Friday, December 18, 2009

Tumours Of The Cerebellopontine angle

Left Cerebellar Abscess

52 year old Indian gentleman, with no known medical illness, admitted with history of severe headache for the past 1 month, and persistent vomiting for 1/7. He was admitted with full GCS with positive left cerebellar sign. Otherwise vital signs was stable. NO history of ENT discharge. Clinically afebrile. RBS 5.3mmol/l. TWBC 11.0. CT scan plain, subsequently proceeded with contrast study revealed ring enhancing lesion at left cerebellar region with displacement of 4th ventricle and obstructive hydrocephalus.
Right frontal burrhole and ETV was performed and omaya placement after ETV. Post ETV CT scan showed smaller ventricles.MRI was planned the next day, however his GCS deteriorated to E1V2M5. He was intubated and ventilated. A repeat CT scan done showed similar findings with worsening of hydrocephalus. Emergency posterior fossa craniectomy was performed. Intra-operatively noted with encapsulated cerebellar abscess with thick capsule wall and frank pus content. A complete excision of the abscess was performed. Omaya was removed and EVD placement was performed. Subsequently EVD was removed after a repeat CT scan showed resolved hydrocephalus with visualization of 4th ventricle and minimal edema over left cerebellar. He was extubated and GCS improved to full.

Friday, October 16, 2009

Brain Metastasis of Testicular Yolk Sac Tumour

28 Years old Male
Diagnosed Left testicular tumour with lungs metastasis 1 year ago
Underwent left orchidectomy and HPE diagnosis of Yolk sac Tumour
He had completed radiotherapy and chemotherapy
Presented with 1/12 history of progresive left sided body weakness and numbness
Associated with worsening headache
Admitted with 1 episode of generalised tonic clonic seizure
O/E Pink, alert
GCS full
BP 120/71
PR 77
Higher mental function intact
No cranial nerves deficit noted
Left hemiparesis 3/5 with sensory impairment

CT scan brain (plain + contrast) done showing homogenous enchanced tomour over right post central gyrus with marked surrounding edema

MRI was performed and he was planned for surgery

He underwent right parietal craniotomy and tumour excision. The tumour was just below a thin grey matter of post central gyrus (detected using intra-operative ultrasound). Post-central gyrus corticotomy done.
The tumour was pink-greyish in colour, soft to firm in consistency, well-circumscribed with surrounding gliotic brain tissue, highly vascular- completely excised

Post-operatively he was extubated and maintained on dexamethasone.
Clinically he still having left hemiparesis power of 3/5

CT scan (plain) post-operative day 1 showing pneumocranium with edema, no post-operative bleeding.

Thursday, September 17, 2009


Referred case from ED yellow zone

16yo malay boy
No known medical illness

Alleged MVA this morning
MB vs MB, at 7.15am near Sek Men Teknik Paya Jaras today Had LOC ? duration, regained consciousness on the way to hospital. No vomiting
No limb weakness- able to move all limbs, but noted by ED MO pt a bit restless- given sedation prior to CT brain done
No ENT bleeding
No SOB/ chest pain/ abdominal pain

GCS E3V3-4M5 (11-12/15)
Pupils 3/3 ++
Noted multiple abrasions wound (small) over the face

Chest/ pelvic spring -ve

No spine tenderness
No obvious long bone deformity

BP 135/87
HR 90
Spo2 100% on air

Lungs: clear
P/a: soft, nontender

Moving all 4 limbs power bilateral UL/LL >4/5
Reflexes normal

CT brainLt frontal contusion with Lt frontoparietal SDH with maximum thickness 0.5cm over 10cuts MLS 0.5cm Brain edematous BS partially efface
Impression: Lt frontoparietal SDH with Lt frontal contusion

He unerwent craniectomy and evacuation of clots with EVD placement for ICP monitoring. Post-op CT scan was performed POD 1

Tuesday, September 15, 2009



33yo chinese man
Background problem:
1) Young HPT (diagnosed 6 years ago age 27-28 years old), last seen by medical team in July 2009 Carotid doppler done: Left ventricular dysfunction, left ventricular thrombus, left internal carotid artery occlusion- on warfarin

2) CVA with dense right side hemiplegia and global aphasia (admitted in medical in Oct 2008- had neurorehabilitation)

Patient was admitted there from 22nd October 2008 to 1st May 2009 :

Hx from brother:
Presentd with less responsive, noted by family members since 2days ago. Condition worsened as previously pt was ADL independent, eventhouigh had Rt sided hemiplegia + global aphasia- pt was still able to bath/ eating by himself. This morning noted that pt was drowsy + PU in bed
. Hence, the family members brought pt immediatly to ED. Family claimed no h/o trauma at home. Compliance to medications - but last night ? took medications (including warfarin) by himself- no eye witness on how much he took
No fitting seen
No vomiting
No SOB/chest pain
No abdominal pain
No other complaint

