Penetrating Brain Injury in Children

Background: Accidental penetrating brain injury through supraorbital route is an unusual occurrence in emergency practice of civilian cases. At time, it could be potentially life threatening. We report an interesting case of supraorbital penetrating brain injury with an iron stick in a 12-year-old female patient. The stick was removed successfully through supraorbital exploration, without any neurovascular complications. Case Report: A 12-year-old female presented to our emergency department with injury to his right eye. History revealed that she was practicing marching band in her school as the leader. As she thrown the iron stick, she lost balance and that iron stick entered into her right supraorbital. Her Glasgow Coma Scale (GCS) score, on admission, was 15. There was circumferential laceration on the right supraorbital, flat margins, visible iron stick penetration with diameter 3 cm but no active bleeding was found. Rest of the physical and neurological examination findings were within normal limits. He was resuscitated promptly according to the advanced trauma life support system. Discussion: Intravenous fluids are given and efforts are taken to maintain high blood oxygen levels.Management of patients with transorbital brain injuries and foreign bodies in situ should follow basic surgical principles, including removal of the object under direct vision in order to reduce further brain tissue damage by the foreign bodies catching on bone fragments. Following removal of the foreign body, thorough debridement with removal of all involved skull bone and foreign materials, hematoma evacuation followed by careful hemostasis along the trajectory, and meticulous dural closure to reduce the possibility of CSF fistula are mandatory.  A transorbital or transcranial approach can be chosen depending on the location of the fragment. Conclusion: In conclusion, supraorbital penetrating brain injury caused by an iron stick is a rare but fatal event. High index of suspicion toward the presence of foreign bodies and emergent surgical intervention is to be considered in spite of consistent lack of evidence on CT scan. Retrieval should be performed on the operating table under direct vision only after preoperative imaging of neurovascular structures. Keyword: Penetrating brain injury, Iron Stic

Long Term Post Traumatic High Flow Carotid Cavernous Fistula with Patent Collateral Vessel : A Case Report

Introduction : A carotid-cavernous sinus fistula (CCF) is an abnormal communication between arteries and veins within the cavernous sinus. Carotid cavernous fistula (CCF) is a very rare case it's difficult to diagnose. because most CCF patients rarely come for treatment. Case Report : A 33-year-old male presented with history of protrusion of Left eye ball, and double vision for the last 2 years. visual disturbances were found in the right eye for 2 years, blurry vision is increasingly. Bruit was audible in orbital region on the left side. DSA showed that there was a fistula in the left sinus cavernous region, the arteries in the left area showed inadequate to direct the left hemisphere, but in the right arety showed that the right artery was adversely affected right and left brain. Discussion : Traumatic CCFs are the most common type, accounting for up to 75% of all CCFs.87 They have been reported to occur in 0.2% of patients with craniocerebral trauma and in up to 4% of patients who sustain a basilar skull fractur.2 The symptoms and signs of CCF always include eyelid swelling, proptosis, chemosis, and hyperaemia, dilated of vessel and the condition is commonly misdiagnosed as Graves’ophthal-mopathy or inflammatory conjunctivitis.3Cerebral angiography is the gold standard for the definitive diagnosis, classification, and planning of endovascular intervention in CCFs. Angiographic results in this patient showed a fistula in the left cavernous sinus and inadequate supply of the left artery to the left hemisphere. Conclusion : This case is very unique because the left brain gets blood supply from the right carotid system, with the left carotid artery system inadequate to direct the left hemisphere because of the carotid cavernous fistula on the left sid

Recent Updates on Experience, Treatment and Prevalence of Adult Brain Tumor : Single Center Study

