akan terjadi kesalahan

Diagnosis Mati Batang Otak (MBO)

Terdapat dua pra kondisi yg diperlukan: a) bahwa pasien dalam keadaan koma & henti napas, yaitu tidak responsif & dibantu ventilator, b) bahwa penyebabnya adalah kerusakan otak struktural yg tidak dapat diperbaiki lagi, yg disebabkan oleh gangguan yg dapat menuju MBO.

Refleks batang otak

Respons terhadap cahaya Refleks kornea Refleks vestibulo-okular Respons motor dalam distribusi saraf kranial thd rangsang adekuat pada area somatik. Refleks muntah (gag reflex) atau refleks batuk thd rangsang oleh kateter isap yg dimasukkan ke dalam trakea Dolls eyes phenomen

Pupillary Reflex
Pupils dilated with no constriction to bright light

Eye Movements

Occulo-Cephalic Response Dolls Eyes phenomen

Eye Movements

Oculo-Vestibular Response Cold Caloric Testing

Facial Sensation and Motor Response

Corneal Reflex

Jaw Reflex Grimace to Supraorbital or Temporo-Mandibular Pressure

Tes Henti Nafas

Pre oksigenasi dengan 100% selama 10 menit Beri 5% CO2 selama 5 menit berikutnya untuk menjamin PCO2 awal 53 kpa (40 torr) Lepaskan pasien dari ventilator. Insuflasikan trakea dengan 100% 02 : 61/menit melalui kateter intratrakea lewat karina. Lepas dari ventilator selama 10 menit. Jika mungkin periksa PCO2 akhir.

Confirmatory Testing

Recommended when the proximate cause of coma is not known or when confounding clinical conditions limit the clinical examination

Confirmatory Testing
EEG

Normal

Electrocerebral Silence

Confirmatory Testing
Cerebral Angiography

Normal

No Intracranial Flow

Confirmatory Testing
Technetium-99 Isotope Brain Scan

Confirmatory Testing
MR- Angiography

Confirmatory Testing
Transcranial Ultrasonography

Confirmatory Testing
Somatosensory Evoked Potentials