Abstract
CASE REPORT: Children with medulloblastoma usually present with ataxia, nystagmus, dysmetria, intention tremor, cranial nerve deficits or signs of elevated intra-cranial pressure. On MRI a midline non-homogenously enhancing lesion is seen often with associated brainstem compression, ventricular dilatation and transependymal CSF migration. We describe a 12 year old child who presented with dizziness, emesis, neck pain and occipital headache resulting from minor head trauma on the preceding day. Past history included recent onset intermittent diplopia corrected with lenses. Neurological examination was normal except for mild left hearing loss and decreased visual acuity. CT scan at admission revealed an acute subarachnoid hemorrhage in the left cerebellopontine angle (CPA) extending through the left foramina of Luschka and Magendie and compressing the adjacent cerebellum and brainstem. MRI /MRA/Cerebral angiogram did not uncover any underlying pathology. After observation for 3 days he was discharged with residual mild left hearing loss and left horizontal nystagmus. On follow up four months later he was found to have lost all hearing (left) and had difficulty with balance. MRI showed a 2.8 x 2.6 x 2.4 cm left CPA mass hypo-intense on T1 with hyperintense foci on T2. The mass extended into the internal auditory canal and compressed the brainstem without causing hydrocephalus. A peri-lesional hemorrhagic stain was observed. On repeat review of an MRI performed 2 months earlier the mass was noted to be present measuring 1.5 x 1.1 x 1.2 cm. Spinal cord MRI was negative. Gross total resection of the mass was complicated by left facial nerve palsy and severe obstructive hydrocephalus requiring temporary EVD placement. The patient is on treatment for medulloblastoma (classic histology/WNT subgroup).Hearing loss persists but his 7th CN palsy is improving. We seek to highlight that on MRI an acute intracranial hemorrhage can camouflage a neoplastic process.
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