Opening eyes spontaneously, on + off obeying commands
GCS E4V1(global aphasia)M5-6
Pupils 3/5 sluggish

BP 160/82
HR 100
Spo2 99% on air

Lungs: clear
P/a: soft, nontender

Tone: Rt UL/ LL increased, Lt normal
Noted Rt sided body hemiplegic- 0/5, Lt UL/LL >3/5
Reflexes left sided briskBabinski: bilaterally downgoing

CT brain: Lt pareital acute SDH, maximum thickness 1.3cm x 4.4cm (AP), over 10cuts MLS of 1.6cm to the right, sulci & gyri not well differentiated- ? generalize edema Lt lateral ventricles compressed- pushed to the Rt, rt temporl horn opened BC partially efface Blood ix: FBC: WCC 8.4, Hb 14.3, Plt 243 RP: U 8.8/ Na 139/ K 3.7/ Cr 86 PT/APTT: 10.8/22.2 INR: 1.15 Impression: Lt parietal acute SDH ? 2' to overwarfarinization
He underwent craniectomy and evacuation of clots. Intra-op FFP was transfused. Post-op he was ventilated and sedated.Sedated on IV midamorphine 5mls/hr o/e:Pupils 2/3 sluggish BP 122/88HR 102AfebrileSpo2 99% on air Noted still slowly oozing head drain site Head drain 22cc

Repeated CT brain post op noted:Reaccumulation of bleeding.
He was subjected for another operation
Post-op, he was put on sedation and ventilation support. A repeat CT scan was performed.

Tuesday, July 7, 2009

Traumatic Extradural Hematoma


No known medical illness

Alleged MVA ( mechanism of injury not known )
brought in to hospital by passerby ( Hospital Banting )
GCS upon arrival in Hospital
Banting was 14/15 ( was confused )
Then pt fitted once , following which IV Valium was given - then GCS dropped to 7/15
Was intubated in Hospital Banting and sent to HTAR for CT Brain

General : Upon arrival in ED
GCS : E1VtM5
Pupil : Pinpoint ( on IV Midam
orphine )
Respiratory : Clear,equal air entry
Abdomen : Soft
Diagnosis : CT Brain findings ( Done at 11pm on 27/06/09 ) :
Thin EDH seen at the (L) posterior fossa measuring 1.5cm in thickness x 4.5 cm ( seen over 4
slides )
+ temporal
contusion seen at the base of (R) temporal fossa
- no midline shift
- Basal cistern patent

He was treated with cerebral resuscitation and ICP monitoring. A repeat CT scan was performed on 28/6/09 showed slight increased in size of EDH, however ICP maintained below 20mmHg.

EET tube was dislodged 2 days later. He was reintubated. Repeat CT scan done.

ICP noted increased trend about 26mmHg. He was subjected for posterior fossa craniotomy.

Tuesday, June 30, 2009

Traumatic Chronic Subdural Hematoma

Case: 67 years old Chinese gentleman, referred from HTAR on 27/6/09 with history of alleged fall at home 2 weeks and became disorientated and bed-ridden 3 days prior to admission.

He was admitted previously on 23/5/2009 when he was alleged fell at home on the same day with admission GCS of E4V2M5. CT scan done showed right frontal ICH. He underwent craniotomy and evacuation of clots and discharged home with full GCS.

On arrival his GCS was E3 V2 M5 with pupils 3+/3+.
BP 146/76,
HR 76
Spo2 100% on air
Lungs: clear
P/a: soft, nontender
Able to move all 4 limbs but unable to assess proper power
CT brain
Mixed hyp & hyperdense lesion - SDH in left frontoparietal
Thickness 4cm
Local mass efeect on ipsolateral ventricle & contralateral MLS
BC still patent
Evidence of previous Rt frontoparietal craniectomy + encaphalomalacia Rt frontal lobe
Impression: chronic Lt frontoparietal SDH
He underwent left parietal burrhole and drainage on 27/6/09. Post-op he is remained ventilated and sedated.

Post-op CT scan on 28/6/09

Display Pacs ReportNON-ENHANCED CT SCAN OF BRAIN dated 28/6/09.

