Diagnosis Topis SA
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TOPICAL DIAGNOSIS
Hasmawaty Basir
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PENDAHULUAN
In Neurology ; 3 diagnosis :1. Clinical Diagnosis 2. Topical Diagnosis 3. Etiological Diagnosis
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I. Clinical Diagnosis based on :description of clinical signs & symptoms .
Examples: - Typical hemiparesis : hemiparesis+ Cr nv paresis
contralateral - Alternans hemiparesis : contralateral hemiparesis+ Nn Cr paresis ipsi/homolateral lesion
- tetraparesis / paraparesis UMN/LMN - cephalgia, seizure, demensia, motoric afasia
- encephalopati, etc
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II. Topical Diagnosis based on : signs & symptoms related with lesion localisation in central nervous systemExamples : - (lesion) hemisfer serebri
sinistra / dekstra - (lesion) (pons / medulla
oblongata / mesensefalon) - (lesion) spinal cord, cranial nv,
spinal nv - etc.
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III. Etiological Diagnosis based on symptoms, signs, lesion localisation,related with pathological process in central nervus system Example : - spinal cord tumour - meningitis -spinal cord trauma - etc
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Dengan demikian resume suatu status neurologis, selalu diakhiri dengan :
Contoh Diagnosis Klinis : hemiparese sinistra cum parese N VII dan XII
tipe sentral. Diagnosis topis : hemisfer serebri dekstra
Diagnosis etiologis : tumor intra kranial
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TANDA-TANDA KLINIS SUATU LESI BERDASARKANLOKALISASI / TOPIS:
I. LESI DI KORTEKS SEREBRILesi struktural :
- hemiparese / plegia tipika UMN - paraparese UMN : lesi di falx cerebri - monoparese / plegia UMN - afasia motorik, sensorik, global dan gangguan fungsi luhur lainnya
Lesi iritatif :- kejang umum (tonik klonik)- kejang parsial (Jacksonian’s type)
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II. LESI DI CAPSULA INTERNA - Lesi kecil : pure motor hemiplegia tipika - Lesi besar : hemiparese / plegia tipika +
hemianestesi
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III. LESI DI BATANG OTAK Tanda umum : hemiparese / plegia alternans: Lokalisasi tergantung dari :- Nn Cr apa yang terlibat - Atau adanya tanda lain yang menyertaisehingga kumpulan tanda-tanda yang ditemukan tergabung dalam apa yang disebut sindrom batang otak.
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a. Lesi di medulla oblongata 1. Sind Lateralis (Wallenberg Syndrome)
Penyebab tersering : trombosis pada PICA (Posterior Inferior Cerebellaris Artery)
- parese N IX, X homolateral- vertigo (gangguan vestibuler)- ataksia homolateral- hemihipestesia alternans
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- Horner syndrome yang tidak lengkap di sisi homolateral
• Miosis : timbul karena lemahnya m. dilatator pupillae
• Ptosis : timbul karena lemahnya m. tarsalis sup
• Enoftalmus : timbul karena lemahnya m. orbitalis
• Anhidrosis pada wajah ipsilateral
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2. Sindrom Retro Olivar : - parese NIX, X, XI, XII
- hemihipestesi kontralateral
3. Sindrom Pra Olivar : - hemi plegia kontralateral
- parese N XII homo / ipsilateral - hemihipestesia kontralateral
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b. Lesi di PONS
1. Sindrom Millard Gubler - parese N VI dan VII homolateral
- hemiparese / plegia kontralateral
2. Sindrom Raymond – Cestan - ataksia serebellar homolateral - hemihipestesia kontralateral - gangguan rasa sikap kontralateral - deviation conyugee pontis
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3. Sindrom Foville (lesi di paramedian PONS)
- hemiparese / plegia kontralateral - deviation conyaguee pontini - hemihipestesia kontralateral
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c. Lesi di MESENSEFALON
1. Sindrom WEBER : disebut pula hemiparese / plegia alternans N III - hemiparese / plegia kontralateral - parese N III homolateral Penyebab tersering : strok, hematoma Epidural
