Cerebellar
tumor
INTRODUCTION
Jaques
Liao is a two and a half year old Chinese boy complaining of a 3-month duration
of unsteady gait and frequent falls together with vomiting and headache.
HISTORY
The
symptoms first started 3 months ago when his mother noticed he has not been
walking as per normal and has a tendency to fall towards his right side. He has
been vomiting soon after waking, the vomiting is of a projectile nature and
consisting of ingested milk. There is no blood or bile in the vomitus. He
complains of headaches in the occipital region with a frequency of once every
two days, each episode lasting for at least one hour. He has become increasingly
lethargic and easily irritable. He has also become more withdrawn and inactive
due to the fear of falling. He has no past history of trauma, fever, fits,
unconsciousness or visual or auditory disturbances.
He
is a full-term baby delivered by Caesarean section at Gleneagles hospital,
discharged one day after delivery with no post-natal complications. The birth
weight is 3.7 kg. He is not breast-fed and is currently on solid food. The
immunization record is followed accordingly. The primary care-giver is his
mother with help from the paternal grandfather and maid. Both parents are
tuition teachers and they have no financial difficulties at the moment.
PHYSICAL
EXAMINATION
On
general appearance, Jaques looked well and behave appropriately for his age. He
is well-nourished, alert and active. The vital signs are as follows: Temp:
36.7C, PR: 98/min, RR: 30/min, BP: 100/60 mmHg. His height, weight and OFC are
between the 25th and 50th percentile of his age.
He
has no speech difficulties and is able to babble simple phrases like �hello�
and �goodbye�. He has no visual field or auditory defects. Fundoscopy
reveals bilateral papilloedema: there is loss of normal depression of the optic
disc with blurring at the margins. Examination of the other cranial nerves,
upper and lower limbs reveals no abnormalities. No horizontal nystagmus is seen
on lateral gaze. There is no drift of outstretched arms. Jacques is unable to
perform the tests for dysmetria and dysdiachokinesia and therefore, intention
tremor, past-pointing and clumsy hand movements, which are indicative of a
cerebellar lesion are not elicited in him. There is slight swaying of the trunk
and he is sited with legs hanging over the bed. Gait is broad based with a
tendency to lean towards the right side.
SUMMARY
Jaques
is a two and a half-years old boy presenting with a three-month history of
frequent falls, unsteady gait, vomiting after waking and headache suggestive of
a cerebellar lesion. Examination reveals bilateral papilloedema indicative of a
raised ICP, truncal ataxia and broad-based gait.
My
diagnoses are:
1)
Tumor in the cerebellum.
2)
Cerebellar haemorrhage.
3)
Hydrocephalus.
INVESTIGATIONS
I
would order the following baseline investigations:
1)
FBC: signs of infection.
2)
U&E.
followed
by a CT or MRI scan to determine the exact brain pathology.
CT
scan shows a 4.5cm cystic and solid midline tumor of cerebellum with
hydrocephalus.
I
would proceed to do a biopsy to determine the histology and grade of the tumor.
MANAGEMENT
Immediate
medical care of patient:
1)
Seizures: start patient on phenytoin or carbamazepine.
2)
Headache and edema surrounding tumor: dexamethasone.
3)
Symptomatic hydrocephalus: VP shunt.
Surgery
is the choice of treatment if the patient is in general good health and the
tumor is accessible.