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Mengenal Nyeri Kepala (TERBARU) - Diagnosis, Pemeriksaan Fisik, Terapi



Nyeri kepala disebabkan karena penekanan pada bangunan-bangunan peka nyeri yaitu sinus venosus, arteri, vena dan duramater. Nyeri kepala akibat peningkatan tekanan intrakranial ditandai nyeri kepala menyeluruh, diperberat dengan batuk atau mengejan, memburuk pada pagi hari, berlangsung progresif, dengan makin meningkatnya tekanan intrakranial akan terdapat muntah, kehilangan penglihatan sementara pada perubahan posisi dan terjadi penurunan kesadaran (Lindsay, 2010).

Tumor Otak
Neoplasma dapat mengenai susunan saraf pusat melalui tiga cara. (1). Tumor primer yang berasal dari otak, medula spinalis, atau bangunan di sekitarnya, (2). Tumor metastasis yang merupakan penyebaran dari tumor primer di tempat lain, (3). Kerusakan otak dan medulla spinalis secara tidak langsung akibat adanya tumor di tempat lain (Gilroy, 2000).
Insidensi tumor otak, baik primer maupun sekunder (metastasis) adalah 15–20 per 100.000 penduduk Amerika Serikat (Huff, 2001). Lebih kurang 80% merupakan tumor primer dan 20% adalah metastasis. Glioma adalah jenis yang paling sering ditemukan. Jenis non glioma terdiri atas meningioma, adenoma pituitary dan akoustik neuroma (Gilroy, 2000).
            Gejala dan tanda klinik awal tumor otak sangat bervariasi tergantung pada lokasi tumor. Manifestasi gejala juga sangat tergantung dari mekanisme yang mendasari yaitu: (1) peningkatan tekanan intrakranial, (2) kompresi langsung dan tidak langsung pada jaringan otak, (3) pergeseran isi intrakranial, serta (4) akibat iskemia serebral. Tumor primer berasal dari jaringan otak sendiri, biasanya diklasifikasikan berdasarkan jaringan asalnya (astrositoma, meningioma, ependimoma, oligodendroglioma, dan meduloblastoma). Tumor otak primer biasanya non invasif dan jarang menginfiltrasi jaringan sekitarnya (Wahjoepramono, 2006).

Tuberkuloma
Tuberkuloma intrakranial adalah lesi pada jaringan otak berupa masa padat yang merupakan kumpulan jaringan nekrotik akibat infeksi Mycobacterium tuberkulosis. Di negara-negara berkembang, 30% lesi desak ruang intrakranial merupakan tuberkuloma. Sedangkan di negara-negara maju, tuberkuloma intrakranial jauh lebih sedikit, sekitar 0,1%-0,2%. dari lesi desak ruang. Tuberkuloma secara tipikal merupakan lesi yang soliter, tetapi 15%-34% kemungkinan multipel, yang tumbuh dari penyebaran secara hematogen dari fokus ekstra serebral. Infeksi secara spesifik disebabkan oleh Mycobacterium tuberculosa. Spesies Mycobacterium lainnya dapat juga sebagai penyebab infeksi, seperti misalnya Mycobacterium africanum, Bovine tubercle baccilus, ataupun non-tuberculous mycobacteria. Mycobacterium tuberkulosa paling banyak ditemukan dari kultur tuberkuloma intrakranial (Perspebsi, 2004).
Tanda dan gejala tergantung pada lokasi primer massa, tapi kebanyakan kasus terdapat nyeri kepala, muntah dan kejang. Diagnosis tuberkuloma dipertimbangkan bila ditemukan tuberkulosis sistemik. Diagnosis ditegakkan dengan pemeriksaan mikroskopis dari spesimen (Gilroy, 2000). Tuberkuloma masih merupakan satu kasus penting dari lesi massa terutama pada negara-negara yang berkembang. CT-Scan menggambarkan suatu lesi hipodens yang homogen dan terdapat enhance pada penambahan kontras, tetapi sering menyerupai astrositoma atau metastasis. Diagnosis pasti tuberkuloma ditegakkan dengan operasi. Beberapa ahli berpendapat bahwa tuberkuloma dapat dipastikan bila pada serial CT Scan atau serial Magnetic Resonance Imaging (MRI) lesi menghilang sesudah mendapat terapi obat anti tuberkulosis (Perspebsi, 2004).

