Epidural Hematom Temporal Sinistra Post

Craniektomy Evacuation Hematom

22 April 2019 – 29 April 2019
Coass : 1. Fitriana Fauziah
2. Imelda Pandori
3. Santhi I.A. Panigoro
4. Sherly S. Yesnath
5. Yolanda Ika P. Toam
Consultant : dr. Tommy, Sp.BS
Cognita Manu Melia Cultu Neurosurgery Division
Mr. Edison Yaku /Male/ 19 y.o/ 452962
 Chief complaint : Syncope
 Present illness : A patient was escorted by his family with a decrease in
unconsciousness. The family said the day before entering the hospital, the patient was
beaten by several people in the head area a day after the event the patient complained of
severe headache until the patient experienced a decrease in consciousness and was taken
to the hospital by the family then the patient fainted and was brought to the hospital by
the family. Nauseous (-) vomit (-).
History of ilness :
 Heart diseases ( - )
 Hypertensi ( - )

Cognita Manu Melia Cultu Neurosurgery Division

Mr. Edison Yaku /Male/ 19 y.o/ 452962
 Physical examination :
• VS, BP: 120/80 : HR: 112 bpm, RR: 38 x/m, T: 37,6˚C, SpO2: 99% spontan
• GCS: E1V2M5
• Normocephal , light reflex +/+, pupil isocor, corneal reflex +/+, Cranial nerve:
palsy (-) racoon eyes -/- battle sign -/-, otorrhagia -/-, bloody rhinorhea -/-
edema palpebra -/-
• Thorax: cor and pulmo within normal limit
• Abdomen: normaly
• Extremities: normaly

Cognita Manu Melia Cultu Neurosurgery Division

Mr. Edison Yaku /Male/ 19 y.o/ 452962
 Clinical Diagnosis : Epidural Hematom Temporal Sinistra Post
Craniektomy Evacuation Hematom
 Topical Diagnosis : Epidural
 Etiological Diagnosis : Rupture Arteria Meningens Media

Further examination :
• Laboratory examination
• Cervical CT scan control without contrast

Cognita Manu Melia Cultu Neurosurgery Division

Laboratorium Examination
Lab Result

HB 12,7
HCT 39,6

PLT 172
Eritrosit 5,48

Leukosit 14,34

Sel basofil 0.0

Sel eosinofil 0,1

Sel Neutrofil 83,3

Sel limfosit 11,2

Sel monosit 5,4

Cognita Manu Melia Cultu Neurosurgery Division

 Planning
 O2 nasal 2 lpm
 IVFD Nacl 0,9% 20 tpm  Observation GCS and VS per hours
 Inj. Ranitidin 50mg / 12 hour  Pro CT scan Head Ct Scan Results
 Inj. Omeprazole 40mg/ 12 hour without Contrast
 Inj. Antrain 1gr
 Check DL, PT, APTT
 Manitol 4x125 mg
 Consul anesthest
 Phenytoin 3x100 mg bolus
 Pro Craniotomy evacuation
 Inj. Antrain 1gr
 Inj. Ceftriaxone 2x1 gr
hematom cito
 Inj. Ketorolac 3x1
 NGT

Cognita Manu Melia Cultu Neurosurgery Division

Instruction post op.
 IVFD Nacl 0,9% 20 tpm
 Inj ketorolac 30 mg/ 8 hours
 Inj. Omeprazole 2x1 vial
 Inj. Ceftrixone 2x1 gr
 Manitol 4x125cc
 Inj. Piracetam 2x1 gr
 Check Hb post operation

Cognita Manu Melia Cultu Neurosurgery Division

Mr. Edison Yaku /Male/ 19 y.o/ 452962
Head Ct Scan Results without Contrast

Cognita Manu Melia Cultu Neurosurgery Division

• Parieto occipital epidural hemorrhage  Subaraknoid spase normal
measuring 3,8x7x8x0,52 = 110 ml pushing the  The midline structure deviation appears
midline structure to the right as far 1,45cm
to the right as far as 1,45cm
 The right parietal bone fracture appears
• Also seen spots of right parietal intracerebral
henorrhage 2,4x1,4x2x0,52= 3,4 ml  Impression
 Sinistra occipital epidural
• Sulcy and gyri, fissurs sulci and gyri corticalis, hemorrhage 3,8x7x8x0,52 = 110 ml.
fissura sylvii bilateral and fissura interhemisfer Pushing the midline structure to the
appear to be lined I right as far as 1,45 cm. 3,4 ml right
extreme intracerebral parietal
• The shape and position of the bilateral lateral hemmorrhage, fracture of the right
ventricle is symmetrical, right and left lateral
parietal bone
ventricle size, pushed to the right, ventricels 3
and 4 appear normal

Cognita Manu Melia Cultu Neurosurgery Division

 Thank You

Cognita Manu Melia Cultu Neurosurgery Division