kuliah-tumor intra kranial
DESCRIPTION
neurologiTRANSCRIPT
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TUMOR INTRA KRANIAL
Dr. Syarif Indra, Sp.SBagian Neurologi
Fakultas Kedokteran Universitas AndalasRS. DR. M. Djamil Padang
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Tumor intrakranial : Massa intrakranial baik primer maupun sekunder yang memberikan gambaran klinis proses desak ruang dan atau gejala fokal neurologis
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Insiden• Tahun 1983 diperkirakan 400.000 orang
meninggal akibat kanker di USA
• 12.000 pasien meninggal karena tumor primer otak dan 70.000-80.000 orang meninggal akibat metastase
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Etiologi• Antecedent :
– Trauma kepala– Infeksi– Kelainan metabolik & penyakit sistemik lainnya– Toksin & Radiasi– Genetik– Sel embriogenik– Karsinogen
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• Tumor berasal dari jaringan vestigial :– Craniopharyngiomas, teratomas, lipomas
and chordomas • Berasal dari glioblast :
– Gliomas • Penyakit genetik:
– Von Reckling Hausen neurofibromatosis, tuberousclerosis, hemangioblastomatosis
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• Tumor yang berasal dari neural tube: – Polar spongioblastoma– Retinoblastoma– Gliomas of optic nerve– Hypothalamus– Cerebellum and spinal cord.
• Tumor berdasarkan usia:– Medulloblastoma– Polar spongioblastoma (piloid astrocytomas)– Pinealomas (< 20 tahun)
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• Meningioma & glioblastoma sering pada usia 50 tahun
• Zat karsinogen : Hydrocarbons dan nitrosamins penyebab glioma
• Konsep patogenesis tumor primer pada SSP : 1. Histogenic theory 2. Neoplastic transformation
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Jenis-jenis Tumor IntrakranialTumor Percent of total
Gliomas :Glioblastoma multiformeAstrocytomaEpendymomaMedulloblastomaOligedendrocytoma
2010645
Meningioma 15Pituitary adenoma 7Neurinoma (Schwannoma) 7Metastatic carcinoma 6Craniopharyngioma, teratoma 4Angiomas 4Sarcomas 4Unclassified (mostly gliomas) 5Miscellaneous(pinealoma, chordoma) 3
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Gejala Klinis• Tanda umum peningkatan TIK :
– Sakit kepala– Mual & muntah– Kejang– Penurunan kesadaran
• Gejala fokal :– Hemianopsia homonim, tidak bisa melokalisir– Perubahan status mental & sensasi– Perubahan fungsi hormonal
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• Tumor intra kranial dapat menyebabkan herniasi: –Herniasi falk–Herniasi trans tentorial–Herniasi tonsilar–Herniasi uncal
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Tipe-tipe Tumor• Tumor primer:
– 90 - 94 % tumor intrakranial berasal dari sel parenkim, meningen, pembuluh darah, hipofise, sel embrional dan selubung saraf
• Tumor sekunder (metastasis)– 5 % – Berasal dari paru, tulang, tiroid, mammae,
servix dan prostat
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Topografi• Supra tentorial:
– Hemisfer : 1. Astrocytoma 2. Glioblastoma 3. Metastasis 4. Meningioma 5. Lymphoma
– Sellar zone : 1. Pituitary adenoma 2. Craniopharyngioma 3. Meningioma 4. Optic and hypothalamic glioma
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• Pineal zone : 1. Pineocytoma
2. Pineoblastoma 3. Germinoma 4. Astrocytoma
5. Metastasis
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• Infratentorial tumors :
– Midline : Pediatric
Medulloblastoma Ependymoma Pontine glioma
Adult Pontine glioma Schwannoma Meningioma CP papilloma Metastasis
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• Cerebellar hemisphere :
– Pediatric Juvenile Astrocytoma
– Adult 1. Hemangioblastoma 2. Astrocytoma 3. Metastasis 4. Medulloblastoma
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• Malignant tumors 1. Astrocytoma grade III & IV
2. Ependymoma grade I - IV 3. Oligodendroglioma 4. Medulloblastoma 5. Neuroastrocytoma
• Benign tumors 1. Meningioma 2. Craniopharyngioma 3. Neurolemoma
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• Foster-Kennedy Syndrome - Fronto basal tumor symptom :
1. Papil atrophy ipsilateral 2. Anosmia ipsilateral 3. Papil oedema contralateral
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Pemeriksaan Penunjang
• Foto polos Schaedel– Erosi bagian posterior dorsum sella– Ballooning sella – Impression digitate
• Angiografi• CT Scan• MRI
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Diagnosis Banding
• Abses serebri• Subdural hematoma• Tuberkuloma• Pseudotumor serebri
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Terapi• Medikamentosa
– Kortikosteroid– Manitol
• Antikonvulsan • Operatif• Radiasi
– Kuratif : Medulloblastoma – Mencegah eksaserbasi :
Astrocytoma, oligodendroglioma, ependymoma, chordoma, metastasis
• Kemoterapi
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PROGNOSIS• Tumor ganas : Tidak memuaskan• Tumor jinak : Baik
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MeningiomaPendahuluan• Tumor jinak >>, 15-20% dari tumor
intrakranial, 25% dari tumor intra spinal• Berasal dari sel arakhnoid menekan
korteks & saraf kranial• Insiden : ♀ : ♂ = 3 : 2 (berkaitan dengan
estrogen)• Rekurensi tinggi 20%
