ToxicToxic-Metabolic Encephalopathies (TME), termasuk 1. Hepatic encephalopathy 2. Uremic encephalopathy 3.Wernicke-Korsakoff encephalopathy Wernicke4. Toxic encephalopathies 5.

. Hypoxic-ischemic encephalopathy HypoxicRUSDIDJAS, RUSDIDJAS, RAFITA RAMAYATI OKE RINA RAMAYANI dan ROSMAYANTY

Definition - Definisi


 

Group of neurological disorders whose hallmark is an altered mental status Kelainan syaraf ditandai dgn perobahan mental Caused by failure of organs other than nervous system or presence of an endogenous or exogenous toxin or drug Disebabkan ok gagal organ selain nervus system atau ok endogenous toxin, atau exogenous toxin atau obat2an obat2 BBB isolate brain Blood Brain Barier terisolasi dari otak / brain Multifocal cortical disorder- Kelainan cortex yg disordermultifactorial

Delirium
A confusional state with superimposed hyperactivity of the sympathetic limb of the autonomic nervous system with consequent signs including tremor, tachycardia, diaphoresis, and mydriasis - Keadaan confusion bercampur hyperactivitas dari cabang sympatetik dari syaraf autonom, akibatnya: Tremor, tachycardia, diapheresis dan mydriasis. diaphe mydriasis.  Confusion: inability to maintain a coherent stream of thought or action - Confusion : Tidak mampu mempertahankan kesadaran kesada berfikir atau berbuat


TME Toxic Metabolic Enchephalopathy

Acute toxic-metabolic encephalopathy (TME): toxicencompasses delirium and the acute confusional state Akut TME ditemukan ada Deliriun dan keadaan confusion  Acute condition of global cerebral dysfunction in the absence of primary structural brain disease -Pada kondisi akut ditemukan global cerebral dysfunction tanpa adanya gangguan struktur otak


TME
common among critically ill patients Sering pd penyakit yg kritis  probably underrecognized and undertreated - mungkin karena tak dikenali dan tak terditeksi  Most TME is reversible, making prompt recognition and treatment important - Kebanyakan TME reversible, perlu pengenalan dan pengobatan cepat  Certain metabolic encephalopathies, including those caused by sustained hypoglycemia and thiamine deficiency (Wernicke's encephalopathy), may result in permanent structural brain damage if untreated -Beberapa TME termasuk yg disebabkan oleh hypoglycemia dan TM defisiensi B1 (Wernicke's encephalopathy) bisa menyebabkan B1 encephalopathy) kerusakan otak yg permanen


Clinical manifestations TME



Mental status abnormalities :range from subtle to deep coma

-Status Mental abnormal mulai dari yg ringan deep coma



Impaired orientation, cognition, memory, affect, perception , judgement

Gangguan orientasi, cognition /daya ingat, gangg persepsi, pengambilan kesimpulan.



Pupils: sluggish, small, irregular

pupil mata lambat, kecil dan ireguler



Eye movement: disconjugate gaze

- Gerakan Mata conjugasi



Motor: increase in tone

- Tonus motorik meninggi



Spasticity with extensor plantar response

- Spastisitas dgn respons plantar yg extensi plan

Pathophysiology TME
Normal neuronal activity requires a balanced environment of electrolytes, water, amino acids, excitatory and inhibitory neurotransmitters, and metabolic substrates - Aktivitas Neuron yg normal memerlukan balans dari Elektrolit, Air, Amino Acid, rangsang dan inhibisi neurotransmitter dan substansi rangsa substan metabolik.. metabolik..  normal blood flow, normal temperature, normal osmolality, and physiologic pH are required for optimal central nervous system function -Normal blood flow, normal tempratur, normal osmolality dan fisiologik pH yg optimal fungsi CNS


1. Hepatic encephalopathy
Liver disease causes encephalopathy by 2 mechanisms : - Peny. Hati menyebabkan encephalopathy dgn 2 cara 1-Hepatocellular failure - 1. Gagal Hati 2-Diversion of toxins from hepatic portal vein into the systemic circulation 2. Diversi toxin dari Hepar dari Vena portae ke sirkuasi systemik

Precipitating factors
     

GI bleed - Perdarahan GE Drug induced - Drug Induced Excess dietary protein- Kelebihan diet protein proteinHypokalmeia - Hypokalemia Constipation - Constipasi Infections - Infeksi

