Sie sind auf Seite 1von 31

CASE PRESENTATION

SCALP TUMOR

Clinical Supervisor :

Dr. Herry Setya Yudha Utama, SpB, MHKes, FInaCS

Created by :

Yoga Pratayoga Misbahudin

1102013309

CLINICAL CLERKSHIP OF SURGERY DEPARTEMENT

FACULTY OF MEDICINE YARSI UNIVERSITY

ARJAWINANGUN DISTRIC GENERAL HOSPITAL

2018

CASE PRESENTATION

1
I. Patient identity
Name : tn.A
Age : 27
Gender : Male
Religion : Islam
Occupation : self-employed
Address : Arjawinangun
Login Hospital : January 29, 2018

II. ANAMNESA

1. Main Complaint : Lump on the head

2. Additional complaints : Headache

3. Current disease history :

The patient came to the Arjawinangun Hospital Polyclinic surgery with


complaints of a lump on the head. The lump is felt increasingly enlarged since ± 3
months SMRS. The lump is palpable soft and difficult digerakan. Patients also
complained of headaches. Complaints of pain in bumps, pallor and weight loss
and decreased appetite are denied by the patient.

4. Past medical history :

History of diabetes mellitus is denied.

The history of hypertension is denied.

The history of trauma is denied.

5. Family disease history:

No family member has the same complaint as the patient

III. PHYSICAL EXAMINATION

General Condition

General situation : Moderate

Awareness : Compos mentis

Blood Pressure : 130/90 mmHg.

Nadi : 90 times per minute, regular.

2
Respiratory : 25 times per minute.

Temperature : 37.3oC.

Local Status
Head:
- Facial expression : looks irritable.
- Shape and size : normal.
- Hair : Black.
- Udema : (-).
- Malar rash :(-).
- Hyperpigmentation :(-).
- Headache :(-).
- There is a 3x2cm ukura period with chewy, immobile and hyperpigmented
consistency
Eyes:
- Eyebrows : normal.
- Exopthalmus :(- / -).
- Ptosis :(- / -).
- Nystagmus :(- / -).
- Strabismus :(- / -).
- Udema palpebra :(- / -).
- Conjunctiva : anemis (- / -), hyperemic (- / -).
- Sclera : icterus (- / -), hyperemia (- / -), pterygium (- / -).
- Pupils : isokor, round, miosis (- / -), midriasis (- / -).
- Cornea : normal.
- Lens : normal, cataract (- / -).
- Movement of the eyeball in all directions: normal

Ear :
- Shape : normal symmetrical between left and right.
- Ear hole : normal, secret (- / -).
- Tenderness : (-/-).
- Inflammation of the ear :(-)
- Hearing : normal.

3
Nose :
- Symmetrical, septum deviation :(- / -).
- Nasal lobe breathing : (- / -).
- Bleeding (- / -), secret (- / -).
-Normal olfactory.

Mouth:
- Symmetrical.
- Lips : cyanosis (-).
- Gums : hyperemia (-), bleeding (-).
- Tongue : glossis (-), papillary tongue atrophy (-),
webbed tongue (-), reddish on the edge (-), dirty
tongue (-).
- Teeth : caries (-)
- Mucosa : normal.
- Pharynx and larynx : can not be evaluated.

Neck:
- Symmetrical :(-).
- Kaku kuduk :(-).
- KGB : (-).
- Trachea : in the middle.
- JVP : R + 2cm.
- Sternocleidomastoideus muscle enlargement (-).
- Thyroid enlargement : (-).
Thorax
Pulmo:
Inspection:
- Shape : symmetrical.
- Size: normal, barrel chest : (-)
- Chest wall movement : symmetrical.
- Chest surface : petekie (-), purpura (-), ecchymosis (-), spider
nevi (-), mass (-), sikatrik (-) hyperpigmentation (-).

4
- Fossa supraclavicula and fossa infraclavicula: basin symmetric
- Use of auxiliary muscles : sternocleidomastoideus (-), intercostal muscle(-)

Palpation:
- Chest wall movement : symmetrical
- Tactile fremitus:
a. Superior lobe: D / S same
b. Lobe medius: D / S same
c. Inferior lobe: D / S same
- Tenderness (-), edema (-), crepitation (-).
Percussion:
- Sonor : (+ / +).
- Tenderness : (-).
- Liver liver limit : ICS 6
Auscultation:
- Vesicular breath sounds :(- / -).
- Additional sound of wet rhonki :(- / -).
- Additional sound of wheezing :(- / -).
Cor:
 Inspection : The cordis iktus is not visible.
 Palpation : Ikcus cordis palpable ICS V linea midklavikula sinistra, thriil (-).
 Percussion : - right heart limit: ICS II linea parasternal dextra.
 left heart border : ICS V linea midklavikula sinistra.
 Auscultation : S1S2 single, regular, murmur (-), gallop (-).

