Jurnal Neuroanestesi Indonesia

Published by Indonesia Society of Neuroanesthesia and Critical Care (INA-SNACC)
Print ISSN: 2088-9674
Publications
Arterio-venous malformation (AVM) is a rare case, particularly among young patients (<40 years old). Maintaining haemodynamic stability and anticipating massive haemorrhage during micro surgery resection of AVM are fundamental for an anaesthetist. Total Intra Venous Anesthesia using propofol is still popular to control intracranial pressure as it is easily titrated and fast acting agent (both in onset and duration). Moreover, general neuruologic evaluation soon after anesthesia terminated is an integral important component of microsurgery of brain MAV. In this case report: a 20-year-old woman suddenly lost her consciousness and left-sided motors strength. Brain angiographic revealed an AVM in right frontal lobe. Microsurgery of brain AVM resection was performed. After 5-minute-preoxygenation, anaesthetic induction was performed by using propofol, fentanyl, rocuronium, and sevoflurane. The surgery went successfully using a combination of dexmedetomidine-sevoflurane 0.5MAC. Post-anaesthesia hemodynamic of this patient was in stable and without new neurologic deficit afterward.
 
Tuberculous spondylitis and tumors of the spine are two of many commonly cause of multiple lesions and spinal cord compression. The location of the lesion often determines the clinical manifestation. Mild to severe limb weakness, urinary disturbance and other abnormality due to posterior column compression are the common clinical manifestations. In most cases, these symptoms were used as guidance for surgical treatment. In a case like this, patient’s position during surgery, in addition to gain optimal access for the surgeon, could affect recovery time, morbidity and mortality. This case reported a 16 years old male, with Glasgow Coma Scale (GCS) score 15, bodyweight 50 kgs with stable haemodynamic, admitted to hospital due to paresthesian both legs. Magnetic Resonance Imaging (MRI) revealed paravertebral abscess at vertebral body T7–T8 and coincidencewith extramedullary tumor of the vertebrae T7–T11. Laminectomy, tumor removal, abscess drainage and posterior fixation were performed under general anesthesia. Surgical intervention was done in prone position.
 
The clinical spectrum of Covid-19 is very broad, ranging from minor no specific symptom, such as fever, dry cough and diarrhea, some time combined with mild pneumonia and mild dyspnoe to severe pneumonia with dyspnoe, tachypnoe and exchange disorders, leading to severe pulmonary dysfunction, necessary ventilation, shock and multiple organ failure. Preliminary unpublished evidence suggest that patient with covid-19 have an increased risk of acute ischemic stroke. Neurologic complaints that oven occurs are headache, dizziness, change in taste and smell. Five percent risk of developing acute ischemic stroke. Coronavirus has a tendency to invade the central nerve system (CNS). The olfactory change that have been seen in covid-19, are attributed to reflex access from the virus to the brain via the transcribial route, although this remain to be proven for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). One report from China showed that neurological complaint, such as dizziness, headaches, hypgeusia and hyposmia, were common (about 36%) in covid-19 patients. Encephalopathy and altered mental status also occurs in patients who have been infected with the SARS-CoV-2 virus. Cerebrovascular disease is more common in severe covid-19; acute ischemic stroke has been reported to occurs in 5.7% of patients and impaired consciousness in 15% of patients, and 1% cerebral hemorrhage was found. CNS disorders that require surgery require special treatment because of the effect of techniques and anesthetics on the CNS, as wll as the protection of health professionals to preventdiseses transmission. Thirty-eight percents of covid-19 patient with cerebrovascular complication died.
 
Cedera otak traumatik (COT) masih menjadi masalah kesehatan utama di seluruh dunia. Meskipun terjadi penurunan angka kejadian COT saat pandemi COVID-19 karena mobilisasi yang dibatasi, namun karena keterbatasan akses ke fasilitas kesehatan, penanganan COT menjadi terlambat. Penanganan pasien COT dengan infeksi COVID-19 berbeda karena adanya protokol dan pertimbangan yang harus dilakukan untuk keselamatan tenaga medis dan kelancaran penanganan pasien. Laporan kasus ini mengenai laki-laki berusia 41 tahun datang dengan penurunan kesadaran pasca kecelakaan kendaraan bermotor 24 jam sebelum masuk rumah sakit (RS). Pasien merupakan rujukan dari RS lain dengan cedera kepala berat. Dari hasil Computed Tomography (CT) scan kepala didapatkan epidural hematoma (EDH) akut frontal kiri – frontal kanan parasagital yang menekan lobus frontal kiri – lobus frontal kanan parasagital dengan midline shift sejauh ± 1.35 cm. Hasil pemeriksaan screening menunjukan hasil swab PCR positif. Pasien awalnya akan dirujuk ke RS rujukan COVID-19 namun tidak berhasil mendapatkan rujukan. Perdarahan epidural merupakan kondisi yang mengancam nyawa sehingga tindakan harus segera dilakukan. Pasien menjalani operasi emergensi kraniotomi evakuasi EDH dalam anestesi umum dengan protokol COVID-19. Penanganan anestesi dengan memperhatikan COVID-19 dan implikasinya pada pasien, neuroanestesi, dengan tetap menerapkan protokol COVID-19
 
The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, Hubei province China, in December 2019, and spread fast to all the world more than 190 countries. Patients should be screened for covid-19 using a combination of history, computed tomography (CT) chest, and real time quantitative polymerase chain reaction (RT-qPCR) testing depending on institutional policies. Neurological symptom as dizziness, headache, hypogeusia and hyposmia, common (36%) at covid-19 patient. Encephalopaty and changed mental status exist in patient infected by SARS-CoV-2 virus. Cerebrovascular diseases more in severe covid-19; acute ischemic stroke had reported in 5.7% and altered level of consciousnes in 15% patient. Surgical measuremet cranial and spinal rutine is safe, endoscopic endonasal surgery not safe and must be avoided. Extubation after general anesthesia if possible do air negative pressure room, and personil still use personal protection equipment (PPE) level 3. Must be avoid patient cough during extubation. After extubation, give oxygen nasal canule, surgical mask, and high flow oxygen (give <6 L/min) avoided given the risk of aerosolization
 
