Neurosurgery Report

Sunday, 30th September 2012

Jaga I : dr. Zaenal Abidin

Jaga II : dr. Syaichu Ali Yusni
NCCU : dr. Ahmad Faried
dr. Agung Budi S.
Team : dr. Andry P. Sinurat
dr. David
I. New patient :2
II. Emergency patient :2
III. Urgent Consult :2
IV. Emergency operation :1
V. Pre op :2
VI. Post op :-
VII.Death case :-
VIII. NCCU / ICU / PICU / NICU/ IHC/HCU Kem/RR :5/3/1/-/-/2
NEW PATIENT
 NP 1. Mr. Maman/♂ /15 yo/12061590/Trauma/MZ
CC : Decrease of consciousness
History :
6 hours prior to admission, when he was riding a motorcycle at Majalaya area, without helmet,
suddenly he was hit by another motorcycle from opposite direction. He fell down and his head hit
the road. History of unconsciousness (+), vomiting (+), bleeding from right ear (+), nose (+) and
mouth (-). He was brought to Majalaya Hospital and then referred to Emergency Hasan Sadikin
Hospital.
Primary Survey :
A = Clear + C-Spine control
B = shape and movement : simetrical, VBS L=R, RR=24 x/mnt
C = BP = 120/70 mmHg, PR = 90 x/mnt
D = GCS = E3M5V3 = 11
Pupils round equal, ø RLO 3 mm, LR +/+
Motoric: paresis -/-
Secondary Survey :
ar right temporoparietal : hematom (+)
ar nostril : Rhinorrhea (+)
ar right EAC : Otorrhea (+). N VII paresis (-)
Skull x-ray : No fracture line
Cervical and Thorax X-ray : within normal limit
Right Antebrachii X-Ray : fracture right ulnar 1/3 distal
Lab : Hb 14,7 pH 7,439
HMT 40 PCO2 24,1
Leko 23.900 PO2 160
Trombo 303.000 HCO3 16,6
Ureum 14 TCO2 17,4
Kreatinin 0,44
BE -7,9
Blood glucosa 172
Saturation 99,7
Na 138
K 3,2

WD/ Moderate Head Injury (GCS : 11) + Skull Base Fracture Anterior Fossa et right
middle fossa + Closed fracture right ulnae 1/3 distal

Th/ Closed Observation

Plan to Head CT Scan (NC)  Financial Problem
posterior slab + Plan ORIF elective (Orthopedi)

EMG
 NP 2. Mr. Asep/♂ /35 yo/12061589/Trauma/MZ
CC : Decrease of consciousness
History :
5 hours prior to admission, when he was riding a motorcycle at Kopo area, without helmet,
suddenly he was slipped. He fell down and his head hit the road. History of unconsciousness (+),
vomiting (-), bleeding from ear (-), nose (-) and mouth (-). He was brought to Immanuel Hospital and
performed head CT Scan and then referred to Emergency Hasan Sadikin Hospital.
Primary Survey :
A = Clear + C-Spine control
B = shape and movement : simetrical, VBS L=R, RR=24 x/mnt
C = BP = 130/80 mmHg, PR = 90 x/mnt
D = GCS = E3M6V4 = 13
Pupils round equal, ø RLO 3 mm, LR +/+
Motoric: paresis -/-
Secondary Survey :
ar right frontal : lacerated wound (+), size 5 cm, post sutured
ar left frontal : lacerated wound (+), size 5 cm, post sutured
ar left parietal : hematoma (+), lacerated wound (+), size 4 cm, post sutured
ar superior labial : lacerated wound (+), size 3 cm, pot sutured
Cervical and Thorax X-ray : within normal limit
Head CT-Scan Immanuel Hospital
30/09/2012
• Soft tissue swelling (+) ar
left parietal et bifrontal
• Bone discontinuity (+) ar left
temporoparietal
• Sylvian fissure compressed
• Sulcy and Gyri compressed
• Cistern and ventricular
system comperssed
• Hiperdens mass biconvex
shape ar left
temporoparietal
• Midline shift (+) < 5 mm to
the right
Lab : Hb 13,9 pH 7,438
HMT 41 PCO2 36,6
Leko 23.500 PO2 138
Trombo 216.000 HCO3 18,2
Ureum 26 TCO2 19.0
Kreatinin 0,54
BE -3,2
Blood glucosa 145
Saturation 99,9
Na 141
K 4
PT 12
aPTT 21,6