Written Clinical Comments: post Burrhole drainage

***No previous image in the PACS for comparison.

Evidence of right frontal craniectomy and left parietal craniotomy.
Left fronto-parietal SDH with fluid level with mass effect to
adjacent lateral ventricle.
Midline shift of 1.8cm to the right with subfalcine herniation.
Right frontal contusion with perifocal oedema.
Basal cisterns are effaced but not obliterated.
No hydrocephalus.
Visualised paranasal sinuses are clear.

ICB with midline shift.

He underwent left parietal mini-craniotomy and subdural drainage on 29/6/2009

Display Pacs ReportNON-ENHANCED CT SCAN OF BRAIN dated 28/6/09.

Written Clinical Comments: post Burrhole drainage

***No previous image in the PACS for comparison.

Evidence of right frontal craniectomy and left parietal craniotomy.
Left fronto-parietal SDH with fluid level with mass effect to
adjacent lateral ventricle.
Midline shift of 1.8cm to the right with subfalcine herniation.
Right frontal contusion with perifocal oedema.
Basal cisterns are effaced but not obliterated.
No hydrocephalus.
Visualised paranasal sinuses are clear.

ICB with midline shift.

On POD2, he was extubated. Pre-extubation GCS E4 VT M6.

Monday, June 22, 2009

Right MCA territory Infarction with mass effect

Case: Refered from tanjung karang on 18/6/2009. 39 years old Indian gentleman, with no known medical illness developed sudden onset of left sided body wekness. He also had vomited few times whereby the vomitus was coffee ground.

Not on any medication. Been unwell since yesterday. Having nausea and persistent vomiting since yesterday. He was unable to tolerate much orally. Today had persistent vomiting too. At about 9 pm, had developed sudden onset of left UL and LL weakness associated with inability to speak. Denies having any headache, No giddiness, No fever, No preceding chest pain or palpitations. Married, Non smoker, occasional alcohol consumption

Alert, Obeying commands. Expressive dysphasia. Gag reflex absent. Right UL and LL: dense hemiplegia with hyperreflexia.
Plantar upgoing right side
lungs clear
PA-soft, non tender
Pupils - equal 3 mms, reactive.
Pulse 92 /min
Respiration 17 /min
Systolic Blood Pressure 117 mmHg Diastolic Blood Pressure 88 mmHg
SPO2 99 %
Analysis / Assessment
ECG - sinus rythm, LVH by voltage criteria

CT scan on 18/6/2009

Findings: Large ill defined wedge shaped hypodensity noted in the right fronto-parietal region with effacement of adjacent sulci. No midline shift. Ventricles and CSF-spaces are normal. Visualised paranasal sinuses are clear.
Impression: Right MCA territory recent infarct.

He underwent OGDS on 18/6/2009.

Esophagitis LA grade B with gastric metaplasiaChronic atrophic gastritis with antral erosionsDuodenum normal
On the next day noted pupils were unequal. Patient opens eyes, obeys commands, localizing to pain but not verbalizing
pupils unequal RT 4mm lt 2mm
BP 150/78
PR 74
Repeat Ct scan on 20/6/2009
Plain CT-brain on 20/6/09. Comparison with CT-scan on 18/6/09. Findings: The previously seen right MCA territory infarct become more well defined with increasing oedema. Associated mass effect to right lateral ventricle with midline shift 13 mm to left side. Hypodensity of midbrain, most likely represent ischaemia. Hyperintensity in basal cisterns and Sylvian fissures, suggestive of subarachnoid haemorrhage which was not seen before. Basal cisterns and sulci are effaced. Left basal ganglia recent infarct as seen before and not increasing in size. Left lateral ventricle is dilated.
He underwent right FTP decompressive cranictomy and left frontal EVD for ICP monitoring
Post-op he underwent cerebral resuscitation. Pupils 3s /2+. ICP maintanied below 20mmHg.
Post-op CT on 21/6/2009
PLAIN CT BRAIN: 21.6.2009 Finding: *** comparison with CT brain dated 20.6.2009. The left lateral ventricle is less dilated with EVD in situ. Lesser degree of midline shift to the leftc with shift of 4mm. Rest of the findings remains similar.

Sunday, June 21, 2009

Left cerebellar infarct with hemorrhagic transformation

Case: Referred from KKB. 57 years old malay male with underlying hypertension went to KKB with full GCS, complained of headache, nausea, vomiting, for 2 days with generalised body weakness. no fever. He was started on iv GTN due to uncontraoled hypertension. At 6pm he was confused, having slurred speech with gsc of E4V2M5. He was then referred to HSB for CT brain
PHYSICAL EXAMINATION General : gsc E4V2M6 pupils 3/3
Head and Neck : NAD
Respiratory : Clear Abdomen : soft, nontender, bowel sound heard
Musculoskeletal System : moving all 4 limbs

CT scan on 16/6/2009

Finding: Ill defined hypodense area seen in the left cerebellar hemisphere with perilesional oedema. The cerebellar fovea are effaced with effacement of the 4th ventricle with resultant dilatation of both lateral ventricle * 3rd ventricle. Area of hyperdensity within suggesting intraparenchymal bleed. No midline shift. Quadrigeminal cisterns are narrowed. Visualized sinuses and mastoid air cells are clear.
IMP: With the given presentation, the findings are suggestive of cerebellar infarct with haemorrhagic transformation. Associated with dilatation of lateral ventricles and 3rd ventricle due to mass effect of the 4th ventricle.

