Pre-Operative Report

Skullbase Division
Thursday, June 8th 2023
Name : Girl Syakila
Sex :♀
Age : 15 mo
Medrec : 0002032148
Admission : June 5th, 2023

WD/ Shunt Malfunction due to Post Repair Shunt due to Shunt

Malfunction due to Post VP Shunt due to Congenital
Hydrocephalus

Th/ Repair Shunt

DPJP : dr. Guata Naibaho, Sp.BS(K).

 Girl Syakila / ♀ / 15 mo / 0002032148 / Skullbase Division / GN
CC: Head Enlargement

March 2022 April 2022 March-June 2023 June 8th, 2023

Since birth, the family

complained that the Progressive head
her head looked Lump on back of enlargement (+),
bigger than other the ear, was developmental
children of her age.
diagnosed with delay (+),
She underwent a non- Shunt fever (-), underwent Planned for Repair
contrast head CT-Scan
(March 25th, 2022) Malfunction, a non contrast head Shunt
and diagnosed with underwent CT-Scan (June 5th,
Congenital Shunt Repair 2023), was
Hydrocephalus diagnosed with
(April 24th, 2022) shunt malfunction
Underwent VP Shunt
(March 29th, 2022)

She was born to a P1A0 mother, aterm (36-37 weeks), by cesarean section due to Ventriculomegaly, directly crying with a
birth weight of 3065 grams. History of ANC (+) routinely controlled to midwife and obstetrician. History of consumption of
folic acid (+). History of infection during pregnancy (-). History of drug consumption during pregnancy (-).
 Physical Examination
(March 29th, 2022)
General State:
HR: 148 x/min RR: 56 x/min T: 36.00 C
BW 3065 g BL 44 cm
Local State:
Head Circumference (29/03/2022) : 42 cm (N : 30 – 37.5 cm)
At Anterior Fontanel : Open, convex, not tense, size 8 x 7 cm, venectations
(-), Frontal Bossing (+), sunset eyes (-)
At Posterior Fontanel : Open, flat, not tense, size 2x1 cm
 Physical Examination
Neurological State:
CCS 11/ pGCS 15, nuchal rigidity (-)
Pupil : Round equal, 3mm/3mm, LR +/+
Visual acuity : Difficult to examined
Fundoscopy : Not performed
Eyeball movement : Following object
Other cranial nerves : within normal limit
Motoric : Paresis -/-
Sensory : Respond to pain (+)
Physiological Reflex : +/+
Pathological Reflex : Babinski +/+
Primitive Reflexes
- Sucking reflex : +
- Rooting reflex: +
- Palmar Grasping reflex: +/+
- Plantar Grasping reflex: +/+
Non Contrast Head CT Scan at Hasan Sadikin Hospital, Bandung
March 25th, 2022
Non Contrast Head CT Scan at Hasan Sadikin Hospital, Bandung
March 25th , 2022
- Enlargement of bilateral
lateral ventricles and 3rd
ventricle
- Cortical mantle (+)
 INTRA OPERATIVE FINDINGS (March 29th, 2022)
Baby. Mrs. Neni / ♀ / 12 do / 0002032148 / Pediatric Division
DO at Right Keen:
- Dilakukan insersi shunt proximal sedalam ± 3.5 cm
- Didapatkan tekanan bukaan 10 cmH2O
- LCS jernih kekuningan

