Traumatic Intracerebral Hemorrhage

44 years old Malay gentle man

Alleged MVA today at Rawang
he was riding a MB before he hit a nearby old tyre by the roadside and skidded
he's wearing a fastened helmet

found unconscious and was brought alone by ambulance

Upon arrival to ED GCS was 5/15 ( E1V1M3)
pupil- rt 6mm lt 2mm fixed

patient was intubated-->noted loss of blood in the oral cavity
ryles tube inserted-->no blood/fluids come out

Pt is intubated and sedated
vital sign
BP 163/57 not on inotrops
pr 55
RR 15 on ventilator
swollen right supra-orbital with hematoma
pupil Rt cannot be asscess, Lt 2mm, non reactive

No oozing of blood from ear and nose
Noted dry blood over the nose and left ear Emergency CT scan brain:
ICB at Left frontal 5x4 cm over 4 cut with midline shift 0.6cm
no hydrochepalus, brain appears tight
Urgent craniectomy and evacuation of blood clot was performed.



Subsequently percutaneous tracheostomy was performed and weaned off ventilator
Currently CGS E4VTM5

Traumatic C2 dens fracture (Type II)

16 years old Chinese gentlemen, with no known medical illness

He was alleged MVA on 24/4/10 at 11 am in Klang.
He was a back seat passenger of a car with another 3 friends, while on the way to work.
The car was collided with a lorry.
LOC with unknown exact duration.

He was brought to HTAR with an ambulance. All other three victims died at the scene.

Upon arrival at HTAR, GCS was 7/15 then improved to 12/15 on the same day
Able to move all limbs and had 2 episodes of vomiting upon arrival

On arrival at Neurosurgical Centre;
He was on cervical collar
conscious, alert
GCS: E3V4M6
pupils:3/3 reactive ( left periorbiotal hematoma, cornea looks clear but conjunctiva hemorrhage seen)

L/W over the left frontal region --> T&S done in HTAR
multiple abrasion wound over the face

BP: 120/87
HR: 94
temp:37
SPO2: 100% on air
CT scan brain : Bifrontal contusion with comminuted frontal bone fracture with the involvement of frontal air sinuses (anterior and posterior wall) and thin left frontal EDH






Cervical X-ray shows C2 odontoid fracture




MRI cervical shows anterior displacement of dens with normal cervical cord



CT cervical shows type II odontoid fracture.





He was subjected to odontoid screw placement. Intra-operatively, reduction of displacement was done guided by the image intensifier. Post-operatively, he was extubated with no neurological deficit.

Post-op Cervical X-rays show the position of the screw.

Glasgow Coma Scale

Literature review of management of pineal region tumour

Literature Review Of Management Of Pineal Region Tumour

Metastatic Squamous Cell Carcinoma

•53 Years old Gentleman
Chronic smoker with underlying COAD
Developed progressive left sided limbs weakness for 2 months, associated with headache.
No other symptoms on systemic review
GCS full, PEARL
Higher mental function intact

No cranial nerves deficit noted
Left hemiparesis 4/5 with no sensory impairment
No cerebellar sign
Other examinations - Normal

MRI showed homogenous enhancing lesion at right motor cortex, left insular and left cerebellum

Tumour markers done – within normal value
CXR - NAD
CT thorax and abdomen - NAD

•Right parietal craniotomy and excision of tumour done under IGS transsulcus approach

Frozen section sent- Metastatic tumour

Post-operatively, his weakness remain same.
On follow-up 2 weeks after surgery his weakness improved
HPE = Metastatic squamous cell carcinoma

Tumours Of The Cerebellopontine angle

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.