Introduction : Brain tumor is a disease with high morbidity and mortality rates. Treating brain tumors requiring medical providers to have basic understanding of brain tumor diagnosis and management. The most common brain tumors are meningiomas, gliomas, pituitary adenomas and brain metastasis. The treatment of each type of brain tumor is different and  multidisciplinary involving other scientific fields besides neurosurgery. Case Series : We reported 131 cases of brain tumors at the Haji Adam Malik Hospital in the period January 2018-December 2019, consisting of 52 cases (40%) of meningioma, 34 cases (26%) of Glioma , 12 cases (9%) of pituitary adenomas and 33 cases (25%) of brain metastasis. Meningiomas were mostly treated with surgery alone in 38% of cases, gliomas with surgery followed by chemo-radiation in 41% of cases, all of pituitary adenomas were treated with endonasal transfenoid surgery, while brain metastasis in 70% of cases required whole brain radiation with controlled primary tumors. Discussion : The modalities for treating brain tumor patients has been increasing recently. Meningiomas are mostly benign and managed by surgical resection only, chemo-radiation reserved for high risk or refractory case of meningiomas. Glioblastoma is the most common glioma and aggressive malignant primary brain tumor, limited response to gross surgical tumor and chemo-radiation. Pituitary adenomas mostly treated with endonasal transfenoid surgery, radiotherapy use in recurrent case. Brain metastasis may require complex multidisciplinary care with neurosurgery, radiation oncology, and medical oncology. Conclusion: The treatment of brain tumors is influenced by various considerations such as age, patient condition,neurological deficits, location of the tumor, comorbidities, experience of the neurosurgeon and available modalities. Treatment methods for brain tumors continue to evolve

Giant Olfactory Groove Meningioma in Pregnancy

Introduction: Meningioma is slow growing neoplasm cells that comes from arachnoid cap most common benign intracranial tumours. Olfactory groove meningiomas (OGM) account for 8–13% of all intracranial meningiomas. Intracranial tumors on pregnancy is a rare event, with few reports. Case Presentation: A 36-year-old- female (G11P9A1) 34 gestational week presented to the Adam Malik General Hospital with smelling disturbances for 6 months and lossing smelling sense in the past 1 month. Slowly progression of vision disturbances for 3 months without improvement in using glasses, progressive loss of vision in both eyes for the past 1 month. CT scan and MRI revealead a solid mass lesion, with 6.3 x 4.2 x 3.1 cm. It was a supratentorial in frontal region, olfactory groove mass. The Craniotomy tumor removal was performed in this patient. Discussion: Meningiomas are mostly silent brain tumors with slow growth, however may get detected and mostly become symptomatic during pregnancy and luteal phase of menstrual cycle due to increase in size secondary to either water retention, enhanced vascularity or progesterones are possible etiologies. The majority of meningiomas express progesterone reseptor, which can be detected also by immunohistochemistry. In fact, tumour growth when progesterone concentrations are higher, shows the role of sex hormones in the mechanism. Regardless of the status of pregnancy, symptomatic and large meningiomas require surgical resection. Conclusion: Changes of plasma concentration hormones during pregnancy and their effect on meningioma growth in the second and third trimester are crucial and critical. The management of brain lesions during pregnancy required professional collaboration between neurosurgeons, obstetricians and anesthesiologists

Planum Sphenoidale Meningioma: A Rare Location of Skull Base Meningioma

Background: Meningioma is common primary central nervous system tumors. Twenty-five percent of all meningioma consist of skull base meningioma. Planum sphenoidale meningiomas are rare. Planum sphenoidale meningiomas can extend into adjacent areas. Approximately two thirds of patients complain of failing vision in one eye as the first symptom. Case Report: A 32-year-old woman presented with 6-month history of progressively worsening blurred of both of vision. She also complained her smell ability was reduced for 3 months. She had headache for 6 months. The pain was worsening in the morning. She is conscious. A neurologic examination revealed bilateral hyposmia and visual deficits but no weakness. Visus of oculo dextra was 1/300 and visus of oculo sinistra was no light perception. Magnetic resonance imaging (MRI) intravena contrast of brain revealed a large extra-axial mass measured ±6,2x5,9x6 cm centred on planum sphenoidale displacing both frontal lobes. She had an operation of tumor removal with cranio-orbito-zygotomy approach. The tumor, which measured ±7cmx7cmx6 cm, was succesfully removed completely. She gets improvement of smell ability and both visual postoperatively. The histopathology of the tumor revealed meningioma WHO grade I. Discussion: Planum sphenoidale meningiomas present a frequently encountered pathology of the anterior skull base. These meningiomas give rise to an early visual disturbance with relatively slow progression. Displacement of the olfactory tracts and optic chiasm occur when the meningioma extends into the paranasal sinuses and nasal cavity. Clinical presentation and diagnosis often occur in the late stage. Anosmia is one of common finding on physical examination. Postoperative improvement of visual symptoms depends on the preoperative duration of those symptoms