Latar Belakang dan Tujuan: Cedera otak traumatik (COT) merupakan salah satu masalah kesehatan di dunia terutama negara berkembang dengan angka kematian yang tinggi pada dewasa muda. Tujuan penelitian ini adalah untuk mengetahui jumlah angka kejadian COT dan karakteristiknya di RS. Hasan Sadikin (RSHS) Bandung. Subjek dan Metode: Penelitian deskriptif retrospektif dengan subyek pasien COT di Instalansi Gawat Darurat RSHS pada tahun 2008-2010. Pengambilan sampel dilakukan memakai data status pasien dan data elektronik catatan medis. Data dicatat dan dikelompokan sesuai dengan variabel karakteristik, outcome, serta dihitung CFR. Hasil: Angka kejadian COT selama 3 tahun di RSHS 3578 kasus, data yang berhasil dicatat sebanyak 2836 kasus, data yang tidak lengkap 483, dan data yang hilang 259, dengan CFR 3,5%. Kejadian COT ringan 1641 kasus, COT sedang 1086 kasus, COT berat 109 kasus. Kejadian pada laki-laki (79,8%) lebih tinggi dibandingkan perempuan (20,2%) dan tertinggi pada 18-45 tahun. Kecelakaan kendaraan roda dua adalah penyebab utama COT pada pasien RSHS. Jumlah terbanyak yang dilakukan operasi adalah fraktur depres dan cedera otak sedang. Interval waktu kedatangan di IGD sampai dimulainya operasi lebih dari 6 jam sebanyak 410 kejadian (60%) dan 273 kejadian (40%) memerlukan waktu operasi kurang dari 6 jam. Outcome pada pasien COT ringan adalah baik yaitu sebesar 94,7%, sedangkan outcome buruk dijumpai pada COT sedang sebesar 5,3%. Simpulan: Insidensi dan mortalitas COT di RSHS masih sangat tinggi dan tertinggi pada laki-laki, terjadi pada kelompok usia remaja sampai dewasa muda. Penyebab utama COT karena kecelakaan kendaraan roda dua dan mayoritas outcome pascaoperasi baik.
 
Background and Objectives: The stroke loss is higher in younger patients compared to the older patients. Stroke incidence is increasing year by year. Epidemiological study can be used as the basis of prevention and reduction of young adult stroke incidence. This study aims to determine the epidemiological picture of young adult stroke patients Subjects and Method: This study is a quantitative study using descriptive method. The datas were taken from the resume of medical records of patients that are diagnosed as stroke and treated in the neurology ward Dr.Hasan Sadikin Hospital(RSHS) in 2011 - 2016. All samples were taken then classified by its age group, sex, stroke type, demographical characteristic and risk factor. Result: 452 samples were obtained. The highest number of cases are found in the 42-45 year old group (45,11%). Ischemic stroke (50,44%) cases are higher compared to the hemorrhagic stroke (49,56%). Stroke cases in women (56,66%) is higher than in men (43,34%). Most of the patient’s last education is high school (32,89%). Most of the patients who have stroke are unemployed (56,22%). The most risk factor is hypertension (42,06%). Conclusion: Stroke cases in RSHS happen to be higher in older age group, ischemic stroke type, women, high school as the last education, unemployment and the highest risk factor is hypertension.
 
Latar Belakang dan Tujuan: Tumor otak adalah kumpulan sel tidak normal pada otak yang bermultiplikasi dan dapat menyebabkan kerusakan pada jaringan sekitarnya dan organ-organ terkait. Tumor supratentorial adalah tumor otak yang terletak superior terhadap tentorium serebeli. Tentorium serebeli adalah lapisan dural yang memisahkan lobus oksipital pada otak besar dengan otak kecil. Tumor supratentorial adalah 33% dari total tumor otak. Penelitian ini bertujuan untuk menggambarkan angka kejadian tumor supratentorial berdasarkan jenis dan letak tumor. Subjek dan Metode: Objek penelitian adalah rekam medis pasien dengan diagnosis tumor supratentorial yang masuk ke Rumah Sakit Hasan Sadikin Bandung pada Januari 2012 hingga Desember 2013. Penelitian ini merupakan penelitian deskriptif memakai rancangan studi kasus. Data dibagi kedalam kelompok sesuai dengan jenis dan letak tumor kemudian dilihat karakteristiknya. Hasil: Terdapat 494 pasien tumor supratentorial tapi hanya ada 168 yang memiliki informasi lengkap. Berdasarkan jenisnya, tumor dikelompokkan secara garis besar menjadi glioma (14,88%), tumor kranial dan paraspinal (0,60%), tumor meningen (70,24%), tumor pada region sella (10,12%) dan tumor metastasis (4,17%). Berdasarkan letaknya, secara garis besar tumor terletak di sisi kanan (35,12%), sisi kiri (36,90%), region sellar (13,69%), sisi tengah (4,16%) dan bilateral (10,12%) Simpulan: Jenis tumor supratentorial terbanyak adalah meningioma dan lokasi tumor supratentorial paling banyak adalah pada sisi kiri otak secara umum, atau pada lobus frontal secara spesifik
 
Background and Objective: Stroke is an important health issue causing the second most death worldwide. Epidemiology of stroke patients based on risk factors is highly variable without data to report regarding risk factors of stroke in West Java. Aim of this study is to find out profile of stroke risk factor. Subject and Method: This study is a descriptive study with cross section design. Data acquired retrospectively with total sampling method from medical records of stroke patients in Hasan Sadikin General Hospital from January 2015–December 2016 that fulfills inclusion criteria and exclusion criteria. Result: Obtained 1044 subjects consisted of 486 males and 558 females. Subjects with age 55–64 years old (33.3%), elementary school graduate (45.3%), and no occupation (56.4%) were the highest prevalence of studied subject. Ischaemic stroke had higher prevalence than haemorrhagic stroke with carotid system (89.6%) higher than vertebrobasilar (10.4%). Highest risk factor were hypertension. Conclusion: Incidence of stroke patients are higher in women, older age group, low education, and no occupation. Ischaemic stroke case patients were found more often than haemorrhagic stroke with carotid system more than vertebrobasilar system. Hypertension is the most common risk factor causing stroke.
 
Background and Objectives: Traumatic brain injury (TBI) is a case with the third highest prevalence among other injuries (16,8%) in Indonesia. Hypotension and hypoxaemia are TBI outcome predictors which can be controlled. This research aims to find out the incidence of hypotension and hypoxaemia in TBI patients. Subjects and Method: This descriptive quantitative research collected the data retrospectively from the medical record of COT patients who were admitted to Emergency Room (ER) Dr. Hasan Sadikin Public General Hospital in 1 January – 31 December 2015. Samples were collected with total sampling technique, and classified based on age, gender, etiology, TBI severity level, oxygen saturation, and blood pressure of the patients. Results: 669 samples were collected. Age average of the samples was 29 years with the highest age group frequency being 15-24 years (30,3%). There were more male patients (71,2%) compared to the female ones (28,8%). The most common cause of TBI was traffic accidents (68,9%). There were 78 (11,7%) severe TBI cases. There were 50 (7,5%) TBI patients with hypoxaemia and hypotension, and the most hypotension and hypoxaemia cases were in severe TBI patients (66%). Conclusion: The proportion of hypoxaemia and hypotension incidence was the highest in severe TBI patients due to traffic accidents.
 