Abses Serebri
Hingga akhir abad ke 19, abses serebral hampir selalu menjadi penyakit yang fatal. Terapi yang sukses dalam menangani abses serebral pertama kali dilaporkan oleh Dr.JF Weeds pada tahun 1868 beliau melakukan drainase abses serebral lobus frontal dari seorang letnan kavaleri yang telah ditembak pada bagian kepalanya. Seorang pionir operasi abses serebral, Sir William Macewen pada tahun 1893 mempublikasikan suatu monograf yang terkenal dengan judul Pyogenic Infective Disease of the Brain and Spinal Cord. Pada laporannya disebutkan dari Sembilan belas pasien yang dioperasi dengan abses serebral dan serebelar, delapan belas diantaranya membaik dan hanya satu yang mengalami kematian. (Perdossi, 2008)

neoplasma otak primer yang berlokasi di batang otak dan regio pineal, dimana kemungkinan neoplasma yang berada di daerah itu antara lain germ cell tumor baik germinoma maupun non germinoma seperti teratoma, choriocarcinoma, yolk sac tumor, pineocytoma, pineoblastoma, astrositoma atau ependimoma (Lindsay,2010).
            Tumor di regio pineal merupakan tumor intrakranial yang relatif jarang terjadi. Manifestasi tumor di regio pineal ini terutama berkaitan dengan lokasinya yang sering menyebabkan obstruksi pada ventrikel 3 dan menyebabkan hidrosefalus obstruktif (Lindsay,2010).
Terdapat beberapa jenis tumor yang sering terjadi pada daerah pineal antara lain tumor germ cell seperti germinoma, teratoma, choriocarcinoma, ataupun yolk sac tumor. Varian yang lain seperti pinealoma baik pineositoma maupun pineoblastoma juga sering menjadi penyebab utama tumor intrakranial di regio pineal. Manifestasi klinis yang paling sering ditemui adalah efek penekanan pada tectum (mesencephalon) yakni seperti sindroma PARINAUD’S ( impaired upward gaze, pupillary abnormalities ) dan hidrosefalus obstruktif dengan tanda peningkatan tekanan intrakranial (Lindsay,2010).
Hidrosefalus merupakan penumpukan cairan serebrospinal (CSS) secara aktif yang menyebabkan dilatasi sistem ventrikel otak dimana terjadi akumulasi CSS yang berlebihan pada satu atau lebih ventrikel atau ruang subarachnoid. Keadaan ini disebabkan oleh karena terdapat ketidak seimbangan antara produksi dan absorpsi dari CSS. Secara keseluruhan, Insidensi hidrosefalus antara 0,2-4 setiap 1000 kelahiran. Insidensi hidrosefalus kongenital adalah 0,5-1,8 pada tiap 1000 kelahiran dan 11%-43% disebabkan oleh stenosis aqueductus serebri. Tidak ada perbedaan bermakna insidensi untuk kedua jenis kelamin, juga dalam hal perbedaan ras. Hidrosefalus dapat terjadi pada semua umur. Pada remaja dan dewasa lebih sering disebabkan oleh toksoplasmosis. Hidrosefalus infantil; 46% adalah akibat abnormalitas perkembangan otak, 50% karena perdarahan subaraknoid dan meningitis, dan kurang dari 4% akibat tumor fossa posterior. Secara internasional, insiden hidrosefalus yang didapat juga tidak diketahui jumlahnya. Sekitar 100.000 shunt yang tertanam setiap tahun di negara maju, tetapi informasi untuk negara-negara lain masih sedikit (Ropper et al., 2005).
Massa di regio pineal yang paling sering terjadi dan tertinggi prevalensinya adalah kista pineal benigna yang meliputi hampir 40% dari massa di regio pineal, dan sebaliknya tumor regio pineal merupakan jenis tumor otak yang jarang terjadi. meliputi 3-8% tumor pada anak-anak dan <1% tumor otak pada dewasa (Regis et al., 1996). Tumor germ cell adalah jenis tumor yang paling sering terjadi di regio ini, termasuk germinoma, teratoma, choriocarcinoma, dll. Tumor ini meliputi 0,3-3,4% tumor otak di populasi barat sementara pada ras asia, insidensinya bisa mencapai hampir 8 kali lipat. Tumor ini juga lebih sering mengenai individu dengan sindroma Down (Gaillard et al., 2010).

