• HPI: 25 y/o woman initially presented 10 years ago with worsening headaches and vomiting. She was found to have a right-sided cerebellar lesion for which she underwent craniotomy and gross-total resection at an outside facility (no images available). The tumor diagnosis was medulloblastoma and she subsequently underwent chemo- and radiation therapy. She had no other lesions/metastases at that time and was tumor-free at subsequent visits. She was then lost to follow-up. She has doing well until approximately 10 days ago when she started developing right-hand clumsiness, slurred speech and gait ataxia. An MRI of the brain was obtained (Figure 1). 

    PMH/PSH : 
    Cerebellar medulloblastoma s/p resection and chemo and radation therapy at an outside facility. No recent imaging/follow-up. 

    SOCIAL HISTORY: No tobacco use. Only uses alcohol moderately. 

    CURRENT MEDICATIONS: Current Medications: None 

    FAMILY HISTORY: Negative 

    PHYSICAL EXAMINATION: 
    Vitals: BP 151/86, temp 37.5, pulse 70. 
    Pertinent findings: Right sided mild dysmetria. Right sided dysdiadokinesis 

    LABS: WBC 9.3, Hct 49, PLT 259, INR is 1.0, Na 138, K 4.3, BUN 28, Cr 1.3, Mg 2.5  

    Imaging. (Below) MRI brain with and without contrast (Figure 1: axial T2-weighted FRFSE; Figure 2: axial T1-weighted post-contrast; Figure 3: axial diffusion-weighted; Figure 4: coronal T2 FLAIR with contrast). Irregular 3.5 cm enhancing lesion located in the superior medial aspect of the cerebellum. Irregular 0.7 cm non-enhancing lesion near the left dentate nucleus. There is no evidence of hydrocephalus.

    Figure. 1

    Figure 2.

    Figure 3.

    Figure 4.

    1. What is your most likely diagnosis?

    2. What is the next step in your management?

    3. What is your surgical management?

    4. What would be your surgical plan for this patient?

    5. What is your surgical approach?

    6. Which cerebellar lesion(s) are you going to resect?

    7. What is your next management step?

    8. Please add any suggestions or comments regarding this case:

    later the ventriculostomy can be converted to VPshunt if needed      

    I think that it's more important to evacuate first the hematoma, because there is not too much hydrocephalus and decreasing intraventriicular pressure may start an ascending herniation! On the other hand, I would have biopsied the lesion prior to its excision, as it could have been a radiation induced tumour.      

    I think that it's more important to evacuate first the hematoma, because there is not too much hydrocephalus and decreasing intraventriicular pressure may start an ascending herniation! On the other hand, I would have biopsied the lesion prior to its excision, as it could have been a radiation induced tumour..

    The patient is taken to the OR, a ventriculostomy catheter is placed and the hematoma is evacuated. She does well and recovers uneventfully. She is subsequently transferred to a rehabilitation facility a few days later.

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