Hemoglobin Levels, Blood Loss and Transfusion in Patients Underwent Brain Tumor Surgery at Dr. Hasan Sadikin Bandung General Hospital During 2015–2016 Background and Objective: Brain tumor surgery is closely related to the risk of numerous bleeding that can cause the patient to be in an anemic condition. The clinical effects of anemia can be improved by administered blood transfusions. Transfusion can be administered with target Hemoglobin (Hb) level between 9 to 10 gr/dL.The purpose of this study was to describe of preoperative and postoperative levels of Hb and hematocrit, blood loss and how blood transfusion administered in patients undergoing brain tumor surgery at Dr. Hasan Sadikin Bandung during June 2015 to June 2016. Subject and Method: This is a descriptive observational study with retrospective approach to 126 objects taken at medical records. Result and Conclusion: The average of preoperative Hb level was 13,23±1,350 gr/dL and the average of preoperative hematocrit level was 39,19±3,54%. Number of patients with postoperative Hb level 10 gr/dL were 105 patients. The average of postoperative Ht were 34,03±6,032%. The rate of blood loss was 1159±1032,66cc. The rate of transfusions administered to 56 patients was pack red cell 365,81±258,70cc, fresh frozen plasma 425,45±274,78cc and whole blood 250cc.
 
Seven to 8% of pregnant women had experienced trauma that can lead to maternal deaths due to trauma not as result of her pregnancy. Management of anesthesia in pregnant women who will undergo surgery with general anesthesia outside caesarean section, especially neurosurgery, providing a challenge to the anesthesiologist, because there are two patients who must be managed in order to have good clinical score outcomes for both patients. We will report a 22-year-old woman who will undergo surgery epidural hematoma evacuation due to a motorcycle accident that occurred previously, without performed caesarean section, reminiscent of gestation is still in the second trimester. Consideration of anatomical and physiological changes in pregnancy and effort that uteroplacental blood flow should be considered carefully, because critical factors will indicate the degree of head injury more severe, so that the results of the clinical outcomes of mother and fetus is bad. In this case mother and her pregnancy can discharge from hospital with good condition.
 
Latar Belakang dan Tujuan: Profesi dokter anestesi merupakan profesi dengan beban kerja tinggi yang dituntut untuk berpikir dan bertindak cepat dan tepat dalam situasi kritis. Kekurangan tidur, kelelahan, dan perubahan irama sirkadian mempengaruhi fungsi kognitif dokter anestesi. Tujuan penelitian ini untuk mengetahui perubahan fungsi kognitif peserta Peserta Program Pendidikan Dokter Spesialis (PPDS) Anestesiologi dan Terapi Intensif Fakultas Kedokteran Universitas Padjadjaran setelah 24 jam kerja yang diperiksa menggunakan Montreal Cognitive Assessment versi Indonesia (MoCA-INA). Subjek dan Metode: Penelitian ini merupakan penelitian deskriptif observasional prospektif dengan pendekatan cross sectional yang dilakukan pada 62 subjek dengan memeriksa MoCA-INA jam ke-0 dan jam ke-24. Hasil: Pada penelitian ini didapatkan penurunan nilai rata-rata MoCA-INA dengan nilai jam ke-0 yaitu 29,84 ± 0,365 dan jam ke-24 yaitu 28,92 ± 1,010. Berdasarkan aspek kognitif yang diperiksa, fungsi atensi merupakan aspek yang mengalami penurunan setelah jam ke-24. Penurunan nilai MoCA-INA paling banyak terdapat pada subjek yang bertugas di kamar operasi. Penurunan nilai rata-rata MoCA-INA setelah 24 jam kerja tersebut masih dalam batas normal karena masih di atas nilai acuan dan secara klinis tidak menunjukkan gangguan. Simpulan: Terdapat penurunan fungsi kognitif peserta PPDS Anestesiologi dan Terapi Intensif Fakultas Kedokteran Universitas Padjadjaran setelah 24 jam kerja. Cognitive Function Alterations on Residents Anesthesiology and Intensive Care of Medical Faculty Universitas Padjadjaran after 24 Hours Shift Abstract Background and Objective: Anesthesiologist is a profession with a heavy workload which is need fast thinking and rapid decision making in a critical and life-threatening situation. Sleep deprivation, extended workshifts, exhaustion and circardian cycle changes can affect anesthesiologist’s cognitive function. This aim of this study was to evaluate cognitive function changes in Residents of Anesthesiology and Intensive Therapy in Medical Faculty Universitas Padjadjaran after 24 hours shift using Montreal Cognitive Assesment-Indonesia Version (MoCA-INA). Subject and Method: This study was an observational-descriptive-prospective study using crosss sectional approach evaluating MoCA-INA score in 0th hour and 24th hour after shift in 62 subjects. Result: The result of this study shown an average MoCA-INA score at 0th hour was 29.84 ± 0.365 while at 24th hours the average score was 28.92 ± 1.010. According to MoCA-INA, attention is the deprived domain at 24th hour after shift. MoCA-INA score declines mostly in subjects working in the operating room. According to MoCA-INA cut off value, the score of 26 is considered normal after 24 hours shift and not showing any clinical disturbance. Conclusion: The conclusion of this study is decreasing cognitive function among Anesthesiology Medical Faculty Universitas Padjadjaran residents after 24 hours shift.
 
