The patient came to the clinic with his parents 27-January-2015 complaining of vomiting and drowsiness for 1 month with the last weak complaining of diffuse headache. CT-scan done 25-January-2015, showing a midline posterior fossa mass.

On examination, Considering his age, it was difficult to evaluate him for Romberg positioning, but there was no nystagmus and neurologically was free.

The patient was admitted urgently to the hospital and MRI of the brain with contrast with MRA of the brain and carotids with spectroscopy and DTI were performed under G.A. There is huge medulloblastoma vermian localization with extension to both foramina of Leuschko. So as to avoid putting shunt to him, massive doses of Decadron were started and the patient started to improve.

Midline posterior occipital approach in setting position. The bone flap reflected to the neck inferior. The dura was opened in V-shape fashion. The tonsils were shifted downward and the vermis is prominent by the tumor. Sharp dissection of the inferior pole of the vermis ( The uvula). The tumor was highly vascular with rich blood supply. The tumor was coagulated sucked and most of the upper part was removed. The inferior part was was removed until the  obex with related structures were seen. The left part of the tumor was followed and resected until the foramen of Leuschko was seen and the left inferior cerebellar peduncle was preserved. The same maneuver was undertaken in the right side. The tumor inside the 4th ventricle was removed and the floor of the 4th ventricle was seen intact with widened aqueduct through which the third ventricle was seen. The superior medullary velum was respected. The floor of the 4th ventricle was flattened due to the previous compression effect of the tumor, that it was impossible to see the median sulcus, nor the paramedian sulci limitantes or the hypoglossal trigone elevations at the calamis scriptorius. I got the impression that the tumor was totally resected, for what intraoperative MRI control with contrast was done. There is still part of the tumor in the right upper corner and the right foramen of Leuschko. Resection of this part was achieved until the normal cerebellar tissues were seen at these angles. Strict hemostasis with water-tight closure of the dura and bone flap was secured with 2 stitches and routine closure of the wound.

Smooth postoperative recovery. The patient extubated and sent to the ICU for 24 hours observation.

The patient has typical spectroscopic data supporting medulloblastoma. The histologic result will give the answer.