DO at Right Hypochondrium:
- Dilakukan insersi shunt distal sepanjang ± 25 cm
- Shunt pump efektif
CSF Results
Pasien terpasang shunt Integra, flat bottom, medium
pressure. Glucose Negative
Area operasi dibersihkan dengan steril dan prosedur Protein 82
ditutup dengan alat steril. Nonne Negative
LCS dilakukan pemeriksaan LCS rutin, kultur, dan
resistensi. Pandy Negative
Color Light Yellow
Clarity Clear
Cell 1
PMN 100
MN 0
 Physical Examination
(April 23rd, 2022)
General State:
HR: 150 x/m R: 52 x/m T: 36.8 C
BW: 3500 g BL: 53 cm BW/Age: -2 and -1 SD
Local State:
• Head Circumference (23/04/2022): 38.5 cm (N: 34 – 38 cm)
• Head Circumference (30/03/2022): 41 cm (N: 32-37.5 cm) Post-op
• Head Circumference (29/03/2022): 42 cm (N: 32-37.5 cm)
• Anterior Fontanelle : Open, flat, not tense, size 5 x 5.5 cm, venectation
(-), frontal bossing (-), sunset eyes (-)
• Posterior Fontanel : Open
• At Right Keen : Scar Post Op (+), Shunt Pump (+) Normal Filling,
Fluctuation (+), Mass (+), redness (-), tenderness (-),
Transillumination (+)
• At Right Hypochondrium : Scar Post Op (+)
 Physical Examination
(April 23rd, 2022)
Neurological State:
CCS 11/pGCS 15, nuchal rigidity (-)
Pupils : Round equal, RLO Ø 3 mm/3 mm, LR +/+
Visual acuity : Difficult to be examined
Fundoscopy : Not performed
Eye Ball Movement : following object
Other Cranial Nerves : within normal limit
Motoric : No paresis
Sensory : within normal limit
Physiological Reflex : +/+
Babinski Reflex : +/+
Primitive Reflexes
Sucking Reflex : (+)
Rooting Reflex : (+)
Palmar Grasping Reflex : (+)
Plantar Grasping Reflex : (+)
Non Contrast Head CT-Scan at Hasan Sadikin Hospital, Bandung
April 23rd, 2022
Non Contrast Head CT-Scan at Hasan Sadikin Hospital, Bandung
April 23rd 2022
• Enlargement of all ventricles
system
• Cortical Mantle (+)
• Shunt Tip (+)
• Midline shift (-)
 INTRA OPERATIVE FINDINGS (April 24th 2022)
Baby. Mrs. Neni / ♀ / 36 do / 0002032148 / Pediatric / GN
Do at Right Keen :
- Ditemukan shunt proximal dan distal terkoneksi
- Ditemukan adanya rembesan dari lubang insersi lama
- Didapatkan lcs jernih, tidak berwarna
- Dilakukan insersi shunt proximal sedalam 3.5 cm
- Dilakukan penambalan pada lubang insersi lama menggunakan fascia
dan fibrin glue
- Pasca repair tidak ditemukan aliran kebocoran LCS
- Shunt pump (+) efektif
- Fascia dan kulit ditutup dengan prosedur steril
 Recent Physical Examination
General State:
HR: 120 x/m R: 40 x/m T: 36.5 C
BW: 9.5 kg BL: 76 cm BW/A: -0.01 SD. BL/A: -0.39 SD BW/BL : 0.28 SD
Local State:
• Head Circumference (05/06/2023) : 57 cm (42.5-48 cm)
• Head Circumference (12/05/2022): 40 cm (N: 36-41 cm)
• Head Circumference (30/03/2022) post op: 41 cm (N: 32-37.5 cm)
• Head Circumference (18/03/2022): 42 cm (N: 32-37.5 cm) When Born
• Anterior Fontanelle : Open, flat, not tense, size 4 x 3 cm,
Venectation (-), frontal bossing (-),
Sunset eyes (-)
• Posterior Fontanel : Open
• At Right Keen : Scar Post Op (+), Shunt Pump (+) Slow
filling,
• At Right Hypochondrium : Scar Post Op (+)
Neurological State:
CCS 11/pGCS 15, nuchal rigidity (-)
Pupils : Round equal, RLO Ø 3 mm/3 mm, LR +/+
Visus : Difficult to be examined
Funduscopy : Papil edema
Eye Ball Movement : Following the object
Other Cranial Nerves : Within normal limit
Motoric : Paresis -/-
Sensory : Within normal limit
Physiological Reflex : +/+
Clinical Picture
Laboratory Finding at Hasan Sadikin Hospital Bandung
June 5th 2023

Labs Results Labs Result

Hb 13.4 Na/K 138/4.3
RBG 93
Ht 43.9
Ur/Cr 12.3/0.46
L 13.100
OT/PT 16/11
Tr 488.000 PT/APTT/INR 13.7/33.6/0.96

Lab Result
Antigen SARS CoV-2 Negative
Thorax X-Ray at Hasan Sadikin Hospital Bandung
June 5th 2023

Within Normal Limit

Shunt Tube (+)
Non Contrast Head CT-Scan at Hasan Sadikin Hospital, Bandung
June 5th 2023
Non Contrast Head CT-Scan at Hasan Sadikin Hospital, Bandung
June 5th 2023

• Enlargement of All
Ventricle System
• Cortical Mantle (+)
• Shunt Tip (+)
• Midline shift (-)
 Intraoperative Planning

4 cm

3.5 cm
Thank You