Hidrosefalus adalah pembesaran ventrikel otak sebagai akibat peningkatan jumlah cairan serebrospinal (CSS) yang disebabkan oleh ketidakseimbangan antara produksi, sirkulasi dan absorbsinya. Perkiraan wanita hamil yang dilakukan operasi non obstetric sekitar 1–2%. Pasien obstetri dengan penyakit bedah saraf selalu dirawat di ICU. Insidensi operasi selama kehamilan dilaporkan 42% prosedur pembedahan terjadi pada trimester pertama, 35% pada trimester kedua, dan 23% pada trimester ketiga. Seorang wanita 35 tahun dengan usia kehamilan 32–33 minggu datang ke IGD dengan penurunan kesadaran tanpa riwayat trauma, tidak dijumpai tekanan darah tinggi. Dari pemeriksaan CT-Scan ditemukan adanya hidrosefalus, sehingga dilakukan tindakan external ventricular drainage (EVD). Anestesi untuk pasien dalam keadaan hamil harus mempertimbangkan bayi dalam kandungan sehingga dilakukan pembiusan scalp block dan occipital block. Obat yang digunakan ropivakain HCl 0,375 % (sebanyak 10cc). Setelah operasi pasien dirawat di ruang pemulihan, 2 jam kemudian dirawat di ruang high care unit (HCU). Pencegahan terhadap hipoksia dan hipotensi adalah keharusan, walaupun periode hipoksemia yang pendek masih bisa ditoleransi. Hipoksemia maternal yang berkepanjangan akan menyebabkan vasokonstriksi sirkulasi uteroplasental yang pada akhirnya menurunkan perfusi sehingga menyebabkan hipoksemia, asidosis dan kematian janin. Scalp Block and Occipital Block Anesthesia for External Ventricular Drainage (EVD) in 32-Week PregnancyAbstractHydrocephalus is enlargement of the brain ventricles as a result of an increase in the amount of cerebrospinal fluid (CSS) caused by an imbalance between production, circulation and absorption. Estimates of pregnant women in non-obstetric surgery are around 1–2%. Obstetric patients with neurosurgery disorders are always treated in the ICU. The incidence of surgery during pregnancy was reported in 42% of surgical procedures occurred in the first trimester, 35% in the second trimester, and 23% in the third trimester. A 35-year-old woman with 32-33 weeks' gestation came to the emergency room with decreased consciousness yet no history of trauma and high blood pressure. Hydrocephalus were found in CT scan, and the external ventricular drainage (EVD) is taken. The patient has intrauterine pregnancy so the anesthesia choice is scalp block and occipital block. Ropivacaine HCl 0.375% (as much 10cc) was used. After surgery the patient was treated in the recovery room for 2 hours, and discharged to the high care unit (HCU) afterwards. Hypoxia and hypotension is a challenge in short periods of hypoxemia that can still be tolerated. Prolonged maternal hypoxemia prevention will cause uteroplacental circulation vasoconstriction which ultimately reduces perfusion, causing foetal hypoxemia, acidosis and death.
 
Craniopharyngioma is an intracranial tumor that occurs in the region of the pituitary fossa and suprasellar cisterns along to the hypothalamus. Craniopharyngioma is brain tumor which is defined by WHO as a benign tumor in the sella region derived from Ratkhe pouch epithelium in which the incidence is 1.34 patients per 1 million population. The average age of patients was 0-14 years of age peaks where the tumor is located between 5 and 14 years. Reported a man 22 years old came to the General Hospital dr. Zainoel Abidin Banda Aceh with symptoms of headache, nausea, vomiting, decreased vision acuity. On physical examination found a decrease in visual acuity, lateral visual field defects, and found the anisokor pupil 4 cm / 2 cm. In routine blood tests found normal value, normal Thyroid Stimulating Hormon (TSH) and normal serum prolactin. MRI head with contrast was found mass measuring 5,12cm x 2.63 cm protruding from the sella tursika demarcated and filled with contrasts. Currently treated by surgical total removal tumor with combination of frontolateral and pterional surgery approach. Postoperative histopathologic results showed a adamantinomatous craniopharyngioma. In this case, complication that occur after surgery procedure is diabetes insipidus.
 
Latar Belakang dan Tujuan: Kraniotomi evakuasi hematoma dan kraniektomi dekompresi merupakan suatu tindakan definitif terhadap pasien cedera kepala berat. Perlu dilakukan suatu evaluasi untuk mengetahui luaran tindakan pembedahan sebagai informasi dalam memperbaiki dan mengurangi morbiditas dan mortalitas baik di bidang anestesi maupun bedah saraf. Subjek dan Metode: Penelitian deskriptif ini dilakukan di Rumah Sakit Umum Dr. Zainoel Abidin terhadap 83 pasien pasien cedera kepala berat yang dilakukan tindakan kraniotomi evakuasi hematoma atau kraniektomi dekompresi yang kemudian di rawat di ICU selama tahun 2012. Pasien dilakukan operasi dalam 24 jam setelah masuk rumah sakit dan kemudian dirawat di ICU. Dilakukan pencatatan umur, jenis kelamin dan luaran setelah operasi yaitu perbaikan fungsi motorik dan angka kematian selama rawatan 5 hari di ICU. Hasil: Pasien yang masuk dalam penelitian dengan jumlah 56 (67%) laki-laki dan 27 (33%) perempuan dengan usia sebagian besar 15-20 tahun 27% usia lebih dari 40 tahun 35%. Terdapat perbaikan fungsi motorik dalam skala penilaian GCS pada pasien setelah operasi terutama pada skala motorik 1 sampai 3 menjadi skala 2 sampai 5 setelah operasi. Angka kematian dalam 5 hari rawatan mencapai 57% (48 pasien) dan pasien yang hidup setelah 5 hari pasca operasi 43% (35 pasien). Sebagian besar kematian terjadi pada perawatan hari ke 2 (25%) dan hari ke 3 (35%). Simpulan: Tindakan operasi kraniotomi untuk evakuasi hematoma atau kraniektomi dekompresi pada pasien cedera kepala berat dapat memperbaiki fungsi motorik dan angka kematian 57% setelah 5 hari rawatan awal di ICU.
 