He underwent right frontal EVD placement. Right frontal EVD inserted (17/6/09)

Post-op patient alert
Pupils 3/3 reactive
The next day, Informed by staff nurse that pt was not opening eyes to call / not obeying commands + stridorGCS dropped from 13/15 to 7/15 ( E1V1M5 )Pupil : 3/3 ( reactive )B/P : 240/125PR : 111spo2 : 94 %
He was immediately intubated stat using ETT size 7.5 and started on IV midamorphine infusion 5ml/HLatest B/P : 192/113PR : 98Spo2 : 100%
Repeat Ct scan on 18/6/2009

Finding: ***comparison with CT Brain dated 17/6/09. Evidence of right parietal craniotomy with EVD traversing the right parietal lobe with tip at adjacent to the wall of right lateral ventricle. The previously noted hypodense area seen in the left cerebellar hemisphere with perilesional oedema is now more well defined. The intraparenchymal bleed in the left cerebellum remains similar in appearance.No new bleed. The cerebellar fovea are still effaced with effacement of the 4th ventricle. There is increasing dilatation of both lateral ventricle and 3rd ventricle. No midline shift. Quadrigeminal cistern is more narrowed.
Imp: Increasing hydrocephalus with narrower quadrigeminal cistern. No new bleed/ expansion of bleed.
He was brought to OT for posterior fossa decompression.
Post-op he was on cerebral protection with ICP maintained below 20mmHg.
Post-op CT scan on 19/6/2009

Finding: ***comparison with CT Brain dated 18/6/09. Evidence of right parietal craniotomy with occipital craniectomy . The intraparenchymal bleed in the left cerebellum remains similar in appearance.No new/expansion of bleed. 4th ventricle is no longer effaced. There is minimal reduction in the degree of dilatation of both lateral ventricle and 3rd ventricle. No midline shift. Quadrigeminal cistern is still narrowed.
Imp: Decreasing hydrocephalus. No new bleed/ expansion of bleed.

Right Frontoparietal convexity meningioma

Case : 55 years old malay gentleman, withn newly diagnosed diabetes mellitus type 2 on T. Metformin 500mg bd, presented in November 2008 with progressive left sided bdy weakness since past few months and was bed-bound on presentation. CT scan and MRI brain revealed right frontoparietal convexity meningioma

CT scan on 28/11/08

Findings: There is a broad based hyperdense mass in the right parietal region measuring 7.2cm X 4.9cm (axial) with medial buckling of the grey-white matter suggesting extra-axial mass. - significant mass effect resulting in effacement of ipsilateral lateral ventricle with minimal contralateral lateral ventricular dilatation. Midline shift of 12mm to the left. - homogenous enhancement with a small area of calcification. - small area of adjacent pressure erosion. No adjacent hyperostosis. - adjacent subtle white matter odema in the right parietal lobe. No mass is seen elsewhere. Basal cisterns are not obliterated.
IMP: Extra-axial mass in the right parietal region with significant mass effect.
DD: Meningioma.

MRI on 15/1/2009


There is a supra-tentorial, extra-axial, right fronto parietal mass which is hypointense on T1W, hyperintense with some ares of hypointensity representing calcification on T2W images. It enhances with contrast. The mass measures 5.1 ( Trans) x 7.5 ( AP) x 5.6 ( CC). It displaces the midline by 1.3 cm and compresses the ipsilateral lateral ventricle. Meningeal tail sign positive.

IMP: Appearances consistent with right fronto-parietal convexity meningioma.

He was advised for surgery but not keen. He was readmitted a month later with one episode of generalised tonic clonic seizure. He was started on phenytoin. In May 2009, he presented with behavioural changes and has been very aggressive. During this admission, the surgery was consented.

power of the lefty side - 4/5

He underwent right frontoparietal craniotomy and tumour excision (Simpson's II) on 16/6/2009

Post-op he was extubated and recovered well.

Post-op CT scan on 17/6/2009

He was discharged well and planned for repeat MRI in 6 weeks.