Medulloblastoma: Intraventricular Recurrences

Abstract :Medulloblastoma is the most common malignant pediatric brain tumor. Incidence in adult population is less than 1 %. Medulloblastoma in adult usually between 20 and 40 years old, which is lateral hemispheric and not midline vermian. Survival rate in adult is 67% lower than adolescents is 69% and children is 72%. Location of recurrences most commonly presents at posterior fossa, spinal, supratentorial, and bone metastases. Recurrences of medulloblastoma in supratentorial ventricular is uncommon. The outcome for patients with recurrent medulloblastoma has historically been poor. 37 years old male who presented with severe headache gradually. Patient has history of headache 2 months ago and gait ataxia 1,5 months ago. Patient had surgery 2 years ago with result of hystopathology medulloblastoma. He had irradiation completely 22 months ago. Physical examination showed GCS 15 with gait ataxia. Head CT scan show multiple isodense lesion intraventricular. Before patient had surgery, Head CT scan showed hiperdense lesion at cerebellopontine angle. Seeding medulloblastoma to intraventricular is recurrences which have poor prognosis. Patient had poor condition in few days. Patient died before got reriradiatio

Tuberculosis of Sacrum: A Rare Location of Spinal Tuberculosis

Abstract :Tuberculosis is one of the most common infectious diseases in the world. The thoracolumbar spine is the commonest form of vertebral tuberculosis, whereas isolated tuberculosis of the sacrum is rarely reported in the literature. A male patient of 22-year old had complained low back pain since 2 years before admission to hospital without history of trauma on back. He also got low-grade fever and weight loss. There was no tuberculosis contagion found, no cough or night sweat. Clinical examination revealed neurological deficit with strength of both lower extremities were 4 and hipestesia in the level of lumbal 5 and downward. Radiographs of lumbosacral showed deformity of lumbal 5. CT scans of spine showed deformity of sacrum. MRI revealed spondylolisthesis L5-S1, S1-S2, S2-S3 and mass in the anterior posterior and lateral of paralumbal 5 and parasacral. There is no involvement of gluteus muscle and the around muscle. The patient underwent surgical of sequestrectomy with drainage abscess and lumbo-sacral-illiac fusion. The culture of sacral tissue showed Mycobacterium tuberculosis. The patient was treated with combination of four antituberculosis agents

INCREASING FOOT CIRCULATION WITH ELECTRICAL STIMULATION IN PATIENTS WITH DIABETES MELLITUS

Background: Peripheral arterial disorders in diabetes mellitus is a common complication that often occurs and can develop into diabetic foot ulcers. High blood sugar levels in people with diabetes mellitus can cause increased blood viscosity resulting in thickening of the capillary membrane, where erythrocytes, platelets and leucocytes are attached to the blood vessels. Electrical stimulation by placing electrodes in the calf muscle is one of the measures to increase foot blood flow that can reduce the poor foot circulation. Objective: This study aims to determine the effect of electrical stimulation in improving blood flow of patients with diabetes mellitus. Methods: The research use one-group pretest-posttest pre-experimental design. Sampling technique using pusposive sampling as many as 62 patients with diabetes mellitus. Electrical stimulation is done by attaching electrodes to left and right calf muscles for 20 minutes, frequency 3 times a week for 2 weeks. Before and after electrical stimulation performed foot circulation examination by ankle brachial index technique. Data analysis using Wilcoxon signed rank test. Results: The results showed that before the stimulation was obtained the mean ankle brakhial index 0.82 mmHg and after stimulation 0.95 mmHg (p = 0.000), meaning there is an effect of electrical stimulation in increasing foot blood flow. A calf muscle contraction during stimulation leads to increased leg blood flow through the addition of vascular endothelial growth factor and increased nitric oxide as a vasodilator of blood vessels. Electrical stimulation can be applied in increasing the blood flow of the foot, thus preventing the occurrence of diabetic foot ulcers. Conclusion: Stimulation is one therapy that can be done to prevent poor foot circulation of diabetes mellitus patients

