Case report

Kepaniteraan Klinik Ilmu Penyakit Saraf

Fakultas Kedokteran Universitas Tarumanagara
Periode 9 september 2019 – 12 oktober 2019
Patient identity

Name : Mr. Tomas hariyanto

Gender : Male
Age : 38 years
Occupation : Self employment
Married status : Married
CURRENT MEDICAL HISTORY

• The patient is a referral patient from RSUD Cengkareng. The

patient fell from a height of 2 meters. The position patient when
fall is sitting down. The patient does not feel his waist to his
feet. The patient is unconscious when the incident happen and
didnt remember about the incident. The patient also had blood
coming out of from the right ear and mouth. Nausea (+) and
vomiting (+).
History

• Hypertension (-)
• Smoking (-)
• Diabetes Melitus (-)
Vital signs

• Blood pressure : 141/89 mm Hg

• Heart rate : 103 bpm
• Respiratory rate : 16 x
• Temperature : 36 c
• GCS : 15 E4 V5 M6 (Compos mentis)
Physical examination
Head Normochepali, hair isn’t easily removed

Pupil: round, equal, Ø 3mm/3mm, palpebral edema (-/-), anemic conjunctiva (-/-),
Eyes
icteric sclera (-/-), direct light reflex (+/+), indirect light relect (+/+)

Ears Normal shape, otorrhea (-/-)

Nose Septum deviation (-), secrete (-/-)

Mouth Mucose: wet, hyperemic (-)

Neck Collar neck (+)

Consciousness : Delerium
GCS :E4M5V3
 Opening mouth +
N. V Moving the jaw +
Biting +
Facial Expression Symmetric
Palpebrae Fissure Symmetric
N. VII Raised Eyebrows Symmetric
Wrink Forehead Symmetric
Lagophtalmus - -
Grinning Symmetric
Puff Cheeks Symmetric
MSCT WHOLE VERTEBRAL
LUMBAL
• T11-T12 listhesis is shown
• Compression Fracture T12 and
corpus T12 are visible in the
posterior direction
• A bit of bone fragments is seen in
T11-T12
• Fracture on Left side processus
transversus L1
• No Postero spur
• A spinal canal stenosis is seen in the
T12 fracture compression area
• Neural foramina in the T11-T12
area seems narrow
• There is no visible thickening of the
ligament flavum
• Does not look mass
• The bulging discs on L3-4 and L4-5
and neural foramen D et S are
rather narrow
• There was no suspicion of a tumor
mass
• There is no visible phenomenon of
vacuum
X RAY THORAX
• Heart in quante status
• Pulmo does not currently have a picture of pneumothorax / edema /
effusion / infiltrate, or thorolumbar vertebral stabilizer

X RAY vertebral thoracolumbal

• Good Alignment
• an orif decompressive stabilizer appears in the vert.thoracolumbalis
• There is no picture of listhesis. Compression fracture 12th
• Bone fragments are still visible on the 11th Vth disc
• Pedicles and facet joints are within normal limits
• Discus is not pinched. No spur image appears
• Intravertebrale foramen is not narrow
MSCT BRAIN WITHOUT CONTRAST
• Cranium showing occipital fractures in S / os petrosum left right medial / mastoid bag suspicious of cranial base and extra cranium
cephal hematome in left and right temporal parietal
• Vague presentation of SH in left occipital and epidural in occipital D et S
• Gloomy on the right-sided sphenoid sinus
• Bleeding in sulci parietal D et S and cerebrie falk
• Intracerebral hemorrhage is seen in the left frontalis / right temporo parietal area / right mastoid region
• Description of bleeding spots in the cerebellum bag D et S especially S and mixed with a picture of hypodens (edema) in the left
cerebellum
• Pneumocehalus in the cerebellum on the right is visible
• Differentiation of white and gray matters within the moral boundary
• There is no visible shift in the midline structure
• Symmetrical ventricular system, sitengah, not widened
• Peripheral sulci, cysterna and Sylvii fissures are rather narrow
• Normal brain stem. Cerebrie edema.
• Total bleeding is approximately 49.65 cc
PEMERIKSAAN HASIL SATUAN NILAI RUJUKAN
HEMATOLOGI
9/10,2019
Hemoglobin 14,8 g/ dl 13,2-17,3

