Terapi komprehensif pada gangguan kognitif akibat cedera otak traumatik: laporan kasus

Abstract

Background: Cognitive impairment due to head trauma or traumatic brain injury is a condition rarely reported but it has major clinical implications and its management is a challenge because there are currently no official guidelines. Repetitive Transcranial Magnetic Stimulation (r-TMS) is a non-invasive neuromodulation technique that uses magnetic fields to stimulate the activity of the cerebral cortex. Donepezil is an acetylcholinesterase inhibitor that works by increasing the levels of acetylcholine in neuronal synapses. Combination of r-TMS and pharmacological therapy such as donepezil has been reported to have a synergistic effect in improving cognitive recovery.

Case Presentation: A 19 years old male was referred to the memory clinic with complaints of difficulty communicating and weakness of the right extremities since suffering a head injury 6 months previously. The results of the Aphasia Test for Diagnosis, Information and Rehabilitation (TADIR) showed Broca's aphasia, Activity Daily Living (ADL) 16/18, Instrumental Activity Daily Living (IADL) 14/14. Magnetic Resonance Imaging-Diffusion Tensor Imaging (MRI-DTI) showed disruption of the left frontotemporal tract with hydrocephalus ex vacuo. Comprehensive treatment was carried out in the form of r-TMS 10 times, cognitive stimulation, and medication with titrated donepezil up to 10 mg. Evaluations at 1 and 6 months after therapy showed improvements in previous norm profile scores and functional status.

Conclusion: There is potential benefit from using donepezil combined with r-TMS and cognitive stimulation as a comprehensive multimodal therapy to improve cognitive impairment due to traumatic brain injury. However, clinical decisions must still consider risks, costs and benefits for each patient holistically, and further research is needed. 

ABSTRAK

Latar Belakang: Gangguan kognitif akibat trauma kepala atau cedera otak traumatik adalah kondisi yang jarang dilaporkan tetapi memiliki implikasi klinis yang besar dan tatalaksananya menjadi tantangan tersendiri karena saat ini belum ada panduan resmi. Repetitive Transcranial Magnetic Stimulation (r-TMS) adalah teknik neuromodulasi noninvasif yang menggunakan medan magnet untuk merangsang aktivitas cortex cerebri. Donepezil adalah inhibitor asetilkolinesterase yang bekerja dengan meningkatkan kadar asetilkolin di sinaps neuron. Kombinasi antara r-TMS dan terapi farmakologis seperti donepezil dilaporkan memiliki efek sinergis dalam meningkatkan pemulihan kognitif

Laporan Kasus: Laki-laki usia 19 tahun dirujuk ke klinik memori dengan keluhan sulit berkomunikasi dan kelemahan gerak kanan sejak mengalami cedera kepala 6 bulan sebelumnya. Hasil pemeriksaan Tes Afasia untuk Diagnosis, Informasi, dan Rehabilitasi (TADIR) menunjukkan afasia Broca, Activity Daily Living (ADL) 16/18, Instrumental Activity Daily Living (IADL) 14/14. Magnetic Resonance Imaging-Diffusion Tensor Imaging (MRI-DTI) didapatkan adanya disrupsi tractus frontotemporal sinistra dengan hydrocephalus ex vacuo. Dilakukan tatalaksana komprehensif berupa r-TMS sebanyak 10 kali, stimulasi kognitif, dan medikasi dengan donepezil titrasi hingga 10 mg. Evaluasi bulan ke 1 dan ke 6 setelah terapi menunjukkan perbaikan skor profil norma TADIR dan status fungsional.

Kesimpulan: Ada potensi manfaat dari penggunaan donepezil dikombinasikan dengan r-TMS dan stimulasi kognitif sebagai terapi multimodal komprehensif untuk memperbaiki gangguan kognitif akibat cedera otak traumatik. Namun, keputusan klinis tetap mempertimbangkan risiko, biaya, dan manfaat bagi tiap pasien secara holistik, serta perlu adanya penelitian lebih lanjut.