PENGARUH BUERGER ALLEN EXERCISE TERHADAP SIRKULASI EKTREMITAS BAWAH PADA PASIEN LUKA KAKI DIABETIK

Luka kaki diabetes (LKD) merupakan komplikasi penyakit diabetes yang disebabkan oleh gangguan sirkulasi darah vena dan arteri. Buerger allen exercise adalah terapi modalitas dengan gerakan postural aktif. Penelitian ini bertujuan untuk menilai pengaruh buerger allen exercise tehadap peningkatan sirkulasi ektremitas bawah pasien LKD. Desain penelitian adalah pre eksperimen pretest dan posttest without control. Teknik pengambilan sampel adalah consecutive sampling sebanyak sampel 43 responden LKD, analisis data menggunakan uji Wilcoxon. Peningkatan sirkulasi di ukur menggunakan Ankle Brachial Index (ABI). Latihan dilakukan sebanyak 2 kali sehari dengan waktu latihan 17 sampai 20 menit, selama 3 minggu. Hasil penelitian menunjukkan perbedaan signifikan antara nilai rata-rata ABI sebelum 0,84 dan sesudah 0,95 intervensi Buerger allen exercise dengan nilai p= 0,000. Buerger allen exercise efektif untuk meningkatkan sirkulasi LKD karena perubahan posisi dan gaya gravitasi membantu mengosongkan dan mengisi kolom darah, sedangkan kontraksi muskulus gastrocnemius sebagai muscle pump mengaktivasi pembuluh darah vena dan arteri untuk membuka jalur sirkulasi collateral lokal.   Kata Kunci: Luka kaki diabetik, ankle brakial indeks, Buerger allen exercise   Abstract   The Influence of Buerger Allen Exercise on Lower Extremity Circulation in Patients with Diabetic Foot Ulcer. Diabetic foot ulcer (DFU) is a complication of diabetes caused by impaired venous and arterial blood circulation. Buerger allen exercise is a modality therapy with active postural movement. This study aims to assess the effect of buerger allen exercise on the circulation of lower extremities in DFU patients. The study design was pre experimental pretest and posttest without control. The sampling technique was consecutive sampling and the large sample of 43 DFU patients, analysis data was using Wilcoxon test. Increased circulation is measured using the Ankle Brachial Index (ABI). Exercise done as much as 2 times a day with practice time 17 to 20 minutes, for 3 weeks. The results showed a significant difference between the average value of ABI before 0.84 and after 0.95 intervention of Buerger allen exercise with a value of p = 0.000. Buerger allen exercise is effective for improving DFU circulation because position changes and gravitational forces help to empty and fill the blood column, and the contraction of the gastrocnemius as a muscle pump activates the venous and arteries and opens the local collateral circulatory pathway.   Keyword: Diabetic foot ulcer, brachial ankle index, Buerger allen exercis

Epidemiology of Pediatric Brain Tumor in the Center of Referral Hospital in North Sumatera from 2013 -2017

Brain tumors are the most common disease group of solid tumors in childhood, and children with brain tumors have a relatively poor survival rate. Epidemiologic data from a hospital-based registry provide the necessary information to obtain a full picture of the frequency of this disease, which is a great challenge in pediatric oncology. One hundred thirty four tumors in children between 0 and 17 years of age diagnosed between 2013 to 2017 were classified according the sex, and topography. Incidence of brain tumor in boys were higher than girls. From the registry data, the prevalence for boys was higher (67%). In the whole series, 54% were supratentorial, 46% infratentorial. The most common histopathologic pattern seen in the registry were pilocytic astrocytoma which accounts for 42 cases (31%) followed by medulloblastoma and craniopharygioma with the percentage of 25% and 18% respectively. The least histopathologic pattern of pediatric tumor seen in our center are diffuse astrocytoma and choroid plexus papiloma which was only seen in 1 patient for the last 5 years of our experience