Germ Cell Tumor
Germ cell tumor atau GCTs paling sering dijumpai pada regio pineal dan suprasellar (Sugiyama et al., 1992). GCT pineal lebih sering dijumpai pada laki-laki, sementara GCT supraselar lebih sering ditemukan pada perempuan. Semua varian dari GCT kecuali teratoma matur bersifat maligna dan berpotensi untuk metastasis. Germinoma yang merupakan hampir 50% dari tumor yang ada di regio pineal adalah suatu seminoma ekstragonadal yang memiliki insidensi puncak pada dekade kedua kehidupan (Villano et al.,2008). Pada germinoma, AFP dan β-hCG biasanya tidak meningkat (Horowitz & Hall,1991). Germinoma memiliki respon yang baik dengan terapi radiasi (Villano et al.,2008). Non Germ Cell Tumors / NGGCTs meliputi teratoma, choriocarcinoma, yolk sac tumor, dan tumor embrional lainnya. NGGCT biasanya muncul dari sel germ totipoten dan memiliki tingkatan diferensiasi yang berbeda mulai dari yang berdiferensiasi baik hingga anaplastik. Pada kasus ini biasanya dapat dijumpai peningkatan AFP dan khusus pada choriocarcinoma biasanya disertai peningkatan kadar β-hCG yang signifikan (Smirniotopopoulos et al., 1992).

Tumor parenkim pineal
Pineal parenchymal tumor (PPT), meliputi 15% dari tumor otak yang berlokasi di regio pineal, biasanya berasal dari pineosit dan berdasarkan WHO, dapat diklasifikasikan menjadi pineositoma, tumor pineal dengan diferensiasi sedang, dan pineoblastoma (Louis et al., 2007). Pineositoma biasanya terjadi pada usia dewasa muda, biasanya berupa massa yang solid maupun kistik, berdiferensiasi baik, memiliki kapsul yang intak dan pertumbuhan yang lambat, sementara pineoblastoma merupakan tumor yang ganas dengan diferensiasi yang buruk dan secara biologis memiliki kesamaan dengan meduloblastoma dan memiliki kecenderungan untuk metastasis.

Astrositoma
Astrositoma merupakan tumor primer otak yang dapat terjadi pada semua golongan umur dengan perbandingan laki-laki dan perempuan 2:1. Predileksi dari astrositoma adalah regio frontal, temporal, parietal, dan talamus, namun beberapa kasus yang jarang pernah dilaporkan astrositoma yang mengenai batang otak. Secara praktis, astrositoma diklasifikasikan menjadi malignant dan low-grade (Lindsay ,2010).
Gejala yang timbul merupakan kombinasi dari kompresi dan infiltrasi jaringan di sekitar tumor, kompresi vaskular, dan peninggian tekanan intrakranial; sehingga gejala yang timbul berupa defisit neurologis fokal dan umum. Gejala umum terjadi akibat peningkatan tekanan intrakranial seperti nyeri kepala (30-50%), mual, muntah, vertigo, dan pusing ; sedangkan gejala fokal menunjukkan lokasi tumor, misalnya hemiparesis, afasia, gangguan penglihatan, gangguan sensoris tergantung pada lokasi, ukuran, dan kecepatan pertumbuhan tumor (Parney et al., 2005).
Pemeriksaan yang paling sensitif dan spesifik untuk tumor ini adalah MRI; terlihat lesi hiperintens atau isointens inhomogen yang dikelilingi oleh daerah hipointens pada T1 atau hiperintens pada T2 sebagai daerah edema yang mengelilingi massa tumor. Dengan pemberian kontras tumor akan menyangat (Bauman & Shaw, 2005).

Ependimoma
Ependimoma intrakranial berasal dari sel-sel yang melapisi ruang ventrikel. Sebagian besar dari ependimoma terjadi di ventrikel 4 dan sebagian besar terjadi pada anak-anak (Lindsay,2010).
Penyebab dari ependimoma belum diketahui, namun ada penelitian yang menyatakan bahwa ependimoma berhubungan dengan infeksi virus tertentu. Manifestasi klinis dari ependimoma sangat bergantung pada lokasi dan ukuran tumor. Gejala yang sering ditemukan adalah mual, muntah, dan nyeri kepala, yang merupakan tanda dari peningkatan tekanan intrakranial yang disebabkan oleh obstruksi saluran drainase ventrikel akibat efek massa. Pemeriksaan MRI sangat diperlukan untuk menegakkan diagnosis, namun diagnosis pasti tetap memerlukan pemeriksaan sitopatologis (ABTA,2006)


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