Abdomen
Inspection:
- Shape : bulge (-)
- Umbilicus : go evenly.
- Skin surface : sikatrik (-), pale (+), cyanosis (-), collateral veins (-),
petechiae (+), purpura (-), ecimosis (-), wound surgery (-),
hyperpigmentation (- ).

5
Auscultation:
- Bowel sound : (+) is normal.
- Metallic sound : (-).
- Aortic noise : (-).

Palpation:
- Turgor : normal.
- Tonus : normal.
- Tenderness :(+) epigastrium, lumbosacral dextra and sinistra
- Hepar and lien are difficult to assess
- Undulation : (+)

Percussion:
- Timpani (+) on the entire field of the abdomen
- Shifting dullness (+).
- CVA pains: - / -

• Extremities:
Upper extremity:
- Akral warm: + / +
- Deformity: - / -
- Edema: - / -
- Cyanosis: - / -
- Ptekie: + / +
- Clubbing finger: - / -
- Infusion attached +/-
Lower limb:
- Akral warm: + / +
- Deformity: - / -
- Edema: - / -
- Cyanosis: - / -
- Ptekie: - / -
- Clubbing finger: - / -

6
IV. PEMERIKSAAN PENUNJANG

Parameter Hasil Nilai Normal


DARAH LENGKAP :
Hemoglobin 13,4 11,5-16,5
Hematokrit 16,9 35,0-49,0
Leukosit 11 4 – 11
Trombosit 118 150 – 450
Eritrosit 2,12 4,4 – 6,0
INDEX ERITROSIT :
MCV 79,7 79-99
MCH 26,9 27-31
MCHC 33,7 33-37
RDW 17,5 11,5-14,5
MPV 10,2 6,7-9,6
PDW 18,7 39,3-64,7
HITUNG JENIS :
Eosinofil 0,1 0–3
Basofil 0,1 0–1
Segmen 89,1 50 – 70
Limfosit 8,2 20 – 40
Monosit 2,5 2–8
Luc 6,4 3-6

V. DIAGNOSIS OF WORK
Scalp parietal a / r tumor

VI. DIAGNOSIS APPEAL


-

VII. MANAGEMENT
Medikamentosa:
- Cefixim 2x1
- Ketorolac 2x1

7
- Lansoprazole 2x1

Operative:
- Excision

VIII. PROGNOSIS
Quo ad vitam: Dubia ad bonam.
Quo ad functionam: Dubia ad bonam.

BAB II

TINJAUAN PUSTAKA

8
II.1 ANATOMI AND FISIOLOGI BRAIN

1. Pelindung otak
a. Cranium

Tulang pembentuk kepala


b. Scalp (Blood-Brain Barrier)
- SCALP structure
a. Skin or skin; except in the occipital region, many mengandug sweat glands
and sebacea, and hair follicles.
b. Connective Tissue or network connector; subcutaneous layer, has many
blood vessels and nerves
c. Aponeurosis or galea aponeurotica; strong connective tissue and tendo for
m. Occipitalists and m. Frontalis
d. Loose areolar tissue or loose support network; It is the site of subgaleal
hemorrhage (subgaleal hematoma). It resembles a sponge because it contains a
space that can expand because it absorbs fluid formed by injury or infection.

9
e. Perikranium; a layer of solid connective tissue, firmly attached to the cranii.

Gambaran Scalp

- Persyarafan scalp
At the front of the auricula are attached to the branches of the cranial nerve V.
Behind the auricula originating from the nerves of the spinal cord

- Scalp vascularization
Arteries are derived from a. Carotir externa through a.occipitalis, posterior
auricular artery, a. Temporalis superficialis and a. Carotis interna through a.
Supratrochlearis and a. Supra-orbitalis.
b. Meningen and Serebrospinal Fluids
1) Meningen
Meningens craniales consist of three layers:
a. Durameter craniales, thick outer layer and strong. The more durameter arteries
deliver blood to calvaria rather than to the durameter itself. A. Meningeal media,
branch of a. maxillary
b. Arachnoidea mater cranialis, intermediate layer that resembles a spider layer
c. The cranial piamater, the smoothest and deepest layer of blood vessels
Ruang-ruang meningeal, salut-salut otak berhubungan dengan tiga ruang
meningeal:
o Epidurale spatium exists between the cranial ossa and the endosteal layer
of the cranialis durameter (because the durameter is attached to the bones,