WD/ Moderate Head Injury (GCS : 13) + EDH ar left temporoparietal + Closed linear
fracture ar left temporoparietal

Th/ Craniotomy Evacuation

SW
WD/ Moderate Head Injury (GCS : 13) + EDH ar left temporoparietal +
Closed linear fracture ar left temporoparietal

Th/ Craniotomy Evacuation

Ar left temporoparietal :
• Found linear fracture ar left temporoparietal, size 6 cm
• Found EDH clot 30 cc lysis 5 cc, Source of Bleeding : Bone Fracture
• Duramater white, intact, not tense
• GCS pre op E4M5V4 = 13
• Interval op 9 hours
EMERGENCY PATIENT
 EP 1. Mr. Heri/♂/67 yo/35779/Trauma/MZ

CC : wound on the head

History :
± 5 hours prior to admission, when he was walking on the street at Riung Bandung
area, suddenly he slipped and fell down with his head hit the trotoar. History of
Unconscious (-), vomiting (-), bleeding from ear (-), nose (-) and mouth (-). He was
directly brought to Emergency Hasan Sadikin Hospital.

General state :
BP : 170/90 mmHg, P : 84 x/m, RR : 22 x/m, T : afebris
Local State :
Ar left parietal : lacerated wound (+), size 4x1x1 cm, based on subcutis
Neurogical state :
GCS = 15
Pupil : Round equal Ø RLO : 3 mm, LR +/+
Motor : No parese
 Skull x-ray :
within normal limit
WD/ Mild Head Injury (GCS 15) + lacerated wound at left parietal

Th/ local debridement & primary suture

Refused Medical Advice

 EP 2. Mr. Asep Saeful/♂/27 yo/35857/Trauma/MZ

CC : wound on the head

History :
± 1 hours prior to admission, when he was walking at Sukajadi street, suddenly he
strucked by a motorcycle from his left side. He fell down and his head hit the road.
History of Unconscious (+), vomiting (-), bleeding from ear (-), nose (-) and mouth (-).
He was directly brought to Emergency Hasan Sadikin Hospital.

General state :
BP : 120/70 mmHg, P : 80 x/m, RR : 20 x/m, T : afebris
Local State :
Ar right parietal : lacerated wound (+), size 1x1x1 cm, based on subcutis
Neurogical state :
GCS = 15
Pupil : Round equal Ø RLO : 3 mm, LR +/+
Motor : No parese
 Skull x-ray :
no fracture line
WD/ Mild Head Injury (GCS 15) + lacerated wound Ar right parietal

Th/ local debridement and primary suture

Sent home
URGENT CONSULT
 UC 1. Girl Revita/♀/13 yo/12035244/trauma/MZ
Patient was consulted from Pediatric Department
CC : wound on the head
History :
± 4 hours prior to admission when she was sitting in the house stairs at
Dayeuhkolot area, suddenly she fell down and her head hit the floor. She got
seizure 1 time, ½ hours before she fell down, all body, about 3 minutes, before
and after seizure she was concious. Because of complaint, she was brought to
Sartika Asih Hospital and then referred to Hasan Sadikin Hospital.
± 3 days prior admission her parent found that she got a fever, continuous,
mialgia (+), retroorbital pain (+), because of complaint she was brought to
general practitioner and back to home. History of seizure (-), decreased of
conciousness (-).