Hematokrit 45 % 40-52

Leukosit 26,5 103/u L 3,8-10,6

Trombosit 255 103/uL 150-440

KIMIA KLINIK

Glukosa Sure Step 162 Mg/dL <110

Ureum 25 Mg/dL 19,0-44,1

Kreatinin 1,1 Mg/dL 0,7-1,2

eGFR 79,8 mL/min/1,73 m2 >= 90 : Normal

ELEKTROLIT SERUM

Natrium 147 Mmol/L 136-146

Kalium 2,8 Mmol/L 3,5-50

Chlorida 104 Mmol/L 98-106

LABORATORI 10/10/2019 UNIT NORMAL
UM RANGE
Hemoglobin 14,3 g/dl 12.0 - 16.0
LED 15 mm/jam 2 - 30
Leukocyte 21,5 103/uL 5.0 - 10.0
Basophils 0 % 0-1
Eosinophils 0 % 1-3
Segmen 89 % 50 - 70
Lymphocytes 8 % 21 - 40
Monocytes 2 % 2-8
MCV 88 u3 82 – 92
MCH 29 pg 26 – 32
MCHC 32 g/dl 31 – 36
Hematocrit 43,1 Vol % 37.0 - 47.0
Erythrocytes 4,91 106/uL 4.00 - 5.00
Platelets 171 103/uL 150.0 - 450.0
GDS 212 Mg/dL 60 – 180

SGOT 83 u/L 15 – 37
SGPT 68 u/L 12 – 78
Kalium 4,40 mmol/L 3,5-5,10
Urinalisasi 10/10/2019 Hasil Satuan Nilai Rujukan
Warna Kurning Agak keruh Kurning jernih
BJ 1.025 1.000-1.030
PH 6,0 5,0-8,5
Protein Negatif Negatif
Glukosa Negatif Negatif
Keton Urin Negatif Negatif
Bilirubin Negatif Negatif
Darah Samar Positif 3 Negatif
Nitrit Negatif Negatif
Urobilinogen 0,2 0,1-1,0
Lekosit Positif 1 Negartif
SEDIMEN URIN
Lekosit 3-4 /LPB 0-3
Eritrosit >50 /LPB 0-2
Silinder Negatif Negatif
Epitel Positif 1+
Bakteri Negatif Negatif
Kristal Negatif -
Lain-Lain Negatif -
PEMERIKSAAN HASIL SATUAN NILAI RUJUKAN
HEMATOLOGI
11/10/2019
Hemoglobin 9,7 g/ dl 13,2-17,3
Hematokrit 15 % 40-52
Leukosit 18,2 103/u L 3,8-10,6
Hitung Jenis
Basofil 0 % 0-1
Eosinofil 0 % 1-2
Segmen 89 % 50-70
Limfosit 7 % 21-40
Monosit 4 % 2-8
MCV MCHC MCH
MCV 90 U^3 82-92
MCH 29 Pg 26-32
MCHC 32 g/dl 31-36
Hematokrit 30,4 Vol% 42-52
Eritrosit 3,37 10^6/ul 4,5-5,5
Trpombosit 146,0 10^3/ul 150,0-450,0
Pemeriksaan Hasil Satuan Nilai Rujukan
Gas Darah
11/10/2019
pH 7,33 7,35-,45
%Fio2 52 % -
PCO2 39,7 mmHg 35-45
PO2 252,1 mmHg 83-108
HCO3 21,3 Meq/L 22-28
SO2 99,9 % 95-98
BE -3,7 Mmol?l (-2)- 2
TCO2 22,5 Mol?l 23-27
Suhu 36,7 Celcius
DIAGNOSIS
• Working diagnosis: Spinal Medal Trauma (Th12 compression
fracture), Subarachnoid Hemorrhage and Subdural Hemorrhage
• Differential Diagnosis:
• Cauda Equina Syndrome
• Am
 Treatment at emergency room