10
the spatiumepidurale is potentia, this potential space becomes real space if
blood from the meningeal vessels are torn, buried therein)
o Spatium subdurale is a potential space that can develop in the deepest part
of the cranialis durameter after head injury
o Spatium subarachnoideum contained between arachnoidea mater cranialis
and pia mater cranialis
1) Cerebrospinal fluid
o Volume in adults: 125 -150ml (produced 400-500m or0.36 ml / min each day)
o Functions: (1) shock absorber; floats the brain (1,400 􀃆50 gr); (2) transport of
nutrients and hormones; (3) disposing of metabolite waste
o FLOW DIRECTIONS:
Production of choroidal diploma - ventriculus lateralis - foramen
interventriculare - ventriculus tertius-aquaductus cerebri - ventriculus quartus - lateral
aperture and mediana - cistern magna - separum subarachnoidale - sinus
sagitalissuperior -villi granulatioarachnoidales - enter the vein
2. Brain
The central nervous system is a neuron that reaches 100 billion, supported by
10 times the glial cell of neurons. Each neuron has a long bulge, axons that function to
carry information out of the neuron (efferent fibers). In addition there are short bulges,
dendrites that serve to bring information to neurons (afferent fibers)
a. Glia cells, or neoroglia (only in the central nervous system)

serves to buffer and support metabolism against neurons. There are 2 kinds of
glia cells; macroglia and microglia. Microglia functions as a very large phagocyte
cell if there is infection or damage to the nervous system, whereas macroglia serves
as a buffer and nutritive function. Microglia there are 4 kinds, namely
Oligodendroglia, schwann cells, astrocytes cells, and ependyma cells. Together
they are viewed as a functionally functionally dynamic system in metabolic
exchange between neurons of the central nervous system of the environment. There
are three types of glia cells, microglia, oligodendroglia, and astrocytes. Microglia is
embryologically derived from the mesodermal layer so it is not generally classified
as a true glia cell. Microglia enters the CNS through the vascular system and
functions as a phagocyte, clearing debris and fighting infections.

11
b. Astrocit
Astrocytes are the largest neuroglia, star-shaped, large berinti, round or
oval, cytoplasm containing many ribosomes and unclear nucleoli. Astrocytes of
protoplasm are primarily present in the substantia of the cerebral and spinal
cord, while the fibrous astrocytes are primarily in the substantia alba. Because
of the large number of external cytoplasm process processes, astrocytes are
important as the structural supporters and structuralities in the CNS. The
function of astrocytes is still being investigated: evidence suggests that these
cells may play a role in delivering impulses and synaptic transmission of
neurons and act as connecting channels between blood vessels and neurons

C. Oligodendrosit
Also called oligodendroglia, smaller than astrocytes with shorter branches
and fewer numbers. The point is small, oval, cytoplasm denser with free ribosomes
and bound in large quantities. Oligodendrocytes are primarily present in 2
locations, within the substantia and between the axons in the substantia alba.
Others are located in perivascular positions around the blood vessels.
Oligodendroglia and astrocytes are true neuroglia and derived from the ectodermal
embryonic layer (just like neurons). Oligodendroglia plays a role in the formation
of myelin.

D. Ependime Cells
The ependim cells originate from the inner layers of the neural tube and
retain their epithelial arrangement. the ependim cells coat the brain cavity and
spinal cord and are immersed in the cerebrospinal fluid of money filling these
cavities. Although the apical end of the ependim cell coats the cavity, it is
essentially uniform and comprises a long procesus extending from the center of the
brain to the peripheral connective tissue, consequently the procesus of the ependent
cell runs between the neural elements and is a support matrix similar to that of the
other glial cells.

D. Cell schwann
The schwann cells enclose all the nerve fibers from the peripheral nervous
system, and extend until their attachment into or out of their attachment in the

12
spinal cord and the brainstem to the end. The swhann cell exhibits a
heterochromatic nucleus, usually flattened, and exposed in the middle of a cell with
many mitochondria, microtubules and microfilaments.
The brain consists of:
a. Cerebrum
b. Cerebellum (cerebellum) is responsible for coordination and balance
c. Truncus encephali formed by mesencephalon, pons and medulla oblongata
(brainstem); set the basic life functions such as heart rate, breathing etc.