General state :
BP : 100/60mmHg (with dopamin) PR : 52 x/reguler RR : 24 x/mnt
T : 37,30 C

Local State : ar left frontal : lacerated wound (+), size 3 cm, post sutured.
Neurological States :
GCS = 15, Nuchal rigidity (-)
Pupil : Round equal ODS : 3 mm, LR +/+
Visus : RLO > 6/60
Funduscopy : papil define border
Eye ball movement : within normal limit
Other cranial nerve : within normal limit
Motorik : paresis -/-
Sensoric : response to pain
Proprioceptive : within normal limit
Vegetative : within normal limit
Physiologic Reflex : +/+
Pathologic Reflex : -/-
Schedel X-Ray : within normal limit
Thorax X-Ray : kardiomegali (+)
Lab :

Hb 13,3 CPK 480

Ht 38 CK-MB 67
Leuko 12.400
Trombo 297.000
Ureum 46
Creatinine 0.91
Blood glucose 153
Na 139
K 4,4
SGOT 103
SGPT 71
PT 13,9
aPTT 28,6
WD/ Mild Head Injury (GCS : 15) + Suspect Cardiogenic Shock
due to myocarditis due to viral infection DD/ autoimmune

Th/ conservative(NC)
improve general condition + Blood pressure regulation
(Pediatrics)

PICU
 UC 2. Baby Gustian R./♂ / 1,5 mo/ 35853/ Pediatric / MS
Patient was consulted from Pediatric Department
CC : Decreased of consciousness
History :
± 10 hours before admission, his parents saw that their baby became lazy to breast feed.
History trauma (-), Vomitting (-).
± 1 days prior to admission, patient had seizure 10x/day, lasting for 3-5 minutes, whole body,
before and after seizure patient was unconscious. Beacuse of her complaint patient was
brought to Cicalengka Hospital and then referred to Hasan Sadikin Hospital. Patient was born
from P1A0, term labour, helped by midwife, directly crying, birth weight 3800 gr. History of
vitamin K administration unknown.

General state :
PR : 130 x/m RR : 60 x/m T : 37,3oC

Local State : HC : 38,5cm (38 – 42 cm)

Anterior fontanel : open, not tense, bulging, sized 4 x 3 cm
• Neurogical state :
CCS : E2M3V2: 7, Neck Stiffness (-)
Pupil : Round unequal RLO : 4/3 mm, LR +/+
Eye ball movement : doll’s eyes (+)
Motoric : parese (-)
Sensoric : (+) with pain stimulus
Thorax X-Ray : within normal limit
Head CT-Scan
– Ventricle and sistern compressed
– Sulcus and gyrus compressed
– Sylvian fissure compressed
– Hyperdense mass crescent shape
ar right parietooccipital
– Hipohyperdens mass ar right
frontoparietal
– Hyperdens mass ar
interhemispheric
– Midline shift (+) > 5 mm to the
left
Lab :
Hb 3,5 Ur -
HMT 9,7 Cr -
Leko 22.700 Glucose 103,6
Trombo 669.000 Na 128
SGOT -
K 5,8
SGPT -
PT 121
APTT 137,7
WD/ Spontaneus SDH ar right parietooccipital et
interhemispheric + ICH ar right frontoparietal ec
susp. APCD

Th/ Closed Observation (NC)

Plan to craniotomy evacuation
Improve general condition (pediatric)

EMG
EMERGENCY OPERATION
 1. Mr. Asep/♂ /35 yo/12061589/Trauma/MZ
WD/ Moderate Head Injury (GCS : 13) + EDH ar left temporoparietal +
Closed linear fracture ar left temporoparietal
Th/ Craniotomy Evacuation