2. Uremic encephalopathy
Coexistence of signs of nervous system depression (obtundation) and neural excitation (twitching, myoclonus, agitation and seizures) -Bersamaan gejala Depresi Nervous system  Due to: Oleh karena Due  Progressive azotemia Azotemia yg cepat meningkat ( sering pada peny. Ginjal)  Effect of treatment :dialysis disequilibrium syndrome, dementia from aluminum accumulation - Effek pengbatan Dialysis, dysequilibrium syndrom  Complication of transplantation and immunosupression -Komplikasi dari Transplantasi dan imunosupresion


Disorders of glucose metabolism - Gangg. Metaboline Glucose



Hypoglycemia - Hypoglycemia NonNon-ketotic hyperosmolar coma Coma ok Non Ketotic Hyperosmolar

3.Wernicke-Korsakoff encephalopathy ok Wernicke       

Chronic alcoholism Hyperemesis gravidarum Malignancy GI surgery HD Prolonged intravenous feeding Anorexia nervosa AIDS

-Kronic alkoholism -Hyperemesis Gravid -Malignancy -GE surgery -HD / Hemodyalisis -Intravenous Feeding lama Int - Anorexia nervosa -AIDS

WernickeWernicke-Korsakoff encephalopathy
Triad of :  Confusion  Opthalmoplegia  Ataxia ada Trias ( 3 tanda) -1.Confusion - bingung .Confusion -2.Ophthalmoplegia -3.Ataxia

Pathology : small hemorrhages in periventricular grey matter around aqueduct,3 aqueduct,3rd and 4th ventricles Patologi: ada perdarahan kecil2 pd periventricle, grey matter sekitar kecil2 aqueducktus, Ventricle ke 3 dan 4. Treatment : Thiamine - Thiamine glucose - Glucose

4. Toxic encephalopathies
Oleh karena:  Alcohol  Salicylaytes  Acetaminophen  Barbiturates

5.Hypoxic-ischemic encephalopathy Hypoxic

brain utilizes oxygen to metabolize glucose. It cannot store oxygen and survives only for minutes after its oxygen supply is reduced below critical levels. Otak memerlukan oxygen utk metabolisme glucose dan tidak mampu mensuplay oxygen, hanya bertahan bbrp menit sesudah oxygem suppay berkurang. Pyramidal cells in Sommer's sector of the hippocampus, Purkinje cells of the cerebellum, and pyramidal cells of the third and fifth layers of the cerebral cortex are vulnerable to even moderate degrees of anoxia Pyramidal sel di Hypocampus; Purkinye sel di cerebelum dan pyramidal sel di lapisan ke 4 dan 5 di cerebral cortex mudan rusak ok amoxia.. amoxia..

HIE (Hypoxic Ischemic Encepjalopathy), timbul akibat;



1.Anoxic anoxia consists of low arterial oxygen content and

tension. This may be secondary to decreased oxygen in the environment or inability for oxygen to enter the circulatory system as in pulmonary disease

2.Anemic anoxia consists of low oxygen content in the

blood secondary to decreased hemoglobin content.

3.Ischemic anoxia describes a state of insufficient cerebral

blood flow. "Low-flow states" may be secondary to "Lowcardiovascular collapse or conditions of increased vascular resistance as in stroke or migraine

HIE


 

Result from a number of conditions such as: -Akibat dari bbrp kondisi seperti; Cardiac arrest - Henti Jantung CO intoxication - Intoxikasi carbon monox monoxyda Septic shock - Septic Shock Septic

Prognosis and Complications

postpost-arrest coma longer than three days carried an unfavorable prognosis -Coma lebih dari 3 hari prognosis kurang baik ba  Individuals with the best chance of recovery had preserved brainstem function following the initial insult -Penderita yg sembuh ok fungsi brainsstem baik


Management Enchephalopathy, sesuai dgn penyebab!

     

obat

Diagnostic difficulty: drugs, sepsis -Diagnosis sukar ; kalau akibat obat2an / sepsis obat2 Continuos monitoring -Terus menerus dimonitor Watch for complications: -Awasi komplikasi yang muncul CT brain -CT scan LP - LP EEG -EEG

TERIMA KASIH