Inpatient Case Report

VESTIBULAR
SCHWANNOMA
Presented by : Christien
Lecturer : dr. Soetedjo, SpS(K)
 Vestibular Schwannoma
Maria Christien Agustie* Soetedjo**

ABSTRACT
Background
Vestibular schwannoma is a benign brain tumor that predominantly occurs in young adult. Tumors usually occupy
cerebellopontine angle (CPA) and extend ed to cerebellum. The diagnosis is often delayed due to a slow-growing tumor
. Patients with unilateral or bilateral perceptive deafness asymmetric or unilateral tinnitus with unclear etiology must
be explored in order to get rid of vestibular schwannoma. The management includes medication , radiotsurgery, and
surgical treatment . The prognosis quite good , with a recurrency ate of < 5 % .
Case Report
Reported the case of a woman , 30 years old , Javanese , right handed , married, a housewife with a chief complaint of
chronic progressive cephalgia accompanied by symptoms of left ear hearing loss, tinnitus, vestibular vertigo, face
asymetry, left side limb weakness, and ataxia since 5 months before admission. On physical examination found signs of
cerebellar syndrome, and leftside limb weakness . From the MRI found a mass in the left CPA that extended to
cerebellum, accompanied hidrocephalus non communicans and increased intracranial pressure.
By history , physical examination, and investigations, the pastient tend to experience SOL derived from the left CPA.
The management of this patient is steroid therapy and tumor resection . Results of histopathological examination
supports the diagnosis of schwannoma .
Conclusion
It has been reported patient with symptoms of hearing loss, chronic progressive cephalgia, vestibular vertigo,
accompanied by leftside limb weakness and ataxia since 5 months before admission. A collection of signs and symptoms
in this patient consistent with increased intracranial pressure due to the masses in the left CPA that extended to
cerebellum. Management of this patient is steroid and tumor resection.. Anatomic pathology examination result
supports the diagnosis of vestibular schwannoma . During the post-operative care, the patient's condition was
improved. Patients were allowed to go home after the 19th day of treatment . This case is a rare case for young adults,
and the prognosis is quite good if handled with good management.
INTRODUCTION

• These are non-cancerous tumors that affect hearing and

balance when they press on the nerve in the inner ear.
• It is a rare tumor that often affects middle-aged people.
No known race & gender predilection.
• 95% : sporadic (unilateral), 5% : related to
neurofibromatosis type 2 gene (bilateral)
• Treatment can include observation (watching and
waiting), surgery or radiation.
DEFINITION
• Vestibular Schwannoma is a
non malignant tumour of cranial
nerve (CN) VIII (vestibular).
Choclear : very rare
• It derived from schwan cells
that covers the vesibular nerve.
• Other name: accoustic neuroma/
neurinoma/ neurilemoma
EPIDEMIOLOGY
Schwannoma : 6% - 8% of all
intracranial primary tumour,
The most tumours that occupying
the CPA

Schwannoma Vestibular :
Schwannoma Trigeminal : 2 – 4%
85 – 90% from all schwannomas
 Cerebellopontine
Angle
Contents :
- Facial nerve (CN
VII)
Bentuknya - Vestibulocochlear
menyerupai nerve (CN VIII)
segitiga - Flocculus of the
cerebellum
- Lateral recess of the
containing CSF, arachnoid tissue,
4th ventriclle
cranial nerves, and associate vessels

It is a structure at the margin

of the cerebellum and pons
THE ANATOMY Of N.VIII
 CEREBELLUM
Anterior Lobe
Primary fissure
Regulation of
muscle tone,
coordination of
skilled voluntary
movement Posterior
Lobe

Planning and
initiation of Flocculo-
voluntary activity
Nodular
Lobe (FN lobe)

Maintenance of
Vestibulocerebellum
balance, control
of eye movements Spinocerebellum
Folia Cerebrocerebelum
ANATOMY There are two types :
1. Antoni A Regio:

PATOLOGY Contain solid cells that had elongated,

shaped as hyperchromatic coil. Every
nucleus of cells lined up in rows like
fence (palisade) alternately with the
area that there is no nucleus (called
Verocay Agency )
A
2. Antoni B Regio :
Compiled by cells with large vacuoles,
B which not arranged neatly ,
sometimes accompanied by the
picnotic nucleus cells or with
irregular shapes .
Cystic changes often occur
Patogenesis
Vestibular Schwannoma

Derived from schwan cell of CN.VIII

In the myelin transtition of “peripher to central” zone

Occur from Internal Auditory Canal

Tend to grow on the vestibular nerve

Clinical Manifestation :

Phases of Tumor Growth

Intracanalicular:
 Hearing loss, tinnitus, vertigo
Cisternal:
 Worsened hearing and dysequilibrium
Compressive:
 Occasional occipital headache
 CN V: Midface, corneal hypesthesia
Hydrocephalic:
Fourth ventricle compressed and obstructed
 Headache, visual changes, altered mental status
Jackler Staging System

