Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit  neurosurgery.tv

On examination, aside to the cerebellar signs there were no motor or sensory deficit. The patient was operated in the setting position and osteoplastic craniotomy over the left cerebellar convexity, radical removal of the mass was achieved and the frozen section demonstrated a malignant nature of the tumor without giving more details about the exact nature of the tumor.

The tumor was well defined with low vascularity and had good cleavage. It was totally removed. Smooth postoperative recovery.

The final histologic result was that of medulloblastoma. For theoretical data concerning medulloblastomas click here!

Control CT-scan performed the same day of the operation and the morning of the second day were acceptable. The second night  08-August at 3.15 a.m. the patient started to complain of headache followed within seconds with difficulty in breathing and sudden apnea. She was put immediately in the ventilator . During that, the right pupil was fully dilated. Emergency CT-scan was performed and the morphologic picture as the same as before. During CT-scan investigation both pupils became fully dilated  and it was decided to urgently take the patient in the clinical basis to explore the area.

The bone flap removed and the bone defect widened and the dura was opened. Removal of the laceration and edematous cerebellar tissues was undertaken and the CSF became to drain from the cisterna magna and the ponto-cerebellar angle after what the brain regained pulsation and the CSF start to flow freely. 35 minutes passed since the progression of the bilateral full dilated non-reactive pupils, after what the pupils became normal with sluggish reaction to light. The dural defect was left and lyodura was placed over the pulsating brain tissues. The patient was kept in ventilator.

The patient after 2 days in ventilator another time progressed dilated right pupil, for what repeat CT-scan was performed and showed swelling both cerebellar hemispheres and the supratentorial compartment. She was taken to the operating room and a wide bone flap was removed over both cerebellar hemispheres and both occipital lobes were exposed.  Transverse incision was made over both cerebellar hemispheres with resection of the falx cerebelli. The right cerebellar hemisphere bulged with pressure and start to pulsate and attempt to put canula to the posterior horns failed due to slit ventricles. The wound was closed superficially and the pupils regained normal position after 20-30 min. The patient, then continued to deteriorate despite aggressive measures and polyuria took place  the morning of 12-August-2006 and  diabetes incipidus was established and minrin started.

The patient progressed mild dilatation of the right pupil 14-August, and she died the morning of 15-August-2006.

Comments:

1. If the tumor was glioblastoma multiforme, then it was wise not to touch the tumor, since surgery play minor role in the long outcome. Here according to the age and the proper cleavage and the ability to totally remove the tumor and the presence of other histologic verification, even a malignant one, make surgery reasonable. It is better to wait and see the final result.

2. Postoperative CT-scan could be insufficient to predict catastrophic events especially in the posterior fossa as in this case. The patient was taken in the basis of clinical estimation.

3. Dexametasone of Egyptian production mostly played an integral role in the catastrophic events. Despite the fact that the postoperative CT-scans were acceptable, except for slowly escalating diffuse edema. the clinical picture was the determinant factor in deterioration contralateral to the lesion.  This drug induced complication needs further investigation.

2. It could be as some tumors contain certain parahormones, have place here in the vasoreactive phenomenon with subsequent diffuse edema. But the level of the ordinary investigations at the present time still far from perfect, to have these predictors and the ways to avoid such phenomena.