Brain division by location:


a. Brain front
1. Big brain (Telenchepalon / cerebri)
When viewed from above, the large brain appears split into two hemispheres
cerebri hemispheres, the left brain & right brain. Both are connected with a kind of
fiber / cable called the corpus callosum (cerebri). The groove that divides the brain
into 2 hemispheres is called the longitudinal fissure
Left brain: linear, sequential thinking, arranging rationale, dealing with words,
language & math.
Right brain: dealing with creativity, art, music, pictures, colors.
a) Lobes
Frontal lobes (front, forehead): for thinking, planning, social concept
and social behavior

13
The temporal lobes (around the ears): are responsible for the perception
of sound & sound
The parietal lobe (dipuncak head): responsible for thinking activities,
especially memory settings
The occipital lobes (behind): responsible for regulating the function of
vision
a) Coating Cerebri
1) Cerebral cortex
A gray layer that covers the entire surface of the brain, with varying thickness
(1.5-4.5 mm). From the outside it looks irregular, there is a river (sulcussulcus) & its
edges rise (gyrusgyrus).
It mainly contains nerve cell body. Most responsible for the process of human
thinking. The center of rational thinking. The cerebral cortex consists of dendrites,
nerve cell bodies and nonmelelinized axons.

2) Basal ganglia
It consists of a collection of nerve cell bodies, located within each of the
hemispheres of the brain. Important parts: caudatum nucleus, putamen, globus
palidum

3) Substansia Medulla
Contains myelin nerve fibers, connecting different parts of the cerebrum and
connecting the cerebrum with other parts of the brain.
1. Diencephalon
o Thalamus : Menyalurkan informasi yang masuk bagia-bagian lain di otak.
Fungsinya analisis sensoris ( tempat persimpangan saraf-saraf sensoris
yang menuju orak)
o Hipothalamus : pusat rasa lapar, kenyang, perilaku seksual, mengatur
keseimbangan tubuh, suhu, tekanan darah, denyut jantung

a. Middle brain (Mesenchepalon)


o Middle brain function for vision, eyeball movement, hearing and body
movement
o Pedunculus cerebri:

14
1. Tractus corticospinal & corticopontin corticopontin: motor signals to the tl
rear nerves & pons
2. Substance of nigra nigra:: part of motor control system of basal ganglia
3. Tegmentum: red nucleus (relays small cerebellum signals), formatio
reticularis (stimulates the entire brain, controls muscle tone muscle), nucleus
III & IV (eye movement control), medial lemniscus (sensory signal to the
thalamus)
o TectumTectum: helps control eye movement, motor reaction to auditor's signal.

b. Brain behind
Function: Plays an important role in regulating the breathing & coordination of body
movement
1. Cerebellum
- Located below the occipital lobe
- is connected to the brain through the pedunculus cerebri
- functions for movement (smooth), balance, posture
2. Pons
3. Medulla oblongata

15
Pons and medulla oblongta are referred to as brainstems as a link between the
brain and the spinal cord

16
17
II.2 Definition of Brain Tumor

The tumor is an abnormal tissue growth caused by DNA mutations inside the cell.
The accumulation of these mutations leads to the appearance of tumors. Actually, our cells
have DNA repair mechanisms and other mechanisms that cause cells to damage themselves
with apoptosis if DNA damage is too severe. Apoptosis is an active process of cell death
characterized by chromosomal DNA division, chromatin condensation, and the fragmentation
of the nucleus and the cell itself. Mutations that suppress genes for these mechanisms can
usually lead to cancer.

Brain tumor is an abnormal tissue growth in the brain is a disease that attacks the
human brain, which is the control center of the human body, so that the general brain tumor
can disrupt the function of other organs can even cause death. Brain tumors can be benign
and malignant.

Intracranial tumors (including lesions urged space) are benign or malignant, and arise
in the brain, meninges, and skulls. Brain tumors originate from neuronal tissue, supportive
brain tissue, reticuloendothelial system, cerebral lining and tissue residual development, or
may metastasize from systemic carcinoma. Brain metastases are characterized by the
systemic malignancies of lung, breast, melanoma, lymphoma and colon cancer. Brain tumors
can occur at any age; can occur in children younger than 10 years, but most commonly occurs
in adults of the fifth and sixth decades. Patients who survived malignant brain tumors have
not changed much in the last 20 years.

II.3 ETIOLOGY

The cause of the tumor is still not known for certain, although many investigations have been
conducted. The factors that need to be reviewed, namely:

1. Herediter

A history of brain tumors in one family member is rare except in meningiomas, astrocytomas
and neurofibromas can be found in family members. Tuberose sclerosis or Sturge-Weber
disease that may be considered a new growth manifest, show a clear familial factor. In
addition to these types of neoplasms there is no strong evidence to think of any strong
hereditary factors in neoplasms.

18
2. Remnants of Embrional Cells (Embryonic Cell Rest)

Embryonic buildings develop into buildings that have morphology and integrated functions in
the body. But there are times when some of the embryonal buildings are left in the body,
becoming malignant and destroying the buildings around them. Abnormal development may
occur in craniofaringioma, intracranial teratoma and cordoma.