Stage Tumor Size

Intracanalicular Tumor confined to IAC
I (small) < 10 mm
II (medium) 11-25 mm
III (Large) 25-40 mm
IV (Giant) > 40 mm
 Phases of Tumor Growth
Intracanalicular Cisternal

Compressive
Hydrocephalic
GROWTH RATE
Supporting BAER
Investigation
Audiometry Vestibular
test

Audiometry : asimetry in high

frequencies
Vestibular test : Caloric response
decreased in affected ear
BAER : late response or decreasing
response in the affected ear
MRI/Brain CT Scan with contrast : shows
a densely "enhancing" (bright) tumor in
the internal auditory canal.
 Differential Diagnosis
• Kista • Aneurysm
Vascular
Arakhnoid • Hemangioma
lesions
• Lipoma • Hemangio-
blastoma

Congenital Intra axial

Lesion tumour

• Astrocytoma
• Epidermoid Other CPA • Glioma
• Meningioma lesions • Medullo-
blastoma
 MANAGEMENT

Depends on:
Expectant Age
General health
Radiotherapy Size of tumor
Neurological
Surgery deficits

Many are so small that they may not need immediate treatment :
Steroid and simptomatic medication can be used
SURGERY
COMPLICATIONS
Because of tumor enlargement

Result of the treatment

Recurrency
POST OPERATIVE
COMPLICATIONS
Facial Palsy (63%)

Hydrocephalus (26%)

Vertigo (21%)

CSF leakage (21%)

Seizures (11%)

Meningitis (11%)
PROGNOSIS
Generally : Good

Microsurgery & Stereotactic radiosurgery

 Satisfying result

Reccurency rate < 5%

CASE REPORT
IDENTITAS
• Name : Mrs. K
• MR Number : C551132
• Age : 30 years
• Sex : Female
• Marriage Status : Married
• Education : Graduated from Junior Highschool
• Occupation : Housewife
• Address : Katong, Grobogan,
• Hospital Admission : October 14th 2015
History : Autoanamnesis 14th Oct 2015
• Chief Complaint : Headahe
• Onset : 5 months before admission
• Quality : throbbing pain
• Kuantitas : ADL partially helped by family
• Chronology : + 5 months before admission patient
complained of throbbing headache, especially in front left of the
head . The headache was intermittent , 1-2x a week , the pain
increased by activities , reduced by taking painkillers medicine
and by relaxing . Patients also felt her left ear hearing began to
diminish and heard the sound of ringing intermeittently, no
discharge from the ear of ear infection, No limb weakness, No
tingling/Numb, No nausea / vomiting, No blurred vision, No
fever, miction and defecation are within normal limits .
• + 2 months before admission the symptom of headache was
increasing, become severe, continuous arise almost every day
,especially early morning / morning when she woke up .
Patients also complain of dizziness or spinning sensation
intermittently, not influenced by position, not accompanied by
vomiting, last more than an hour. The patient went to the clinic
physician, were given oral medication . The symptom reduced
when she took the drug, but re-ocurred when she didnt take the
drug.
• + 1 month before admission patient began to stagger/ unsteady
and should be assisted / being carried while walking, her left
eyelid is difficult to closeface asymetry (+), and left ear can
not hear at all. Her visual views began to blur, No projectile
vomiting denied, No seizures. Patient also began to feel left
limb weakness, She frequently drop things she carried, and she
felt numb of her leftside of body.
• + 2 weeks before admission, patient felt the headache was
severe, she started vomiting without prior nausea,
decreased appetite, she became weak. Then the family take
her to check the Panti Rahayu Hospital, treated for 2 days,
underwent brain CT scan, she was told having a brain
tumor. The patients was then referred to RSDK for the
further treatment.

• Aggravating Factors : activity

• Relieveng Factors : pain-killer, resting
• Concommitant symptoms : left ear tinnitus, hearing loss,
left eyelid was hard to close, staggering, vomiting, leftside
limb weakness, leftside limb numbness
Past Medical History

• No history of trauma Riwayat h

• No history of Hypertention
• No history of tumor
• No history of DM
• No history of ear infection
• History of 3 months of contraceptive injection, since two
years ago
Family Disease History :
• No other familiy suffering the same history of disease
• No history of malignancy in the family

Social Economic-Status And Personal History :

Patient is a housewife, the husband is a farmer, she has only
one child who wasn’t independent yet, medical expenses
covered by BPJS.
 Clinical Findings
Status presens
• LOC : Compos mentis GCS : E4M6V5 = 15
• Vital signs :
BP = 120/80 mmhg; HR = 80x/menit;
RR = 20x/mnt; T = 370C ; Visual Analog Scale : 6

• Height: 155 cm weight : 45 kg BMI: 18,7 (normoweight)

