Posterior Fossa Syndrome

Acute Management

Day #1

Katie was admitted to the PICU secondary to complaints of headaches, nausea, and vomiting.

A plain CT was performed the day of admission and showed a tumor in the posterior fossa of the brain, with obstructive hydrocephalus.

Presumed diagnosis: obstructive hydrocephalus with posterior fossa polycystic astrocytoma tumor. Katie was given Decadron IV to minimize brain swelling. Surgery planned to be performed in two days.

Day #2

Katie improved with IV corticosteroids. The doctor explained if the tumor was left untreated, it will continue to grow, causing potential compression of the brain stem and progressive hydrocephalus that could cause cognitive impairment, visual loss and potential death.

The physician recommended surgery to confirm the diagnosis, attempt cystoreduction, and remove the mass to relieve hydrocephalus by performing a suboccipital craniotomy and partial C1 laminectomy.
An external ventricular drain was placed pre-operatively to help minimize compression.

Katie continued taking corticosteroids until surgery.

Day #3

Katie underwent the planned suboccipital craniotomy and partial C1 laminectomy today.

Katie experienced respiratory failure postoperatively and was therefore placed on an endotracheal ventilator. Otherwise, surgery went as planned without severe complications.

Day #4, Postoperative Day #1

Physicians confirmed Katie's diagnosis of medulloblastoma, the tumor was not an astrocytoma as was initially thought.

An MRI was done this morning and Katie did reasonably well, though she was somewhat hypertensive with a low heart rate in 50s. Katie was arousable with occasional spontaneous eye opening, showing equal, round, and reactive pupils.

ICP monitor read 8, revealing a normal intracranial pressure. Katie demonstrated random arm movement spontaneously. Status unremarkable; Katie received IV fluids, and a Foley catheter was inserted.

Day #6, Postoperative Day #3

The mechanical ventilator was removed yesterday and Katie had been stable from a respiratory stand-point for the past 24 hours. She had been more talkative, and appeared to understand everything being said to her. She had been smiling and interacting with her parents, but had not spoken any words. Katie remained quite weak from surgery; she had not turned her head to the right but was able to move all 4 extremities with coordination. Katie presented with horizontal nystagmus.

Katie's vital signs were afebrile, with a maximum temperature of 99.2° F, heart rate 140-170 bpm, respiratory rate 7-24 per minute, and ICP 6-12 cc over past 24 hours.

A nasogastric tube was initiated for feeding today.

A cerebrospinal fluid culture was taken and showed no bacterial growth at 24 hours.

CSF drainage in the past 24 hours was 152 cc. Katie's pain was controlled with Tylenol. Tracheal and urine cultures were positive for gram-negative bacilli so Katie was started on the antibiotics ceftazidime and vancomycin.

Katie had the following lines: EVD, IV in the right wrist and left hand, arterial line in the left radial artery, and a NG tube for feeding.

Day #9

The external ventriculoperitoneal drain was removed today.

Day #21

Inpatient Discharge Summary

Diagnosis: medulloblastoma & posterior fossa syndrome. Surgery for removal of tumor. Awoke 1st day postoperatively and within 24 hours showed evidence of mutism & irritability. Began radiation therapy and chemotherapy per protocol. Extensive therapy performed. Started oral VP and IV steroids.