Tetralogy of Fallot (TOF) was first described in 1888 by a French physician named Etienne-Louis Arthur Fallot. Tetralogy of Fallot (TOF) is one type of cyanotic congenital heart defect most widely found. Tetralogy of Fallot (TOF) has four abnormalities: (1) pulmonary infundibulum stenosis, (2) VSD (Ventricular Septal Defect), (3) overriding aorta, and (4) right ventricular hypertrophy. Patients with congenital cyanotic heart disease (right to left shunt) have a risk of brain abscess. The incidences of cyanotic heart disease is about 12.8-69,4% of all cases of brain abscess and the highest incidence occurs in children. We reported an 8-years old 16-kg boy with multiple brain abscesses accompanied with cyanotic congenital heart defect Tetralogy of Fallot (TOF) and whom abscess aspiration would be performed. Patients was present with body temperature 39oC, GCS 13, blood pressure 90/50 mmHg, pulse 120 beats/min, SpO2 90% with a simple mask using oxygenation of 6 L/min. Lab results showed Hb 14gr%, hematocrit 41%, platelet count 250.000/mm3, PT /aPTT: 13.2/26.9. Patient was mounted infusion from the emergency ward (ER), given 1 mg intravenous midazolam premedication, induction with propofol, fentanyl, vecuronium, maintenance with oxygen-air anesthesia and sevoflurane. The operation lasted for 1.5 hours, the infusion targeted to normal volume, postoperative care was given in the neurointensive care unit for 3 days. Pre-surgical fasting plan plays an important role because the patient must remains well hydrated. TOF patients with polycythemia when dehydrated, will increase the viscosity and sludging events. This patient was well hydrated and fasting replacement fluid therapy was given intravenously. Patients should be in a state of calm and relaxed. Patient was given intravenous midazolam premedication. Premedication with intramuscular injections should be avoided, since anxiety and stress may lead to "tet" spell. Heavy premedication should also be avoided because of respiratory depression leading to hypercarbia can increase the Pulmonary Vascular Resistance (PVR) and precipitate increased shunting from right to the left. Cerebral abscess aspiration can not be performed under local anesthesia because it increases the anxiety and the patient's blood pressure. Anesthesia should be performed under general anesthesia. Management of perioperative TOF patients who will underwent surgery elsewhere (not for TOF) requires deep understanding on TOF pathophysiology and neuro-anesthesia techniques to get a good outcome
 
Acute respiratory distress syndrome (ARDS) is one of the complications of severe traumatic brain injury (TBI), it can be caused by neurogenic pulmonary edema (NPE), pneumonia, aspiration, and pulmonary embolism. This study was determine the correlation glasgow coma scale score on severe head injury with insidence and degree of acute respiratory distress syndrome. This study was using prospective observational cross-sectional method in 32 patients with severe TBI at Dr. Hasan Sadikin General Hospital Bandung on May 2015 untill September 2015. Data collection was performed by consecutive sampling. Parameters were recorded in this study include age, gender, weight, GCS, time scales, diagnosis, incidence and degrees of ARDS. Linear correlation analysis was calculated based on two variables Spearman correlation analysis and correlation ETA. The results showed a correlation between GCS score on severe COT with the incidence of ARDS with the strength of the correlation moderate (r=0.402), significantly (p
 
Akromegali merupakan penyakit akibat produksi growth hormone secara berlebihan dan umumya disebabkan oleh adenoma kelenjar hipofisis. Insidensi akromegali pertahunnya mencapai 5 kasus per 1 juta orang dengan prevalensi 60 kasus per 1 juta orang. Manifestasi klinis pada tiap pasien berbeda, tergantung dari kadar dari growth hormone, insulin-like growth factor-1, usia pasien, ukuran tumor, dan keterlambatan diagnosis. Pasien dengan akromegali telah dilaporkan memiliki tingkat mortalitas dan morbiditas yang tinggi, peningkatan angka kematian pada umumnya terkait dengan komplikasi kelainan kardiovaskular, serebrovaskular dan masalah respirasi. Pada kasus ini, seorang laki-laki usia 57 tahun, berat badan 86 kg, dengan PS-ASA II, perawakan khas akromegali dan ditunjang dengan hasil pemeriksaan hormon. Pada pemeriksaan CT-scan ditemukan massa di ruang sella tursica. Pemeriksaan lebih lanjut menunjukkan pembesaran lidah yang menimbulkan kesulitan manajemen jalan nafas dan diklasifikasikan sebagai mallampati kelas II. Pasien akan dilakukan prosedur reseksi tumor adenohipofise melalui pendekatan sublabial transpheonidal dengan anestesi umum. Sebagian besar anestesi untuk operasi pada pasien akromegali membutuhkan perhatian khusus dibandingkan dengan tumor kepala yang lain. Kata kunci: Akromegali, manajemen anestesi, pendekatan sublabial transfenoid, tumor adenohipofisis.
 
Adenoma hipofisis merupakan tumor otak dengan gejala klinis tergantung hormon yang dihasilkan oleh sel tumor, ukuran, dan invasi lokal. Perempuan 50 tahun dengan adenoma hipofisis dengan riwayat hipotiroid. Pada pemeriksaan prabedah GCS E4M6V5, tekanan darah 114/76 mmHg, denyut nadi 81x/menit, pernafasan 18x/menit, dan saturasi 99%. Pada pemeriksaan fisik berat badan dan visus mata kanan menurun. Pemeriksaan fungsi tiroid kesan hipotiroid, lalu pasien diterapi levotiroksin natrium 100 µg perhari tablet selama 14 hari sampai dengan eutiroid. Tatalaksana lanjutan yang dilakukan adalah kraniotomi reseksi adenoma hipofisis. Premedikasi hidrokortison 100 mg dan midazolam 0,1mg/kgbb intravena. Induksi propofol 1 mg/kgbb, fentanyl 2µg/kgbb, rocuronium 1 mg/kgbb, lidokain 1 mg/kgbb dan propofol pengulangan dosis 0,5 mg/kgbb. Manitol diberikan 0,5 mg/kgbb dan dexamethason 10 mg. Rumatan anestesi sevoflurane 0,5% dan propofol 50–100 µg/kgbb/menit. Pasca operasi pasien di ICU diberikan dexmedetomidine 0,2 µg/kgbb/jam dan suplemen steroid H-1 diberikan 25 mg hidrokortison setiap 12 jam. Pada H-2 diberikan 20 mg hidrokortison pagi hari dan 10 mg sore hari kemudian dapat dihentikan. Pasien dirawat di ICU 3 hari sebelum pindah ruang rawat biasa. Manajemen perioperatif adenoma hipofisis dengan riwayat hipotiroid adalah mengoptimalkan pra operasi pasien sehingga pasien mencapai eutiroid, menjaga stabilitas hemodinamik, mengoptimalkan oksigenasi serebral, mencegah serta mengatasi komplikasi. Anesthesia Management of Patient with Pituitary Adenoma with Hystory of Hypothyroidism Abstract Pituitary adenoma is a brain tumor has clinical symptoms depending on hormones produced by tumor cells, size, and local invasion. A 50-year-old woman with pituitary adenoma with history of hypothyroidism. On preoperative, GCS E4M6V5, blood pressure was 114/76 mmHg, pulse was 81x/minute, respiration was 18x/minute, and saturation was 99%. On physical examination, body weight and the visual acuity in the right eye decreased. Examination of thyroid function suggests hypothyroidism before surgery, patient was treated with levothyroxine sodium 100 g per day tablets for 14 days until euthyroid. The next treatment was resection craniotomy of the pituitary adenoma. Premedicated with hydrocortisone 100 mg and midazolam 0.1 mg/kg body weight. Induction propofol 1 mg/kg body weight, fentanyl 2 µg/kg body weight, rocuronium 1 mg/kg body weight, lidocaine 1 mg/kg body weight and repeated doses of 0.5 mg/kg body weight propofol. Mannitol was given 0.5 mg/kgbw and dexamethasone 10 mg. Maintenance anesthesia with sevoflurane 0.5% and propofol 50-100 µg/kgbw/min. Postoperative the patient in the ICU was given dexmedetomidine 0.2 µg/kgbw/hour and steroid supplement day-1 was given 25 mg hydrocortisone every 12 hours. On day-2, 20 mg of hydrocortisone in the morning and 10 mg in the evening, then can be discontinued. The patient was admitted to the ICU for 3 days before moving to the ward. Perioperative management of pituitary adenoma with a history of hypothyroidism is optimizing preoperatively the patient reaches euthyroid, maintaining hemodynamics, optimizing cerebral oxygenation, preventing and treatment if there are complications.
 