• Check ABC
• Insert IV line
• Ringer lactate 500 cc/ 8 hours
• Pranza 1 x 40 gram
• Bio TT
• Kalnex
• Phytomenandion
• Manitol 300 mg
 Spinal Cord Injury
• Insult to the spinal cord resulting in a change, either temporary or
permanent, in the cord’s normal motor, sensory, or autonomic
function.
• The following terminology has developed around the classification of
spinal cord injuries:
1. Tetraplegia (replaces the term quadriplegia): Injury to the spinal
cord in the cervical region, with associated loss of muscle strength
in all 4 extremities. Most common neurologic level of injury is C5
2. Paraplegia: Injury in the spinal cord in the thoracic, lumbar, or
sacral segments, including the cauda equina and conus medullaris.
T12 and L1 are the most common level.
 Signs and Symptoms
• The extent of injury is defined by the American Spinal Injury Association (ASIA) Impairment Scale
(modified from the Frankel classification), using the following categories: [1, 2]
• A = Complete: No sensory or motor function is preserved in sacral segments S4-S5 [3]
• B = Incomplete: Sensory, but not motor, function is preserved below the neurologic level and
extends through sacral segments S4-S5
• C = Incomplete: Motor function is preserved below the neurologic level, and most key muscles
below the neurologic level have a muscle grade of less than 3
• D = Incomplete: Motor function is preserved below the neurologic level, and most key muscles
below the neurologic level have a muscle grade that is greater than or equal to 3
• E = Normal: Sensory and motor functions are normal
• A direct relationship exists between the level of cord injury and the degree of
respiratory dysfunction, as follows:
• With high lesions (ie, C1 or C2), vital capacity is only 5-10% of normal, and cough is
absent
• With lesions at C3 through C6, vital capacity is 20% of normal, and cough is weak and
ineffective
• With high thoracic cord injuries (ie, T2 through T4), vital capacity is 30-50% of normal,
and cough is weak
• With lower cord injuries, respiratory function improves
• With injuries at T11, respiratory dysfunction is minimal; vital capacity is essentially
normal, and cough is strong
 Neuropathways

1. MOTORIC
• Spinal cord organized series of tract that carry motor (descending)
and sensory (ascending) information
• The corticospinal tracts are descending motor pathways located
anteriorly within spinal cord. Axon extends from the cerebral cortex
in the brain, where they form synapses with motor neurons in the
anterior (vetral) horn. They dessucate( cross over0 in the medulla
bfore entering the spinal cord
2. SENSORIC
• Dorsal Columns are ascending sensory tracts that transmit light touch,
proprioception and vibration information to the sensory cortex
• The lateral spinothalamic tracts transmit pain and temperature sensation
• The anterior spinothalamic tract transmits light touch

3. AUTONOMIC
• Autonomic function traverses within the anterior interomedial tract
• Sympathetic nervous system fibers exit the spinal cord between C7 and L1,
whereas parasympathetic system pathways exit between S2 and S4.
 Mechanism of Injury

• Classification of vertebral column injuries divides them into fracture-

dislocations, pure fractures, and pure dislocations.
• The spinal cord that is traumatized by direct compression as a result
of dislocation of spinal bones, or by buckling of the ligaments inside
the spinal canal
• All three types of spinal injury are produced by a vertical
compression of the spinal column, to which either anteroflexion or
retroflexion
Acute Evaluation

• Diaphragmatic paralysis occurs with lesions of the upper three

cervical segments (transient arrest of breathing from brainstem
paralysis is common in severe head injury
• Complete paralysis of the arms and legs usually indicates a fracture
or dislocation at the fourth to fifth cervical vertebrae
• Legs are paralyzed and the arms can still be abducted and flexed, the
lesion is likely to be at the fifth to sixth cervical vertebrae
• Paralysis of the legs and only the hands indicates a lesion at the sixth to
seventh cervical level
• The spinal cord ends at the first lumbar vertebra, usually at its rostral
border. Vertebral column lesions below this point give rise predominantly
to cauda equina syndromes; these carry a better prognosis than injuries to
the lower thoracic vertebrae, which involve both cord and multiple roots.
• prognosis for recovery is more favorable if any movement or sensation is
elicitable during the first 48 to 72 h.
 Initial Management