Status Internus
Internal Status
• Head : mesocephal, symmetrical
• Eye : anaemic conjunctiva (-/-), ikteric sclera (-/-)
• Neck : symmetrical, no lymph node enlargement, no
increased JVP
• Thorax
Cor : normal heart sound,murmur(-), gallop (-)
Lung : normal breathing, Rh-/-, Wh -/- -
• Abdomen : normal peristaltic, unpalpable liver and spleen,
ascites (-)
 Mental and Higher Function State

• Appearance and Behavior : normal

• Mood : normal
• Vegetative symptoms : normal
• Cognitive function : normal
 Neurological Status

• Level of conscioussness : GCS E4 M6 V5 = 15

• Head : mesocephal, symmetrical
• Eye : round pupil, isocor 2.5/2.5 mm,
light reflex +/+
• Neck : nuchal rigidity (-)
• Cranial Nerves : Left CN. VIII peripheral
Motoric :
Motoric Superior Inferior
Gerakan +/↓ + /↓
Kekuatan 555/444 555/444
Tonus N/N N/N
Trofi E/E E/E
RF ++/+++ ++/+++
RP -/+(H,T) -/+ (B)
Klonus -/-

Sensibilitas : Hemihypestesi sinistra

Vegetatif : within normal state
Coordinasi
• Gait ataxia : difficult to evaluate (because patient cannot
walk
• Romberg test : difficult to evaluate
• Ataksia : Truncal ataxia (+)
• Dysdiadochokinesia : difficult to evaluate
• Rebound phenomen : (+)
• Dismetri : (+) hypermetri

Abnormal Movements
Tremor : intensional tremor (+)
Athetose : (-)
Mioklonik : (-)
Khorea : (-)
LABORATORY FINDINGS
Laboratorium (14/10/15) Result Normal Values
Hb 12,0 gr% 12-15
Ht 41,2% 35-47
Eritrosit 4,81 mill/mmk 3,9-5,6 mill
MCH 29,0 pg 27-33
MCV 85,70 fl 76-96
MCHC 33,80 g/dl 29-36
Leukocyte 12.900 /mmk 4000-11000
Thrombocyte 292.000/mmk 150-400thousand
Random Blood Sugar 105 mg/dl 80-110
Ureum 19 mg/dl 15-39
Creatinine 0,8 mg/dl 0,60-1,30
Natrium 142 mmol/l 136-145
Potassium 3,9 mmol/l 3,5-5,1
Osm = 300,8 mOsm
Chlorida 100 mmol/l 98-107
Fluid Deficit = 0,64 L
Magnesium 1,09 mmol/L 0,74-0,99
Calcium 2,1 mmol/L 2,12 – 2,52
Radiology
Brain Ctscan Kepala from Panti
Rapih Hosp (08/10/2015)

Expertise :
There is a lesion with mixed density of
in the cerebellum, after the
administration of the contrast, the
section was enhanced,
- there is a narrowing cisterna & sulci
around the lesion
- The fourth ventricle narrowing, dilation
of the left and right lateral ventricle and
ventricular -III balooning.
- Midline shifting (+)
- Pons structure is difficult to assess.

Impression: SOL cerebellum with

increased ICP
THORAX X-RAY
• Normal cor
• No lung
infiltrates
EKG

Normosinus
rhytme
 NEUROLOGIC FORMULATION
• Female patient, Mrs. K, 30 years old, Javannesse, a housewife, right handed,
married, came with a chief complain of chronic progressive headache since 5 months
ago, preceeded by left ear hearing loss, tinnitus, and vestibular vertigo
intermittently. Since 2 months before admission the pain intensity and vestibular
vertigo became severe. Since 1 month before admission he became unsteady, have to
be carried when walking, accompanied face asimetry, blurred vision.. Since 2 weeks
before admission, she began to have projectile vomiting, severe vestibular vertigo,
and ataxia. Also leftside limb weakness & numbness. Then she was taken by to check
the Panti Rahayu Hospital. She was treated for 2 days, underwent Brain CT scan.
She said she was diagnosed having brain tumor. The Patient then referred to Kariadi
Hospital for the further treatment.
• On physical examination was found vital signs within normal limits. On neurological
examination found the consciousness was composmentis, GCS: E4M6V5, cephalgia
with VAS 6, infanuclear paresis of left N.VII, and dysfunction of the left N.VIII, with
the signs of cerebellar syndrome (+) including ataxia, intentional tremor, dysmetria.
On Investigations of contrast Brain CT scan was noted a space occupying lesion on
the cerebellopontine Angle extended to the cerebellum with increased cranial
pressure.
• The above collection of signs and symptoms consistent leading to increased
Intracranial Pressure from SOL on the CPA.
Diagnosis
1. Clinical Diagnosis :
Chronic Progressive Headache
Vertigo central
Paresis of Left CN.VII Peripheral (infranuclear)
Left CN. VIII paresis
Left Hemiparesis (UMN type)
Hemihypesthesi sinistra
Truncal ataxia
Intensional tremor
Topical Diagnosis : Left cerebellopontine angle, Cerebellum
Ethioogical Diagnosis : CPA Tumor dd/ primer
secunder
2. Leucocytosis (12,1 thousand/ mmk) dd/ reactive
 INITIAL PLANS (14/10/15)