Background and Objective: Chronic low back pain caused by compression of spinal nerves roots or thecal sac is common and can lead to disability. Percutaneous epidural adhesiolysis (PEA) is an interventional pain management to relieve the pain.This study aims to evaluate the effectiveness of the PEA using lidocaine 2% in relieving lower back pain. Material and Methods: This retrospective cohort study was done using five patient’s data taken from medical record, with all patients had underwent PEA using 5 mL of 2% lidocaine, outcome measurements were evaluated using Visual Analogue Score (VAS), Oswestry Disability Index (ODI) and the useage of opioid drugs at 3rd and 6th month afterward. Results: The oldest age was 60 years and 80% of patients were male with a maximum value of VAS before procedure was 9, VAS score at 3rd month was 3 and VAS score at 6th month was 2. The maximum value ODI before procedure was 90, ODI at 3rd month was 50, while the 6th month was 25. Friedman test and post hoc Wilcoxon test revealed a significant difference in VAS score between before procedure, 3rd month and 6th month post-procedure (p
 
Nyeri merupakan suatu perasaan atau pengalaman yang bersifat subjektif yang melibatkan sensoris, emosional, dan tingkah laku yang tidak menyenangkan yang disebabkan oleh kerusakan jaringan. Manajemen nyeri pascaoperasi dinilai esensial karena akan memberikan hasil luaran yang baik pada pasien serta meningkatkan kualitas hidup pascaoperasi. Opioid merupakan obat analgesik intravena yang paling sering digunakan sebagai terapi nyeri perioperatif, namun memiliki efek samping yang kurang menyenangkan. Pengembangan dalam penggunaan obat analgesik yang lebih efektif diperlukan, salah satu adalah lidokain intravena yang memiliki efek samping yang lebih kecil dibandingkan opioid. Beberapa studi menunjukkan bahwa penggunaan lidokain sebagai obat analgesik intraoperatif memiliki efek samping minimal dan pemulihan lebih cepat. Penelitian lain juga menunjukkan penggunaan lidokain sebagai analgesik pada operasi bedah saraf memiliki efek yang cukup baik. Maka dari itu, tinjauan pustaka ini akan membahas mengenai penggunaan lidokain sebagai terapi adjuvan obat analgesik, khususnya pada operasi bedah saraf. The Use of Intravenous Lidocaine as Adjuvant Analgesia in Neurosurgery Abstract Pain is a subjective feeling or experience involving sensory, emotional, and unpleasant behavior caused by tissue damage. Postoperative management is considered essential because it will provide excellent results for patients and improve postoperative quality of life. Opioids are intravenous analgesic drugs that are most often used as perioperative pain therapy but have unpleasant side effects. Developments in using more effective analgesic drugs are needed, one of which is intravenous lidocaine which has fewer side effects than opioids. Several studies have shown that lidocaine as an intraoperative analgesic drug has minimal side effects and faster recovery. Other studies have also shown lidocaine as an analgesic in neurosurgery surgery to have a fairly good effect. Therefore, this literature will discuss lidocaine as an adjuvant therapy, especially in neurosurgery operations.
 
Latar Belakang dan Tujuan: Dexmedetomidin untuk kasus-kasus neurotrauma masih kontroversi, antara yang setuju dan menolak. Dexmedetomidin sebagai agonis adrenoseptor α2 memiliki beberapa keuntungan dalam kaitannya dengan kemampuannya sebagai neuroprotektan. Penelitian ini bertujuan untuk mengkaji efek neuroproteksi dari dexmedetomidin yang dilihat dari pengaruhnya terhadap penurunan kadar glutamat. Subjek dan Metode Penelitian single blind randomized controlled trial dilakukan pada 16 orang yang datang ke IGD RSUD Prof. Dr. Margono Soekarjo dengan cedera otak traumatik dengan GCS ≤8 pada Mei–Desember 2013. Subjek dibagi dalam 2 kelompok yaitu kelompok dexmedetomidin dan NaCl 0,9%. Pembedahan dilakukan dalam rentang waktu 9 jam pascatrauma. Pemeriksaan kadar glutamat dengan menggunakan metode ELISA. Analisis data menggunakan uji-t dan uji Mann-Whitney. Hasil: Kelompok yang mendapatkan dexmedetomidin menunjukkan bahwa pemberian dexmedetomidin 0,4 μg/kgBB/jam secara kontinyu, menunjukkan penurunan kadar glutamat yang diukur mulai dari awal perlakuan hingga jam ke-24 sebanyak 27,9% (p=0,025), dari jam ke-24 hingga jam-72 sebanyak 9,6% (p=0,208), serta dari awal perlakuan hingga jam ke-72 sebanyak 57,1% (p=0,036). Kelompok yang tidak mendapatkan dexmedetomidin mengalami peningkatan kadar glutamat. Simpulan: Pemberian dexmedetomidin 0,4 μg/kgBB/jam dapat menurunkan kadar glutamat pada pasien cedera otak traumatik dengan GCS ≤ 8.
 