2. Sindrom BENEDIKT - parese N III homolateral - hemimovement disorder kontralateral (hemichorea,
hemiatetosis, atau hemiparkinson)
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3. Sindrom CLAUDE - parese N III homolateral - hemiataksia kontralateral - hemihipestesia kontralateral
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IV. LESI DI MEDULA SPINALIS1. Setinggi segmen cervical (C1 – C3):
- tetraparese / plegia UMN - hip / anesthesia dari akral s/d
distribusi segmental medulla spinalis yang terganggu
- gangguan susunan saraf otonom (miksi, defekasi, fungsi
seksual)
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2. Setinggi segmen C4 – Th 1 - tetraparese / plegia :
setinggi lesi → LMN di bawah lesi → UMN
- hip / anesthesia setinggi segmen m.s yang terganggu
- gangguan SS otonom
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3. Setinggi Th 2 s/d bagian atas pleksus lumbosakral - paraparese / plegia UMN - hip / anesthesia setinggi segmen
m.s yang terganggu - gangguan SS otonom
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4. Setinggi pleksus lumbosakral - paraparese / plegia LMN - hip / anesthesia setinggi segmen
m.s yang terganggu - gangguan SS otonom
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5. Setinggi konus medularis - anastesia selangkang ( saddle anaestesia) simetris - gangguan SS otonom - refleks anus negative
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6. Setinggi cauda equina - anastesia selangkang asimetris - gangguan SS otonom - tanda laseque positif
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7. Lesi yang mengenai separuh potongan melintang medulla spinalis (hemilesi di m.s) akan menimbulkan SINDROM BROWN – SEQUARD dengan tanda sbb:a. kelumpuhan extr. Sup dan atau
extr. Inf. homolateral : disebabkan oleh terputusnya traktus piramidalis sesisi
b. gangguan proprioseptif homolateral : disebabkan oleh terputusnya traktus Goll dan Burdach sesisi
c. gangguan eksteroseptif kontralateraldisebabkan oleh terputusnya traktus
spinothalamikus yang membawa impuls dari kontralateral
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contoh : hemilesi di m.s Th.4 kiri akan ditemukan kelainan sbb :a. motorik : monoparese inferior kirib. proprioseptif : rasa sikap terganggu di kaki kiric. exteroseptif : hip / anestesi di extr inf kanan
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MENENTUKAN TINGGI LESI DI MEDULA SPINALISPeriksa batas atas dari gangguan sensibilitas, dengan cara :
• pemeriksaan eksteroseptif• tes keringat (tes perspirasi)
lalu cocokkan temuan yang diperoleh dengan peta sensibilitas dari FOERSTER
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Bila batas atas setinggi :• papilla mammae, maka medulla
spinalis yang bermasalah terletak di segmen Th.4.
• pusat / umbilicus : Th. 10• lipat paha : Th. 12 / L.1• dst
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MENGAITKAN LESI di MEDULA SPINALIS dengan DUGAAN LESI TERSEBUT DITIMBULKAN OLEH KELAINAN PADA RUAS TULANG BELAKANG
Semasa embrional, pertumbuhan med. Spinalis jauh lebih lambat daripada pertumbuhan columna vertebrae, sehingga pada waktu lahir ujung bawah medulla spinalis terletak setinggi corpus vertebra L1 – L2. Keadaan ini tidak berubah lagi dan disebut ASENSUS MEDULLAE, sehingga akan tampak bahwa :
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1. segmen C3 terletak di belakang ruas corpus vertebra C22. segmen C6 terletak di belakang ruas corpus vertebra C43. segmen Th4 terletak di belakang ruas corpus vertebra Th14. segmen Th8 terletak di belakang ruas corpus vertebra Th55. segmen L1 terletak di belakang ruas corpus vertebra Th96. segmen L4 terletak di belakang ruas corpus vertebra Th117. segmen sakral terletak di belakang ruas Th12 – L1
Hal tersebut di atas perlu diingat untuk dijadikan panduan dalam meminta sentrasi atau fokus suatu foto tulang belakang.
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