1. SOL Left CPA dd/ Primary, Secondary

Program :
Consult to Ophtalmologist, Consult to Physical Medicine and Rehabilitation
MRI with contrast
Therapy :
- IVFD RL 20 dpm
- Inj. Ketorolac 30 mg/ 8 ho intravena
- Inj. Dexamethasone 10 mg/ 6 ho iv
- Ranitidin 50 mg/ 12 ho iv
- Dimenhidrinate 50 mg/ 12 ho po
IMx : GCS, vital signs, neurology deficits
IEx : educate the family about pt condition, additional examination, plan management,
deterioration that could happened

2.Leukositosis dd/ reaktif

Program : (-)
• Monitoring : sign of infection
• Education : about the disease & plan management
 2nd DAY HOSPITALIZATION (15st Oct 2015)

S Headache

GCS E4M6V5 = 15
BP: 120/90 mmHg, HR: 80 x/min, RR: 20 x/min, Temp: 36,5°C
Vital signs VAS 5
O Within normal state
Internal st
Paresis of Left CN.VII Peripheral (infranuclear), Left CN. VIII paresis, Left
Neurology
Hemiparesis (UMN type), Hemihypesthesi sinistra, Truncal ataxia, Intensional
status
tremor

Assesment 1. SOL of Left CPA 2. Leucocytosis

-Consult to - IVFD RL 20 tpm

Opthalmol - Inj. Ketorolac 30 mg/ 8 jam intravena
ogist , - Paracetamol tab 500 mg/ 8 jam po
Consult to - Inj. Dexamethasone 10 mg/ 6 jam iv
Physical - Ranitidin 50 mg/ 12 jam iv
Medicine - Dimenhidrinate 50 mg/ 12 jam po
Program
and
Rehabilitati
on,
MRI with contrast
 Consult to Physical Medicine and Rehabilitation :
Physiotherapy : breathing exercise, active ROM, general
exercise, early mobilisation, Strenghtening exercise of left
extremity, balancing coordination,
Occupation therapy : movemnet coordination, balance
exercise with activity
 Consult to Ophtalmologist :
Impression : Chronic papil edema ODS, visus : > 3/ 60 ODS
Suggestion : Asetazolamide 250 mg/ 24 ho po,
KCl tab 250 mg/ 24 ho po
 3rd DAY HOSPITALIZATION (16st Oct 2015)

S Headache

GCS E4M6V5 = 15
BP: 110/80 mmHg, HR: 84 x/min, RR: 20 x/min, Temp: 36,5°C
Vital signs VAS 3
O Within normal state
Internal st
Paresis of Left CN.VII Peripheral (infranuclear), Left CN. VIII paresis, Left
Neurology
Hemiparesis (UMN type), Hemihypesthesi sinistra, Truncal ataxia, Intensional
status
tremor

Assesment 1. SOL Leftt CPA 2. Leucocytosis

-Consult to - IVFD RL 20 tpm

neurosurge - Inj. Ketorolac 30 mg/ 8 jam intravena
on, - Paracetamol tab 500 mg/ 8 jam po
MRI with contrast - Inj. Dexamethasone 10 mg/ 6 jam iv (III)
Program - Ranitidin 50 mg/ 12 jam iv
- Dimenhidrinate 50 mg/ 12 jam po
- Asetazolamide 250 mg/ 24jam po
- KCl 250 mg/ 24 jam po
 Consultation to Neurosurgion :

- Dx : SOL Left cerebellum dd/ Left CPA

• Will be discussed in neurosurgery conference
- Suggestion :
• - Inj. Dexamethasone 10 mg/ 8 ho iv
• - Inj Ranitidin 50 mg / 12 ho iv
• - Phenytoin 200 mg tab / 24 ho po
 5th DAY HOSPITALIZATION (20st Oct 2015)

S Headache

GCS E4M6V5 = 15
BP: 110/80 mmHg, HR: 84 x/min, RR: 20 x/min, Temp: 36,5°C
Vital signs VAS 3
O Within normal state
Internal st
Paresis of Left CN.VII Peripheral (infranuclear), Left CN. VIII paresis, Left
Neurology
Hemiparesis (UMN type), Hemihypesthesi sinistra, Truncal ataxia, Intensional
status
tremor

Assesment 1. SOL Leftt CPA 2. Leucocytosis

-Consult to - IVFD RL 20 tpm

neurosurge - Inj. Ketorolac 30 mg/ 8 jam intravena
on, - Paracetamol tab 500 mg/ 8 jam po
MRI with contrast - Inj. Dexamethasone 10 mg/ 6 jam iv (III)
- Ranitidin 50 mg/ 12 jam iv
Program
- Dimenhidrinate 50 mg/ 12 jam po
- Asetazolamide 250 mg/ 24jam po
- KCl 250 mg/ 24 jam po
- Phenytoin 200 mg/ 24 jam po
 Brain MRI + Contrast