Trombosis sinus venosus serebral (TSVS) merupakan penyakit akibat oklusi struktur vena intrakranial, termasuk sinus serebral, vena korteks, dan bagian proksimal vena jugularis. Keterlambatan diagnosis dan terapi dapat mengakibatkan terjadinya komplikasi seperti infark berdarah bahkan kematian. Trombosis yang menyebabkan TSVS adalah proses pembentukan bekuan darah dalam pembuluh darah. Trombosis terjadi jika keseimbangan antara faktor trombogenik dan mekanisme protektif trombogenesis terganggu. Kelainan fungsi trombosit pada kasus TSVS dapat berupa gangguan fungsi adhesi, gangguan reaksi pelepasan atau sekresi, dan gangguan fungsi agregasi. Disfungsi dan gangguan struktur endotel akibat inflamasi menyebabkan adhesi trombosit sehingga trombosit saling melekat dengan kolagen pada sel endotel. Proses adhesi dan sekresi granul trombosit dapat diprediksi dengan pemeriksaan Platelet-selectin (P-selectin) merupakan protein transmembran tipe 1 pada granul trombosit dan granul megakariosit serta berperan dalam memediasi interaksi antara leukosit dengan ligan yang membantu proses adhesi leukosit dan trombosit sehingga dapat dijadikan prediktor trombosis pada pasien dengan TSVS.
 
Dexmedetomidine, agonis reseptor α2 adrenergik-memberikan efek "sedasi kooperatif," ansiolitik, dan analgesia tanpa depresi pernafasan, efek simpatolitik dan antinosisepsi memungkinkan untuk stabilitas hemodinamik perioperatif. Kasus ini akan membahas neurofarmakologi dan neurofisiologi dari α2-adrenergik agonis dan penerapan dexmedetomidine sebagai ajuvan. Bayi 1 tahun,10 kg, didiagnosa hidrosefalus obstruktif oleh adanya tumor di regio fossa posterior (yang telah menjalani 3 kali revisi VP-shunt), GCS10: E4V2M4, tekanan darah 90/40mmHg, laju nadi 150 x/menit, laju nafas 30 x/menit, suhu 36,8°C, akan menjalani kraniektomi untuk pengangkatan tumor di regio fossa posterior pada posisi prone. Monitor non-invasif (tekanan darah, denyut jantung, SpO2, EKG, Kapnograph dan kateter urin). Premedikasi dengan midazolam 0,5 mg intravena. Induksi anestesi dengan ajuvan dexmedetomidine. Pemeliharaan anestesi dengan oksigen/udara, sevoflurane 0,6-1,0%, infus kontinyu dexmedetomidine dan pemberian selimut penghangat 370C. Pemantauan ketat dilakukan di ICU anak (PICU) dengan ventilasi mekanik dan diekstubasi pada esok pagi. Setelah hari ke-10 rawatan di PICU, pasien dipindahkan ke ruangan tanpa komplikasi neurologis perioperatif (GCS 12: E4V3M5). Manajemen, evaluasi serta pencegahan yang tepat terhadap kemungkinan komplikasi yang terjadi dapat meningkatkan luaran pasien
 
Latar Belakang dan Tujuan: Perdarahan intraserebral (PIS) mempunyai angka morbiditas dan mortalitas yang tinggi. Hanya 20% individu yang bertahan dari penyakit ini dapat hidup dalam 6 bulan. Masih terdapat kontroversi dalam tatalaksana PIS, seperti meregulasi tekanan darah, mencegah perluasan hematoma, edema otak, dan mempertahankan perfusi serebral. Tujuan penelitian ini adalah untuk membahas prosedur tatalaksana perioperatif PIS dengan hipertensi emergensi. Subjek dan Metode: Penelitian serial kasus dari 3 kasus dengan gangguan kesadaran (skor GCS ≤14), didiagnosa PIS, akan dilakukan kraniotomi evakuasi hematoma. Dilakukan pengelolaan tekanan darah prabedah dengan target tekanan darah rata-rata (TAR) 125–130 mmHg. Induksi dengan fentanyl 3 ug/kg, propofol 2,5 mg/kg, vecuronium 0,1 mg/kg, lidokain 1,5 mg/kg dan rumatan anestesi dengan O2, air, isoflurane 1–1,5 vol%. Hasil: Pascabedah 2 kasus dirawat di ICU selama 2–3 hari dan satu kasus dirawat di neurocritical care unit (NCCU) selama 3 hari dan terdapat perbaikan GCS menjadi 15. Setelah itu dipindahkan ke ruangan dan mendapat perawatan selama 5–7 hari, dan dipulangkan setelah 7–15 hari. Simpulan: Masih ada kontroversi tentang terapi PIS yang optimal terutama dalam pengendalian tekanan darah. Tekanan darah yang tinggi dapat menimbulkan hematoma, tapi penurunan tekanan darah dapat menimbulkan penurunan perfusi otak. The Intensive Blood Pressure Reduction of Acute Cerebral Hemorrhage Trial (INTERACT) menemukan bahwa penurunan tekanan darah yang segera akan mengurangi resiko perluasan perdarahan tapi tidak mempunyai efek pada outcome, akan tetapi, pada ke 3 kasus tersebut menurunkan tekanan darah dalam waktu kurang dari 24 jam memberikan hasil yang baik
 
