• HPI: 22-year-old woman was in excellent health until two months ago when she suffered several weeks of dizziness including both vertigo and lightheadedness starting with simple movements and then just generally. She is somewhat better by the time she sees you in clinic, but there is still some minor residual. 

    FH: (+) mother breast cancer 

    PMH: Unremarkable 

    Social Hx: No tobacco or alcohol use. Travel to Mexico about 1 year ago but denies any sickness related to last trip. Recently graduated from college and currently unemployed. 

    Neurological Examination: Mental status: A&O X 3. No right-to-left confusion. No dysarthria or aphasia. Cranial nerves II-XII grossly intact. 
    Motor: Normal tone, bulk, and strength throughout. Sensation intact to all 4 extremities. 
    Coordination: Finger-to-nose, heel-to-shin done without difficulties. 
    Reflexes 2+ throughout with downgoing toes bilaterally. 
    Normal arm swing and gait. 
    Negative Romberg. 

    MRI Brain with and without contrast. 
    A round mass within the central vermis measuring 1.8 x 1.5 x 1.3 cm with decreased T1 signal intensity, increased heterogeneous T2 signal, and peripheral enhancement with contrast. There is minimal mass-effect on the posterior aspect of the 4th ventricle. There are two smaller areas of increased T2 signal and decreased T1 signal within the superior aspect of the vermis measuring 8 mm, as well as the left inferior vermis measuring 8 mm—these do not enhance following contrast administration. There are no areas of restricted diffusion on diffusion weighted imaging. 

    Figure 1. Coronal T2 without contrast

    Figure 2. Axial T1 with contrast.

    Figure 3. Axial T1 with contrast.

    Figure 4. Axial T1 with contrast.

    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. What position would you place the patient for surgery?

    7. Once he is stabilized and recovered from surgery do you offer adjuvant therapy (such as radiation or chemotherapy)?

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

    THESE KIND OF RADIOLOGICAL PICTURE WE USUALLY GET BUT THESE WILL BE TUBERCULOUS.I AM FROM INDIA.

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