- Solid extra-axial mass with calcification inside the left cerebellopontine angle, with
perifokal edema seemed encasing ventricle III and IV, extended to mesencephalon, pons
and cerebellum vermis – pressing it to the right, as well as pressing the vertebral artery
left to right. It also seems that the thickening of the left canal of the internal acousticus ,
dd / Acoustic schwannoma
meningioma
- Hydrocephalus non communicans
- Infarction lakuner the centrum semiovale left-right, left-right corona radiata, the capsule
of the left externa.
 9th DAY HOSPITALIZATION (24st Oct 2015)

S Headache

GCS E4M6V5 = 15
BP: 110/80 mmHg, HR: 84 x/min, RR: 20 x/min, Temp: 36,5°C
Vital signs VAS 2
O Within normal state
Internal st
Paresis of Left CN.VII Peripheral (infranuclear), Left CN. VIII paresis, Left
Neurology
Hemiparesis (UMN type), Hemihypesthesi sinistra, Truncal ataxia, Intensional
status
tremor

Assesment 1. Susp. Schwannoma Vestibular dd/ meningioma 2. Leucocytosis

- Pro craniotomi - IVFD RL 20 tpm

dasar tengkorak : - Inj. Ketorolac 30 mg/ 8 jam intravena --stop
Consult to - Paracetamol tab 500 mg/ 8 jam po
anestesi, informed - Inj. Dexamethasone 10 mg/ 8 jam iv (IX, tapp.off)
consent, - Ranitidin 50 mg/ 12 jam iv
Program
- Lab : - Dimenhidrinate 50 mg/ 12 jam po
PPT/PTTK - Asetazolamide 250 mg/ 24jam po
- KCl 250 mg/ 24 jam po
- Phenytoin 200 mg/ 24 jam po
 10th DAY HOSPITALIZATION (25st Oct 2015)

S Headache

GCS E4M6V5 = 15
BP: 110/80 mmHg, HR: 84 x/min, RR: 20 x/min, Temp: 36,5°C
Vital signs VAS 2
O Within normal state
Internal st
Paresis of Left CN.VII Peripheral (infranuclear), Left CN. VIII paresis, Left
Neurology
Hemiparesis (UMN type), Hemihypesthesi sinistra, Truncal ataxia, Intensional
status
tremor

Assesment 1. Susp. Schwannoma Vestibular dd/ meningioma 2. Leucocytosis

- Preparing for the - IVFD RL 20 tpm

surgery : order - Inj. Ketorolac 30 mg/ 8 jam intravena --stop
PRC blood, - Paracetamol tab 500 mg/ 8 jam po
Whole blod, order - Inj. Dexamethasone 10 mg/ 8 jam iv (IX, tapp.off)
for bed after post - Ranitidin 50 mg/ 12 jam iv
Program
op in ICU - Dimenhidrinate 50 mg/ 12 jam po
- Asetazolamide 250 mg/ 24jam po
- KCl 250 mg/ 24 jam po
- Phenytoin 200 mg/ 24 jam po
 Consult to Anesthesia :
Agree anesthesia management : ASA II
Informed consent
Infus RL 20 tpm
Premedication in OK
Fasting 6 ho pre operasi
Bed & Ventilator available (+)
 Laporan Operasi
Pre operation dx : Left CPA tumor,
Tumor resected, piece by piece
Treat the bleeding
- A/r retrosigmoid sinistra
Duraplasty
- Pts posision right oblique, in deep anesthesia
Close the wound
-Desinfection
Operation finished
-Sterile doek placement
- S Insition, deepend to the bone, Borrhole in
Operation Lenght : 255 minutes;
4 sites,
Bleeding : 1000 cc.
- Open duramater in inverted T shpae
- Follow through the edge of the cerebellum
in the corner of the CPA
- DO : showed tumor in yellowish colour,
relatively minor bleeding, with lot of
vascularization in the outer wall
 POST SURGERY
Laboratorium Vakue Normal
Hasil Satuan Nilai Rujukan
Hb 10,2 gr% 12-15
Ht 30,0% 35-47 FiO2 45 %
Eritrosit 3,52 mill mmk 3,9-5,6 milll pH 7,36 7,37 – 745
MCH 29,0 pg 27-33 pO2 161 mmHg 83.0 – 108.0
MCV 85,30 fl 76-96
pH (T) 7,36 7,35 – 7,45
MCHC 34,00 g/dl 29-36
pCO2 (T) 31 mmHg
Leukosit 20.900 /mmk 4000-11000
pO2 (T) 163 mmHg
Trombosit 169.000/mmk 150-400 thousand
HCO3- 17,5 mmol/L 18 – 23
GDS 148 mg/dl 80-110
TCO2 18,5 mmol/L
Ureum 32 mg/dl 15-39
Creatinin 0,8 mg/dl 0,60-1,30 BE ecf -7,9 mmol/L