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Gejala Klinis Sakit kepala Kejang Perubahan status mental Defisit neurologis fokal Insiden kejang pasca operasi >>>
Lokasi otak yang terkena : Parasagital (25%) Konveksitas (20%) Sphenoid wing (10%) Olfaktory groove (10%) Suprasella (10%) Fossa posterior (10%) Intraventrikel (2%) Lain-lain (3%)
Tergantung lokasi yg terkena
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Diagnosis :• Foto polos kepala hiperostosis,
erosi, pelebaran pembuluh darah & kalsifikasi
• Angiografi (konfirmasi vaskularisasi tumor)
• CT scan (dengan & tanpa kontras)• D/ pasti : PA (klasik, angioblastik,
agresif & maligna) Psammoma body : prognosis lebih baik
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Terapi • Operatif : reseksi total jaringan tumor• Radiasi:
– Mencegah rekurensi: residu tumor (+)– Tumor non operatif
• Terapi pd meningioma rekurensi : antiprogesteron mifepristone
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AstrositomaPendahuluan• Berasal dari astrosit• Klasifikasi WHO : grade I – IV• Glioblastoma multiforme (GBM) : paling
ganas & paling sering, >> pd dewasa (> 50 thn), ♀ : ♂ = 2 : 3
• Astrositoma grade rendah >> pd usia muda (35 thn)
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Gejala klinisKombinasi dari kompresi & infiltrasi jaringan sekitar tumor, kompresi vaskular & peninggian tekanan intrakranial• Gejala umum peningkatan TIK : sakit kepala, mual,
muntah, vertigo & dizzines• Gejala fokal (tergantung lokasi, ukuran & kecepatan
tumbuh tumor ) : hemiparesis, afasia, gangguan penglihatan & gangguan sensoris
• Tumor >> di frontal & temporal : perubahan perilaku, afasia motorik & sensorik, gangguan memori
• Tumor pd girus angularis : sindroma Gerstman
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Diagnosis :• MRI : lesi hiperintens / isointens
homogen
Terapi :– Mediakamentosa : dexametason, manitol &
antikejang– Operatif + pemeriksaan PA– Radiasi (exterbal beam radiotherapy)– Kemoterapi
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Tumor HipofisisPendahuluan• Insiden : 5-20 % dari tumor intrakranial
urutan ketiga setelah glioma & meningioma
• Frekuensi sama ♀ : ♂ , 2-5 % pd anak• Termasuk kelompok sindroma multiple
endocrine neoplasia tipe I
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Gejala Klinis
Hiperfungsi kelenjar, insufisiensi kelenjar & efek massa
Hipersekresi : Prolactine Releasing Hormon (PRL) :
amenorea, galaktore, impotensi & penurunan libido
Growth Hormone (GH) : akromegali & gigantisme
Efek massa : Sella : nyeri kepala Jaras visual anterior : gangguan lapang
pandang & visus Hipotalamus : gangguan tidur, kewaspadaan,
perilaku, pola makan & emosi
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Diagnosis Radografi : makrodenoma & mikroadenoma Foto sella MRI Pemeriksaan hormon : PRL, GH, kortisol
darah, ACTH, LH/FSH & TSH
Terapi Operatif Glukokortikoid perioperatif : meminimalisasi
gangguan aksis hipotalamus hipofisis Radioterapi : mencegah pertumbuhan &
rekurensi
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Neurinoma AkustikPendahuluan • Disebut schwannoma vestibuler :
berasal dari sel schwan N. VIII• Tumor jinak, 3-8 % dari tumor
intrakranial, >> pd usia 50 thn, ♀ < ♂ , >> pd cerebellopontin
• Dapat mengakibatkan obstruksi ventrikel IV hidrosefalus
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Gejala KlinisVertigo, dizzines, tinnitus, hipestesi wajah, facial twitching, gangguan menelan, gangguan gait, penurunan kesadaran, sakit kepala & muntah bila hidrosefalus (+)
PemeriksaanFisik
Nistagmus, lesi N.VIII, gangguan sensorik & motorik wajah, ataksia gait, gangguan cerebellum serta papil oedem
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Pemeriksaan Penunjang• Audiometri• CT scan • MRI
Terapi• Operatif : resekti total segera
(microsurgery)• Kortikosteroid : dexametason pasca
operasi
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Tumor MetastasisPendahuluan Paling banyak Pada dewasa 30 %, pada anak 6-10% Berasal dari paru, mammae dan melanoma
(paling sering) Cerebrum >> Cerebellum (banyakya aliran
darah) Tumor pelvis dan abdomen fossa posterior Mampu metastase karena : tumbuh secara
efisien, penetrasi p.darah & limfe, terperangkap dimikrosirkulasi, ekstravasasi, migrasi ke organ target TUMBUH
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Gejala Klinis• Akibat peningkatan tekanan intrakranial
oleh massa tumor, oedem & hidrosefalus – Sakit kepala– Kejang– Penurunan kesadaran– Perubahan kognitif – Kelemahan ekstremitas
• Interval waktu tumor primer & metastasis bervariasi– Tumor paru : 4 bulan– Tumor payudara : 3 tahun
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Diagnosis Curiga pd pasien tumor dengan defisit
neurologis fokal CT Scan MRI
Terapi Kortikosteroid : untuk menurunkan
permeabilitas kapiler & oedem vasogenik Operatif Radiasi : Whole brain radiotherapy Radiosurgery Kemoterapi
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Kasus baru tumor otak
Dokter umum, neurolog, non neurolog
NEUROEMERGENSIPem. Neurologis klinis
Antisipasi Medis
Ro, CT scan, MRI, MRA, MRS, PETLab : tumor markerEE, EMG, EKG, EP, Dopler
Bukan Tumor OtakTumor
OtakTumor otak primer
Tumor otak sekunder
Konsul bedah saraf :VP shuntBiopsi
Perawatan lanjutan
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