3. Radiation

The tissues in the central nervous system are sensitive to radiation and may undergo
degeneration changes, but no evidence of radiation can trigger a glioma. It has been reported
that meningiomas occur after the onset of radiation.

4. Viruses

Many studies of viral inoculation of small and large animals are done with the intent to know
the role of viral infection in the process of neoplasm, but to date there has been no
relationship between viral infection with tumor development in the central nervous system.

5. Carcinogenic Substances

Investigations of carcinogenic substances are long and extensive. It has now been recognized
that there are substances that are carcinogenic such as methylcholanthrone. This is based on
experiments conducted on animals.

II.4. TYPES OF BRAIN TYPES

1. GLIOMA

The amount of glioma is about 40-50% of brain tumors. Gliomas are grouped by
embryological origin. In adults the neuroglia cells of the central nervous system function to
repair, support and protect the soft nerve cells. Gliomas consist of connective tissue and
support cells. Neuroglia has the ability to continue to divide during life. The glial cells
converge to form a dense sikatriks in the part of the brain where the neurons disappear
because of injury or disease. Tumor glia is the cause of almost half the brain tumors in
children. Most pediatric glia tumors are the lowest-grade tumors most commonly located in
the posterior fossa and the diencephalon region.

19
Gambar 2.4 CT Scan Glioma

2. MENINGIOMA
Meningioma was first named by Harvey Cushing in 1922. It was described that
meningioma is a tumor derived from meningen cells. It can occur intracranial and in the
spinal canal. In general, meningiomas are found on the surface of the brain, even at the
base of the skull. Meningiomas can be found intraventricular or intraosseous, but very
rare.
Meningiomas are found in about 15% of primary brain tumors and 25% of spinal cord
tumors. The mortality rate in meningioma is 6%. Meningiomas are usually found at age
20 - 60 years, but although rarely can also be found in children, which is about 2% of the
child's brain tumor. More commonly found in women with male: female ratio is 1: 1.4-
2.8.
Ninety percent found supratentorial (parasagital, sphenoid ridge, pll olfactorius /
planum sphenoid and juxtasellar), 8% -10% found in infratentorial (most commonly in
cerebellopontine angle) and elsewhere 1% -2% (intraventricular, paranasal sinuses) .
Multiple meningiomas are a condition in which patients are found to be more than 1
meningioma at several sites in intracranial. The incidence of multiple intracranial
meningiomas is between 1% -10%.
Meningioma is associated with sex hormones. The role of sex hormones in the
formation of meningiomas is still unclear, but about 2/3 cases of meningioma found the
progesterone receptor.

20
CT-Scan head

In general, the basic meningioma is dura. Seventy to seventy-five percent of


hypergens. Warm homogeneous after injection with contrast. Udema around the lesions can
be widespread. There may also be hyperostosis and intratumor calcification. Calcification is
found in 20-25% of cases. Peritumoral cysts can be found in 2% -3% of cases. The tumor
suppresses the brain without invading it.

3. ASTROSITOMA

Astrocytomas often infiltrate the brain and are often associated with cysts of varying
size. Although they infiltrate the brain but its effect on brain function is very slight at the
beginning of the disease. In general, astrocytoma is not malignant, although it can undergo
malignant changes in the form of glioblastoma, which is a very malignant astrocytoma.These
tumors generally grow slowly. Therefore, patients often do not come for treatment even
though the tumor has been running for years. Astrositoma degree I shows an astrocytic image
that is not much different from normal astrocytes, only the numbers are different, so its
density in a region stands out. Second grade, III, and IV astrocytomas show successively
increased malignant features. Astrositoma degree III illustrates a histological, mitotic,
infiltrative and expansive picture that many necrosis and hemorrhagic occur. Moreover,

21
astrositoma degree IV, various types of cells in the stage of mitosis found in either a typical
formation, or scattered irregularly with many necrosis and hemoragi.maka astrositoma
degrees III and IV are given its own name is Glioblastoma multiform. Until symptoms occur
(eg epilepsy attacks and headache). Complete surgical excision is generally not possible
because the tumor is invasive, but is residual to radiation.

Gambar 1. Axial CT scan low grade astrocytoma pada lobus frontal kiri,

kiri tanpa kontras, kanan dengan kontras, tidak tampak penyangatan.

4. MEDULLOBLASTOMA

This is a highly invasive neuroepithelial embryonal tumor that appears in the cerebellum and
has a tendency to spread the entire initial CNS in its course. Similar morphologic tumors
arising in the pineal region called pineoblastomas, and which arise at other CNS sites are
called primitive neuroectodermal tumors (PNETs).