Ar left temporoparietal :
• Found linear fracture ar left temporoparietal, size 6 cm
• Found EDH clot 30 cc lysis 5 cc, Source of Bleeding : Bone Fracture
• Duramater white, intact, not tense
• GCS pre op E4M5V4 = 13
• Interval op 9 hours
PRE OP
1. Mr. Luki/♂/40 yo/12061557/Skullbase/RS
WD/ SOL supratentorial ar sellar region due
to macroadenoma hipofise
R/ Transphenoid tumor removal
2. Boy Nafis./♂/5 yo/12062046/Trauma/IM
WD/ Mild HI + Open fracture depressed > 1
tabulla ar right parietal
R/ Craniectomy elevation
POST OP
NCCU
No Name Sex Age Day GCS initial GCS today Diagnosis Problem Therapy KS
NCCU
Post craniotomy tumor removal a.i.
R/ pindah
1 Dewi Pradita F 33 yo POD 5 15 15 SOL supratentorial ar FP sinistra e.c. RS
ruangan
Suspek convexity meningioma
Post EVD due to Acute Non
Communicans Hydrocephalus due to
FU IPD
2 Dimyati M 62 yo POD 1 E1M4VT = 6 E2M5V2 = 9 Spontaneous IVH et SAB ec susp Breathing AD
FU B.Thorax
Aneurysm Rupture + Left Pleural
Effusion due to TB dd/ Malignancy
Post EVD a I hidrocephlus akut FU IKA
Yusuf komunikans a I meningitis serosa dd (correction of
3 M 6 mo POD 3 E2M3V2:7 CCS=11 Hyponatremia MS
Maulana meningitis TB bronkopnemonia hyponatremia)
bilateral

Post EVD + ETV a.i Congenital

4 Lia Warliah F 1 yo POD 3 CCS = 11 E4M4V2 =10 hydrocephalus e.c Susp Aquaduct FU IKA MS
stenosis

Post Craniotomy Evacuation +

Devridement due to Moderate HI +
R/ pindah
5 M. Irfan M 22 yo POD 1 E2M5V2 = 9 E3M6V3 = 12 open # linear ar Temporal Sn + Open # MZ
ruangan
depressed at Frontal Sn + EDH ar
Temporal Sn + Pneumocephalus
No Name Sex Age Day GCS initial GCS today Diagnosis Problem Therapy KS
ICU

Post Craniotomy Evakuasi ai ICH spontan

R/ pindah
1 Neneng F 46yo POD 4 E3M6V4=14 15 a r frontotemporoparietal dx + SAB AD
ruangan
spontan ec susp hipetensi

Post craniotomy tumor removal a I SOL

R/ pindah
2 Eutik F 48 yo POD 2 15 15 Supratentorial a/r Sphenoid wing (Dx) IM
ruangan
e.c . Convexity meningioma

Post Craniectomy Decompression due to

Moderate HI + closed # linear ar
Hb Post Op 8.4 Transfusi PRC
3 Novi P F 22 yo POD 1 E2M5V2 = 9 E2M5VT = 9 Temporoparietal dx + SDH et ICH ar MZ
Gravida FU Obgyn
Temporoparietal Sn + G1P0A0 gr 23-24
weeks

No Name Sex Age Day GCS initial GCS today Diagnosis Problem Therapy KS
PICU
Vent PC RR 20
CCS : E1M1VT Decreased of consciousness due to susp PEEP5 IPL 16
1 Baby Paiza F 1 Mo H-3 CCS : E1M1VT Breathing MS
intracranial lesion Fi02 60%
R/ C T Scan
No Name Sex Age Day GCS initial GCS today Diagnosis Problem Therapy KS
HCU Kemuning ruangna
Moderate HI + closed # depreased > Leader Bedah
1 tabula a/r frontoparietal sinistra + anak
1 Sani M 14 yo H-6 E3M6V4= 13 15 SBF media dextra et sinistra+Hematom FU urologi MZ
lien AAST grade II + Hematom liver + R/ pindah
contusio buli ruangan

Mild HI + Post Necrotomy

Observasi
2 Adang M 71 yo POD 3 15 15 Debridement due to Neglected Electric MA
Leader B.Plastik
Burn Injury gr II-III 45 %
Dr. Zaenal Abidin
Dr. Syaichu Ali Yusni
Dr. Ahmad Faried
Dr. Agung S.
Dr. Andry P. Sinurat
Dr. David