Stroke dapat terjadi akibat terhentinya aliran darah ke otak, yang terjadi secara mendadak. Penyebab terbanyak stroke adalah berkurangnya pasokan darah ke otak (stroke iskemik). Penyebab stroke lainnya adalah perdarahan (stroke hemoragik). Perdarahan subaraknoid (SAH) biasanya dapat terjadi baik karena ruptur aneurisma, atau karena trauma. Perempuan, 46 tahun dengan GCS 14 (E4M6V4) dengan hipertensi tidak terkontrol mengalami nyeri kepala hebat. Dari pemeriksaan CT scan memperlihatkan adanya perdarahan subaraknoid dan edema sereberi. Pasien ini dilakukan tindakan coiling aneurisma cito dengan anestesia umum. Pasca coiling pasien dirawat di ruang intensive care unit (ICU). Pasca perawatan 1 hari di ICU, pasien dipindahkan ke ruang high care unit (HCU), dengan kondisi stabil. Penurunan kesadaran mulai terjadi saat perawatan hari kedua, sempat dilakukan pemasangan lumbar drain pada hari ketiga, untuk membantu mengurangi hidrosefalus dan juga menurunkan tekanan intra kranial. Pada perawatan hari ketigabelas kesadaran menurun drastis menjadi E1M1V1, pasien dipindahkan ke ruang ICU, dan meninggal esok harinya. Penurunan kesadaran pasca coiling diakibatkan oleh peningkatan tekanan intra kranial, yang pada kasus ini disebabkan oleh edema sereberi luas. Early Brain Injury ¬ditambah dengan adanya vasopasme menyebabkan terjadinya delayed ischemic neurological deficit. Terapi yang sudah dikerjakan baik farmakologis maupun non farmakologis, tetap tidak bisa memperbaiki keadaan pasien. Delayed Ischemic Neurological Defisit (DIND) Pasca Coiling Subarachnoid Hemorrhage (SAH) e.c Ruptur AneurismaAbstractStroke can occur due to the cessation of blood flow to the brain, which occurs suddenly. The most common cause of stroke is reduced blood supply to the brain (ischemic stroke). Another cause of stroke is bleeding in the brain (hemorrhagic stroke). Subarachnoid hemorrhage (SAH) usually results from ruptured aneurysms or because of trauma. Women, 46 years old with GCS 14 (E4M6V4) with uncontrolled hypertension experienced severe headache since 2 days before admitted to the hospital. The CT scan examination showed subarachnoid hemorrhage and edema of the brain. This patient then performed emergency coiling of aneurysm with general anesthesia. During the procedure the patient is in stable condition. Post coiling the patient was sent to the ICU room. After 1 day in ICU, the patient was transferred to high care unit (HCU) room, with stable condition. Decreased of consciousness began to occur during the second day of treatment, had done lumbar drain installation on the third day, to help reduce the hydrocephalus and also improve intra-cranial pressure. On the thirteenth day care GCS was decrease suddenly to E1M1V1, the patient was transferred to the ICU room, the next day the patient was declared dead. The decrease of consciousness post coiling results from an increase in intra-cranial pressure, which in this case is due to severe brain edema. Earlu brain injury along with the occurence of vasospasm lead to delayed ischemic neurological deficit. Pharmacological and non-pharmacological therapy had been given to the patient still couldn’t improve the patient condition
 
Management of severe head injury cases, in any given situation, is targeted to maintain cerebral perfusion pressure (CPP), and preventing increase of intracranial pressure that possibly cause secondary brain injury. In a case of pregnancy, besides considering the maternal status, fetus condition is equally important to observe. Hyperventilation should be avoided due to its possible detrimental effect to both the brain perfusion and placental blood flow. A 25 year old female, 60 kg, 160 cm, was taken to the hospital due to head trauma caused by a traffic accident, roughly about an hour prior to hospitalization. GCS was E4M6V4. The patient was in her 28 – 30 week of pregnancy (G1P0A0). Sudden decrease in consciousness occurred and GCS lowered to E1M5V1. Endotracheal intubation was then prompted. Epidural haematoma subarachnoid haematoma with midline shift revealed in CT scan. The patient underwent epidural hematoma evacuation with general anesthesia then transferred to Intensive Care Unit (ICU) with ETT maintained. Fetal heart rate remains heard, followed with close monitoring of the fetal heart rate during treatment in the ICU. After 3 days in ICU, fetus died. Summary: A pregnant patient with severe head injury of epidural and subarachnoid bleeding, has undergone an operation with general anesthesia. The fetus was unfortunately cannot be saved due to the patient long ventilator treatment.
 
Epidural hemorrhages (EDH) are bleeding in epidural space, usually occur in the middle cranial fossa via laceration of the middle meningeal artery, although they can also occur in the anterior and osterior fossae. They are usually lenticular shaped and are bounded by suture lines where the pericranial ayer of dura attaches to the skull. Classically patients suffered from EDH experience a lucid interval which is a period of intact consciousness prior to deterioration.Clinical symptom of intracranial hematoma such as EDH, mainly depend on volume and rate the hematoma formed. If the intracranial hematoma formed rapidly, there will be a sudden rise on ICP which led to neurologic deterioration that could be deleterious. Perioperative management of intracranial hematoma such as EDH is to maintain brain perfusion and oxygenation, control the ICP, and surgical decompression in some cases. We are scussing perioperative management of two cases suffered from EDH due to traumatic brain injury who underwent emergency craniotomy for clott evacuation.These are important injuries to identify;if detected early they are usually associated with good outcome and have a mortality of less than 10%. Early bleeding control and hematoma evacuation are very important to patient safety and avoid any permanent neurologic injury.
 
Acromegaly as a clinical manifestation of functional pituitary macroadenoma is a rare case. A 28-year-old male was consulted with a space occupying suprasellar cerebral lesion with a differential diagnosis of meningioma or adenoma which would require tumor resection. On the pre-operative examination, it was found that patients with signs and symptom of acromegaly such as a more prominent jaw, the size of the nose, tongue, and hands were relatively larger than normal people but without symptoms of obstructive sleep apnea. Intraoperatively, the patient was successfully intubated with a video laryngoscope with a fiber optic preparation. Post-operatively the patient developed diabetes insipidus and was transferred to the room from ICU on the seventh postoperative day when she was free of vasopressin. There are several things that should be considered during the perioperative management of patients with pituitary macroadenoma, such as airway management if there is acromegaly and diabetes insipidus as a postoperative complication.
 
Pituitary tumors are common in adults and represents 10% of intracranial tumors. Acromegaly is a clinical syndrome caused by the production of excess growth hormone and it is known as a rare disease, which is characterized by excessive secretion of growth hormone (GH) and growth factors such as insulin (IGF-1, Insulin Growth Factor-1). The overall incidence of acromegaly is estimated at 3 to 5 new cases per million population. Acromegaly can coexist with thyroid disorders. First-line treatment for acromegaly is transsphenoidal surgery. Perioperative management of pituitary surgery requires treatment by a team of neurosurgeons, neuroanaesthesiologists and endocrinologists. All patients with pituitary adenoma requires a thorough pre -operative endocrine evaluation and a follow- up in post- operative period. A 50 years old woman entered a hospital with complaints of swollen both hands and feet, thicken and crooked foot, enlarging of jaw and nose. She had a history of ± 3 years hyperthyroid treatment. Magnetic resonance imaging (MRI) examination of the head with the contrast obtained macroadenoma pituitary. Patiens underwent micro- surgery procedures of craniotomi transsphenoidal. Post-surgery, Patient being observed in the ICU and her condition was deteriorated and she eventually died on the second day due to thyroid crisis.
 
Top-cited authors
Tatang Bisri
  • Medical Faculty Universitas Jenderal Achmad Yani, Bandung, Indonesia
Yulianti Bisri
Sri Rahardjo
  • Universitas Gadjah Mada
I Putu Pramana Suarjaya
  • Sanglah Hospital
Kenanga marwan Sikumbang
  • Universitas Lambung Mangkurat