With aggressive surgery, craniospinal radiotherapy and chemotherapy, more than 50% of
children with medulloblastoma can be expected to be free of disease 5 years later. Using
current treatments, 80-90% of those without disseminated diseases can be cured, however,
treatment for this disease is often

Initial symptoms are secondary to increased intracranial pressure. The classic triad consists of
morning headaches, vomiting, and lethargy. Headaches consist of headache that arises at a

22
time of relief with vomiting and gradually reduces daylight. Cushing triads (ie, hypertension,
bradycardia, and hypoventilation), a general finding in children with increased intracranial
pressure, usually indicate an upcoming herniation.

The early signs of increased intracranial pressure are usually subacute, specific, and
nonlocalizing.

Cerebellar disfungsi

With increasing tumor size and invasion into the surrounding brain tissue, more
characteristic symptoms appear. One of the worsening symptoms of ataxia involves lower
extremities, often with relative spacing of the trunk and upper extremities.

The brain stem deficit

Brainstem tumor infiltration or elevated ICP may result in diplopia and some other
cranial nerve findings, such as facial weakness, tinnitus, hearing loss, head tilt, and stiff neck.

CT scan showed- dense white large infratentorial mass in the posterior fossa, in the midline occupying
nearly 70% of the posterior fossa, without any calcification or hemorrhage Patient was Diagnosed as –
Medulloblastoma with Hydrocephalus

5. EPENDIMOMA

Ependymomas are rare malignant tumors and are derived from close links to the
ependim covering the ventricles, most commonly in the posterior fossa, but can occur from
any part of the ventricular fossa. These tumors are more common in children and adults. Two

23
major factors affecting successful tumor resection and long-term survival are age and
anatomical location of the tumor. The younger the patient's age the worse the prognosis
(usually seen at the age of the child less than 7 years) the reason for the poor prognosis is still
unknown. It is believed that the embryonic tumors in children differ from tumors in adults
and the more immature the tumor tissue in children leads to an increasingly aggressive nature
of tumors that worsen its prognosis (Spagolli, 2000). tumor sufferers located at the base and
roof of the ventricles can be resected perfectly than the tumor patients in the lateral processus.
This difference between the base and the roof of the tumor tends to infiltrate the cerebral
peduncle structure and the pons, causing impossible removal. Radiation treatment is
performed postoperatively, except in children younger than 3 years who undergo
chemotherapy.

Ependymoma arising from the fourth ventricle. A 13-year-old girl with recent onset of
headache, nausea, vomiting, and papilledema. Nonenhanced axial computed tomography
image demonstrates a large, round tumor arising from the fourth ventricle with attenuating
nodular calcifications. Obstructive hydrocephalus is noted with frontal lobe white matter of
low attenuation resulting from subependymal cerebrospinal fluid absorption

24
6. HEMANGIOBLASTOMA

Hemangioblastomas are rare tumors that occur in the blood vessels of the brain and
spinal cord. They may appear anywhere in the brain, but the most commonly found in the
cerebellum and brain stem in the lower part of the skull is called the posterior cranial fossa. It
is estimated that hemangioblastomas make up 8 percent to 12 percent of the tumors in this
area but only 1 percent to 2.5 percent of all brain tumors.

Although benign (non-cancerous) hemangioblastomas tumors, if they are located


adjacent to the essential structure they can pose a serious and difficult to treat threat. They
attach to the piameter, the innermost layer of the membrane that surrounds the brain and the
spinal cord (meninges), deriving their blood supply from this source.

Because these tumors involve blood vessels, they pose a threat of rupture, and
because they tend to grow slowly, they may not be detected for months or years. A previously
undiagnosed hemangioblastoma occasionally ruptures - causing bleeding into the brain -
before any other symptoms occur.

Rarely in children, hemangioblastomas are twice as common in men as in women and


are usually diagnosed between the ages of 20 and 40.

A 46 year old man presented with headaches, an elevated hematocrit, and this CT scan. This shows a
classic appearance of a hemangioblastoma of the posterior fossa.

II.5 DIAGNOSIS

To establish a diagnosis in patients who are suspected of having a brain tumor is


through careful history and physical examination neurologik, as for investigations that can
help the CT-Scan and MRI. From anamnesis we can know the symptoms felt by the patient
who may be in accordance with the symptoms described above.

25
General Clinical Symptoms

Common symptoms arise due to increased intracranial pressure or due to diffuse


infiltration of the tumor. The most frequent symptoms are headache, mental status change,
seizures, severe headache, papilloedema, nausea and vomiting. Malignant (malignant) tumors
cause more progressive symptoms than benign (benign) tumors. Tumors in the front and front
temporal lobes can develop into tumors of enormous size without causing neurological
deficits, and initially give only general symptoms. Tumors in the posterior fossa or in the
parietal and occipital lobes often give focal symptoms first and then give general symptoms.