Natrium 136 mmol/l 136-145 BE (B) -6,9 Mmol/L -2 – 3

Kalium 3,5 mmol/l 3,5-5,1 Sat O2 99 %

A-aDO2 119 mmHg

Chlorida 104 mmol/l 98-107
PF ratio : 362
Magnesium 0,89 mmol/L 0,74-0,99

Calcium 1,64 mmol/L 2,12 – 2,52

Albumin 3,1 3,4 – 5,0

 12th DAY HOSPITALIZATION (27th Oct 2015) – Post Op Day 2

S Contact (+), Schlemm >>

GCS E4M6V5 = 15
BP: 120/75 mmHg, HR: 84 x/min, RR: 20 x/min, Temp: 36,5°C
Vital signs

O Ventilator (+) : mode CPAP FiO2 35%; PEEP 3, PS 8,

Internal st
NGT (+)
Paresis of Left CN.VII Peripheral (infranuclear), Left CN. VIII paresis, Left
Neurology
Hemiparesis (UMN type), Hemihypesthesi sinistra, Truncal ataxia, Intensional
status
tremor
1. Post craniotomy ec. CPA tumor 2. Anemia (10,2) 3. Leukositosis (20.900) 4.
Assesment
Hipoalbumin (3,1) 5. Hipocalcemia (1,64)
- Fluid balance : - Infus NaCl 0,9% 1500 cc/ 24 Ho
+ 223 cc - RL 500 cc/ 24 ho
- Weaning pro - Morfin drip Syringe Pump 1 mg/ ho  stop
extubation - Ranitidin 50 mg/ 12 ho iv
Program -Nebulizer/8 ho - Dexamethasone 10 mg/ 8 ho iv – tappering off (H. 12)
- Tramadol 50 mg/ 8 ho iv
- Paracetamol inj. 1 gram/ 8 ho iv
- Ca Gluconas 1 gram/ 8 ho iv
 15th DAY HOSPITALIZATION (27th Oct 2015) – Post Op Day 5

S Contact (+), Schlemm >>

GCS E4M6V5 = 15
BP: 110/70 mmHg, HR: 84 x/min, RR: 20 x/min, Temp: 36,5°C, VAS : 2
Vital signs
O Within normal limit, Lab : Ca : 2,1
Internal st

Neurology Paresis of Left CN.VII Peripheral (infranuclear), Left CN. VIII paresis
status

1. Post craniotomy ec. CPA tumor 2. Anemia (10,2) 3. Leukositosis (20.900) 4.

Assesment
Hipoalbumin (3,1)
- Fluid balance : Infus RL 20 tpm
+ 800 cc - Ranitidin 50 mg/ 12 jam iv
- Move to the ward - Dexamethasone 5 mg/ 8 jam iv – tapp off (H.15

Program
 17th DAY HOSPITALIZATION (2nd Nov 2015) – Post Op Day 7

S Contact (+), Schlemm >>

GCS E4M6V5 = 15
BP: 110/70 mmHg, HR: 84 x/min, RR: 20 x/min, Temp: 36,5°C, VAS : 2
Vital signs
O Within normal limit, Lab : Ca : 2,1
Internal st

Neurology Paresis of Left CN.VII Peripheral (infranuclear), Left CN. VIII paresis
status

1. Post craniotomy ec. CPA tumor 2. Anemia (10,2) 3. Leukositosis (20.900) 4.

Assesment Hipoalbumin (3,1)
- Active Infus RL 20 tpm-
Mobilisation - Ranitidin 50 mg/ 12 jam iv
- Check CBC - Dexamethasone 5 mg/ 12 jam iv – tapp.off (H.17)