1. administered methylprednisolone in high dosage (bolus of

30 mg/kg followed by 5.4 mg/kg every hour), beginning
within 8 h of the injury and continued for 23 h
2. Hypotension is treated with infusions of normal saline and
may require the transient use of pressor agent
3. imaging examinations (MRI is ideally)
4. traction on the neck (use of a halo brace)
5. early surgical decompression, correction of bony
displacements, and removal of herniated disc tissue and
intra- and extramedullary hemorrhage
 EPIDURAL HEMORRHAGE

• blood collects in the potential space between the dura and inner table of the
skull
• 1% of all head trauma admissions and in 5–15% of patients with fatal head
injuries
• more common in males (M:F = 4:1)
• usually occurs in young adults
• 90% of EDHs are due to arterial bleeding -> fracture at the middle meningeal
artery groove
• 10% are due to venous bleeding ->violation of a venous sinus by an occipital,
parietal, or sphenoid wing fracture
Location of EDH:
• lateral convexity of a cerebral hemisphere (70%)
• frontal (5–10%)
• parieto-occipital (5–10%)
• posterior fossa locations (5–10%)
CT scan
• hyperdense, biconvex (lenticular) mass adjacent to the inner
table of the skull (84%)
• medial edge being straight (11%)
• crescentic -> resembling an SDH (5%)
Additional associated findings -> SDHs and cerebral contusion
Guidelines:
• Surgical -> EDH of >30 cm3 should be evacuated regardless of GCS score
• Conservative -> EDH of <30 cm 3 and <15 mm of thickness and >5mm
midline shift (frequent neurological examinations and serial CT scan)
Relative indications -> EDHs that are neurologically symptomatic or have a
maximal thickness >1 cm.
Absolute indication -> acute EDH in coma (GCS ≤ 8) and anisocoria
Craniotomy -> complete clot evacuation with meticulous hemostasis and
use of tackup sutures to decrease the potential epidural space
 SUBDURAL HEMORRHAGE
• blood collects between the arachnoid and inner dural layer
• Type/variants:
1. Hyperacute ( <6 hours)
2. Acute ( 6 hours to 3 days)
3. Subacute (3 days to 3 weeks)
4. Chronic ( 3 weeks to 3 months)

Etiologies
• Traumatic stretching and tearing of cortical bridging veins
• Coagulopathy
• Subdural dissection of ICH
• Rupture of a vascular anomaly (AVM, aneurysm,
cavernoma, dural AV fistula)
• Guidelines suggestion for SDH evacuation:
1. acute SDH with thickness >1 cm or a midline shift >5 mm
regardless GCS score
2. acute SDH < 1 cm and midline shift <5mm and in coma ( GCS=<8)
if: GCS decreased by 2 points, pupil that are asymmetric or dilated,
ICP > 20 mmHg
• Outcome-> mortality improements from 66-90% down to 30-59% if
the patient was operated on in less 4 hours
 SUBARACHNOID HEMORRHAGE

• blood located between the pial and arachnoid

membranes
• results from venous tears in the subarachnoid space
• 33% of patients with moderate head injury and is found in
nearly 100% of trauma patients at autopsy.
• CT scan -> sulcal hyperdensity
• MRI -> FLAIR hyperintensity
• Clinical presentation headache, emesis, and lethargy
• Treatment :supportive using IV fluids, anticonvulsants,
and nimodipine (to prevent vasospasm)
• 1. Mattox K, Moore E, Feliciano D. Trauma, Seventh Edition. McGraw Hill
Professional; 2012.
• 2. Jr HRJ Jr, Srinivasan J, Allam GJ, Baker RA. Netter’s Neurology. Elsevier
Health Sciences; 2011.
• 3. American College of Surgeons, Committee on Trauma. ATLS, advanced
trauma life support for doctors: student course manual. 8th ed. Chicago,
IL: American College of Surgeons; 2008.
• 4. Adams and Victor’s .Principles of Neurology. tenth edition.