Impaired consciousness due to elevated intracranial pressure

Progressive increases in progressive intracranial pressure lead to impaired


consciousness and manifestations of brainstem dysfunction called uncus syndrome, or
diencephalon compression syndrome, central rostrokaudal central compression syndrome,
and cerebellum herniation to the foramen magnum. Common symptoms of elevated
intracranial pressure consist of headache, vomiting and seizures, mental disorders and
abnormal feelings in the head.

Headache, a common symptom that can be felt at each stage of an intracranial tumor.
The nature of pain berdengyt or full sense headed. The pain is most severe in the morning
because of the increased cerebral PCO2 nighttime sleep resulting in an increase in CBF and
thus heightening the intracranial pressure. Also a spike in intracranial pressure for a moment
due to coughing, straining or deflecting aggravate headache. Headache is an early symptom
of an intracranial tumor in about 20% of patients.

Gag. Also symptoms of vomiting often arise in the morning after waking up. This is due
to the intracranial pressure of nyang becoming higher during sleep. The vomiting properties
of patients with elevated intracranial pressure are typical of projectiles or spurs and are not
preceded by nausea.

Local seizures. May be the first manifestation of intracranial tumor in 15% of


patients. Generalized seizures may arise as rapidly rising intracranial pressure manifestations,
especially for multiform glioblastoma manifestations. Tonic seizures corresponding to
desercrasi rigidity attacks usually occur in fossa franii posterior tumors and are incorrectly
termed cereberal fits.Mental disorders. Cerebral tumors can result in dementia, apathetic,
disruption of character and intelligence, even psychosis no matter the location.

26
Abnormal feeling in the head. Many patients with intracranial tumors feel a variety of
feelings that are faintly light in their heads, dizziness, or seven circumferences. Perhaps once
the feeling arises due to the increased intracranial pressure due to the vague, most of such
complaints are ignored by the examiner and are often perceived as functional complaints.

A misleading localisatoric sign

An intracranial tumor can cause manifestations that are incompatible with the
function of the place it occupies. Such manifestations are called misleading localisatoric
signs. The sign is;

• Nerve palsy of the brain. Because the insistence of brain tumor nerves can be attracted or
depressed. The urge is not direct to the brain's nerves.

• Pathological reflexes. Positive pathological re fl ections on both sides can be found in


patients with tumors within one of the hemispheres only. This phenomenon can be explained
by the presence of mesensefalon shift to the contralateral side that is compressed and the
pathological reflexes on the tumor side become positive because of damage to the
corticospinal tract at place occupied by its own tumor.

• Mental disorders. May occur in any patient with an intracranoidal tumor located
anywhere.

• Endocrine disorders. Can also arise due to the process of urge space in the pituitary region.
The pressure from a distance and indirect tumor shift in the supratentorial space can interfere
with the pituitary and hypothalamus functions as well.

• Encephalomalacia. As a result of compression of the cerebral artery by a tumor can occur in


an area some distance away from the tumor itself, so any deficits such as hemianopsia or
aphasia can not be considered as a localisatoric sign.

The correct localisatoric signs or focal symptoms

Cerebral neoplasm grown in a typical functional area generates a certain cerebral


deficit before the manifestation of intracranial hypertension becomes a reality. The cerebral
deficits are monoparese, hemiparese, hemiapsia, aphasia, anosmia, and so on. In that case the
above symptoms and signs have local meaning, but when intracranial pressure is high enough
and generate symptoms and signs then, emerging hemiparesis or newly emerging aphasia

27
have no localized meanings. Often symptoms or early signs of escape are appreciated as a
localisatoric sign, since the process of space insistence has not been considered. Only after
the manifestation of elevated intracranial pressure appears. These signs or symptoms are
known retrospectively as a localisatotic sign.

A diagnostic physical marker on an intracranial tumor

• Papiledema. May occur at elevated intracranial pressure. Or by direct suppression of the


optic nerve by the tumor. Edema edema has no relationship with the increased duration of
intracranial pressure. When intracranial pressure soars rapidly, papillary edema exhibits clear
venous congestion. With a dark red papilla and bleeding around it.

• Intracranial hypertension. Resulting ischemia and disturbance to cerebral vasomotor


centers, resulting in progressive increased systemic bradycardia and systemic blood pressure.
This phenomenon can be considered as a compensatory mechanism to combat the state of
ischemia.