Program
19th Day Hospitalisation (05/11/2015)
S : (-)
O : composmentis; GCS : E4M6V5
TD 120/70; HR 82 bpm;
RR 20x/min, t : 370C, VAS : 0
Defisit neurologis :
Nn. Cranialis : paresis N.VII sin
(infranuclear type), Paresis N.VIII sin
Anatomy Patology :
Supporting the schwannoma feature
Lab results :
Hb : 11, 9 gr%, Ht 31%,
Leukosit 12,900/mmk, Tromb. 249.000/
mmk
Alb : 3,6
A:
1. Post craniotomy ec.
Schwannoma Vestibular
(D.O IX)
2. Leucocytosis (improved)
P:
Go home, control to RSUD to
aff stiches
Tx :
- Ranitidin 150 mg/ 12 ho po
- Vit B complex 3 x 1 tab po
- Paracetamol 500 mg/ 8 ho po
(k/p) nyeri
BAGAN ALUR
Tanggal 14/10/2015 (HP.1)
S : nyeri kepala, kurang pendengaran telinga kiri
O : K/U : Sedang, CM,
TD:120/80, HR 80x/mnt, RR20x/mnt, t :37oC. VAS : 6
St.neurologis : Nn. Craniales : Paresis N.VII sin perifer,
Disfungsi N.VIII sin. Motorik : Hemiparesis sin spastik, Sensorik :
Hemihipestesi sinistra. Truncal ataxia (+), Intensional tremor (+)
Lab : lekosit : 12.900/mmk.
Ctscan kepala kontras : SOL cerebllum dgn peningkatan TIK.
A : 1. SOL intracranial 2. Lekositosis
P : Konsul Mata, RM., MRI Kepala kontras
Tx : Inf.RL 20tpm, Inj.Ketorolac 30mg/8jam iv, Inj.Dexamethasone
10mg/6jam iv, Inj.Ranitidin 50mg/12jam iv,
Dimenhidrinate50mg/12jam po.
Tanggal 15/10/2015 (HP.2)
S : nyeri kepala cekot-cekot
O : K/U : Sedang, CM, TD:120/90, HR 88x/mnt,
RR20x/mnt, t :37oC. VAS : 5
St.neurologis : tetap.
Konsul RM : Fisioterapi : Breathing exercise, aktif ROM general
exercise, mobilisasi, Strenghtening exercise, kordinasi keseimbangan.
Okupasi terapi : peningkatan koordinasi, peningkatan keseimbangan.
Konsul Mata : papil edema(+), visus >3/60 ODS.
A : 1. SOL intracranial 2. Lekositosis
P : Konsul Mata, RM., MRI Kepala kontras
Tx : Inf.RL 20tpm, Inj.Ketorolac 30mg/8jam iv, Inj.Dexamethasone
10mg/6jam iv, Inj.Ranitidin 50mg/12jam iv, Dimenhidrinate50mg/12jam
po.
Tx bag.. Mata : Asetazolamide 250 mg/24jam po, KCl 250mg/24jam po.
Tanggal 20/10/15 (HP.5)
S : nyeri kepala berkurang
O : K?U : sedang, CM. TD 120/70, HR 82x/mnt, RR20x/mnt, t 36,80C.
VAS : 3. St.neurologis : tetap.
Hasil MRI : massa extraaxial di CPA kiri dd/ Acoustic Schwannoma,
Meningioma.. Hydrocephalus non communicans. Konsul BS : tunggu
jadwal craniotomy (diskusi bedah syaraf)
A : 1. Tumor CPA kiri dd/ Schwannoma vestibular, Meningioma. 2.
Lekositosis
P : rencana craniotomy (tunggu jaddwal)
Tx : Inf.RL 20tpm, Inj.Dexamethasone 10mg/6jam iv, Inj. Ketorolac
30mg/8jam iv (k/p), Inj.Ranitidin 50mg/12jam iv,
Dimenhidrinate50mg/12jam po. Asetazolamide 250 mg/24jam po, KCl
250mg/24jam po, Phenytoin 200mg/24jam po.
Tanggal 26/10/2015 (HP.11)
S : nyeri kepala berkurang, sulit tidur
O : K?U ; sedang, CM. TD 130/89, HR 86x/mnt, RR18x/mnt, T :
36,5oC. VAS ; 2. St.neurologis ; tetap.
A : 1. Tumor CPA kiri dd/ Schwannoma vestibular, Meningioma.
2. Lekositosis
P : craniotomy hari ini, informed consent (+), puasa 6 jam pre
operasi, post op ke ICU - tempat & ventilator (+), konsul
anestesi (+)
Tx : Inf.RL 20tpm, Inj.Dexamethasone 10mg/8jam iv,
Inj.Ranitidin 50mg/12jam iv, paracetamol 500mg/8jam po,
Dimenhidrinate50mg/12jam po, Amyrtiptillline 12,5mg/24jam po
(malam), Asetazolamide 250 mg/24jam po, KCl 250 mg/ 24jam
po, Phenytoin 200mg/24jam po.
Tanggal 27/10/2015 (HP12, ICU H-2)
S : Kontak (+),nyeri kepala (+), slem (+)
O : K/U : sedang, Kes : CM. TD 120/75, HR 82x/mnt, RR 18x/mnt, t :
37oC. VAS : 5. Terpasang ET, Ventilator : CPAP FiO2 35%. Terpasang
NGT, DC. St.Neuro : Paresis N.VII sin perifer, Disfungsi N.VIII sin.
Motorik : general weakness (+). BC : + 223 cc. Lab : Hb:10,2gr%,
lekosit:20,9rb/mmk, calcium 1,64, Alb : 3,1. Xfoto Thorax : dbN
A : 1. Post craniotomy dasar tengkorak ec. SOL CPA sinistra (Hari II),
2. Anemia 3. Lekositosis, 3.Hipocalcemia, 4. Hypoalbuminemia.
P : ekstubasi, Inhalasi/8jam, diet cair I 200 cc/ 4jam
Tx : Inf.NaCl 0,9% 1500 cc/ 24jam, RL 500cc/24jam, Morfin drip
Syringe Pump 1 mg/ jam  stop, Ranitidin 50 mg/ 12 jam iv,
Dexamethasone 10 mg/ 6 jam iv (Hari ke 2 post op), Tramadol 50 mg/
8 jam iv, Paracetamol inj. 1 gram/ 8 jam iv, Ca Gluconas 1 gr/8jam iv
Monitoring : K/U, TTV, Kesadaran, Defisit neurologis, balance cairan
Tanggal 01/11/2015 (HP16)
S : nyeri bekas luka operasi (+)
O : K/U : sedang, kes : Cm, TD 120/80, HR 76x/mnt, RR 20x/mnt, t :
370C, VAS : 2. St.neurologis : paresis N.VII sin perifer, Paresis N.VIII
sin. Motorik : dbn. Sens : dbN.
A : 1. Post craniotomy dasar tengkorak ec. SOL CPA sinistra
(Hari II), 2. Anemia 3. Lekositosis, 3. Hypoalbuminemia.
P : NGT aff  diet lunak tim tingggi serat 1300Kkal/ Protein 50 gr.
Pindah ruang biasa (R.2A)
Tx : Infus RL 20 tpm, Ranitidin 50 mg/12jam iv, Dexamethasone 5
mg/12jam iv.
Monitoring : K/U, TTV, Kesadaran, Defisit neurologis, balance
cairan
Tanggal 04/11/2015 (HP18)
S : nyeri bekas luka operasi (+) hilang timbul
O : K/U : sedang, kes : Cm, TD 110/70, HR 80x/mnt, RR 20x/mnt,
t : 36,90C, VAS : 2.
St.neurologis : paresis N.VII sin perifer, Paresis N.VIII sin.
Motorik : dbn. Sens : dbN.
A : 1. Post craniotomy dasar tengkorak ec. SOL CPA sinistra
susp. Schwannoma Vestibular (Hari VIII), 2. Anemia 3.
Lekositosis, 4. Hypoalbuminemia.
P : diet biasa tinggi serat 1300Kkal/ Protein 50 gr. Mobilisasi aktif,
Persiapan rawat jalan. Cek Lab DR , Alb
Tx : Infus RL 20 tpm  stop, Ranitidin 50 mg/12jam iv  ganti
oral Ranitidin 150 mg/12jam po, Dexamethasone 5 mg/24jam iv
lalu stop.
Monitoring : K/U, TTV, Kesadaran, Defisit neurologis,
balance cairan
Tanggal 05/11/2015 (HP19)
S : nyeri bekas luka operasi (-)
O : K/U : sedang, kes : Cm, TD 120/70, HR 82x/mnt, RR 20x/mnt, t :
370C, VAS : 0. St.neurologis : paresis N.VII sin perifer, Paresis N.VIII sin.
Motorik : dbn. Sens : dbN.
Hasil PA : sesuai gambaran schwannoma
Lab : Hb 11,9, Lekosit 12,900, Alb : 3,6
A : 1. Post craniotomy dasar tengkorak ec. Schwannoma Vestibular
(Hari IX) 2. Lekositosis
P : Rawat Jalan
Tx : Ranitidin 150 mg/12jaam po, VitBcomplex 3x1 tab, Paracetamol
500mg/8jam po k/p nyeri.
Edukasi : Kontrol ke poli syaraf 1 minggu post rawat jalan, Kontrol
ke poli bedah syaraf untuk perawatan luka post operasi dan aff
hecting,
DECISION
MAKING
PROBLEM LIST
Pasive
No Active Problems Date Date
Problems
1 Cefalgia kronis progresif 14/5/2015 Intravena 2013
(since 5 months)  9 Contraceptive
2 Vertigo (since 5 months)  9 14/5/2015

3 Paresis N.VII sinistra (infranuclear 14/10/2015

type)  9
4 Disfunction of N. VIII sinistra  9 14/10/2015

5 Hemiparesis sinistra (UMN type)  9 14/10/2015

6 Hemihipestesi sinistra  9 14/10/2015

7 Truncal ataxia (1 bulan)  9 14/9/2015

8 Intensional tremor  9 14/10/2015

9 SOL CPA sinistra 14/10/2015

10 Leucocytosis 14/10/2015

11 Anemia 28/10/2015
12 Hipoalbumin 27/10/2015
 Observasi
• Pertumbuhan tumor bervariasi antara 0-2 cm per tahun dengan rata-
rata 2 mm
• 38.9-82% have some growth at ≥38 months
• 14 sampai 24 persen dari pasien akan menunggu atau diobservasi
sampai mendapatkan terapi pilihan
• Faktor usia perlu dipertimbangkan:
1. Pasien usia muda dengan ukuran tumor yang kecil
2. Pasien usia tua dengan ukuran tumor yang besar
3. Pasien usia tua dengan ukura tumor yang keil
• MRI tidak boleh dilakukan hanya sekali, perlu diulang setiap 6 bulan
dan kemudian setiap tahun
• Pasien-pasien dengan progresivitas kehilangan pendengaran yang
lama mungkin menunjukkan pertumbuhan tumor yang lebih lama
juga