• Rhythm changes and breathing frequency. Due to surging intracranial pressure.


Compression of the brainstem from the outside accelerates the breathing interspersed by the
breathing type of cheyne-stokes. Central rostrokaudal compression of the brain stem leads to
slow but deep breathing. The skull part of the skull can undergo destruction or stimulation,
due to a tumor adjacent to the skull bone.

• Head size change. In children the increased intracranial pressure can increase the size of the
head with the strain of sutures. In percussion there is the sound of a rattling jug. In the
presence of vascular tissue tumors or vascular malformations, head auscultation can produce
audible noises.

Signs and Symptoms According to the location of the tumor:

1. Frontal lobes

Mental disorders / mild personality disorders: depression, confusion, strange behavior,


difficult to argue / assess true or not, hemiparesis, ataxia, and speech disorders.

2. Posterior posterior cortex

Weakness / paralysis of the facial muscles, tongue and fingers.

28
3. Paracentral lobes

Weakness in the congenital limb

4. The Oxipital Lobe

Ophthalmic lobe tumors often cause congruent homonym hemianopsia. Focal seizures
of occipital lobes are often characterized by episodic contralateral perception of flashlight,
color or on geometric shapes.

5. The temporal lobes

o Symptoms of temporal lobe tumors include contralateral corticospinal tract


dysfunction, homonymous field deficits, personality changes, memory dysfunction
and complex partial seizures. The dominant hemisphere tumor causes aphasia,
sensory disorders and reduced concentrations that are the main symptoms of parietal
lobe tumors. Other symptoms include the contralateral corticospinal tract
dysfunction, inferior hemianopsia / quadrianopsia of the contralateral homonym and
simple motor or sensory seizures

6. Parietal lobes

Missing sensory function, corticalis, sensory localization disorder, visual impairment

Classic Triassic:

a. Headache

b. Papil edema

c. Gag

Supporting investigation

• Diagnostic Examination:

o Rontgent anterior-posterior skull

o EEG

o CT Scan

29
o MRI

o Cerebrospinal fluid examination

o Anatomical pathology

o Angioserebral

CT scans and MRIs exhibit all intracranial tumors and become preliminary investigative
procedures when the patient presents with progressive symptoms or signs of diffuse or focal
brain disease, or one specific sign of syndrome or tumor symptoms. Sometimes it is difficult
to distinguish tumors from abscesses or other processes. CT Scan depiction in brain tumors,
generally seen as an abnormal lesion of the mass that pushes the brain structure around it.
Usually a brain tumor surrounded by a clear udem tissue due to its lower density. The
presence of calcification, bleeding or invasion is easily distinguished from the surrounding
tissue due to its hypertensive nature. Some types of tumors will look more real if at the time
of examination CT Scan accompanied by the provision of contrast substances.

Assessment of CT Scans on brain tumors

• Signs of space urging process are the impetus for the structure of the midline and the

suppression and alteration of the ventricular form

• Density abnormalities in lesions: hypodens, hypergens or combinations, calcification,

bleeding

• Peripheral edema

Plain chest and other examinations should also be performed to determine if the tumor
originates from a metastasis that will give a single or multiple nodule appearance of the brain.

Cerebrospinal fluid examination can also be performed to see the presence of tumor
cells and tumor markers. But this examination is not routinely performed especially in
patients with large brain mass. Generally, histologic diagnosis is established through
anatomic pathology examination, as an appropriate way to distinguish tumors by infection
processes (cerebral abscesses).

30
DAFTAR PUSTAKA

Harsono, Tumor Otak dalam Buku Ajar Neurologi Klinis edisi I, Gajah Mada University
Press, Yogyakarta, 1999 : 201 – 207

Mahar, M., Proses Neoplasmatik di Susunan Saraf dalam Neurologi Klinis Dasar edisi 5,
Dian Rakyat, Jakarta, 2000 : 390 – 402

Uddin,Jurnalis. Kerangka Umum Anatomi Susunan Saraf dalam Anatomi susunan saraf
manusia. Langgeng sejati. Jakarta; 2001: 3-13

Price,Sylvia A.Tumor Sistem Saraf Pusat dalam Patofisiolosi edisi 6, EGC. Jakarta.2005.
1183-1189

Stephen,Huff. Brain neoplasms.Access on www.emedicine.com.

Informasi tentang Tumor Otak access on http://www.medicastore.com

Syaiful Saanin, dr, Tumor intrakranial Access on www.angelfire.neurosurgery.

Japardi, Iskandar. Gambaran CT SCAN Pada Tumor Otak Benigna. Access on


www.usudigitallibrary.com.

31

Das könnte Ihnen auch gefallen