Left Cerebellar Signs Research Articles

Papillary meningioma of the jugular foramen: A case report.

Papillary meningioma (PM) is a rare histological variant of intracranial meningioma, which displays an aggressive behavior and its management is difficult. The present study reported the case of a 21-year-old male patient, who presented with headaches and dizziness. Upon neurological examination, left hypoglossal nerve palsy and left cerebellar signs were observed. Computed tomography and magnetic resonance imaging scans of the brain revealed a high-density mass in the left jugular foramen area. Following an uneventful complete surgical resection of the tumor, a definitive diagnosis of Grade III PM was determined based on the histopathological findings, according to the World Health Organization classification. CT scanning one day after surgery confirmed that the tumor had been completely resected, and after four years of follow-up, no evidence of transformation or recurrence was observed.

Advanced Small Cell Lung Cancer with Cerebellar Metastases – A Case Report

Background: Small cell lung cancer is an aggressive subtype of lung cancer whereby about one-third of cases are complicated with brain metastases. However, cerebellar metastases are uncommon and contribute to less than 10% of brain metastases. Case: We report a 76-year-old Malay male, an active smoker who presented with dyspnea and occasional cough with hemoptysis for one week. He also presented with headache and constitutional symptoms of malignancy. Clinical examination suggested the presence of right upper chest pathology and positive left cerebellar signs. His condition deteriorated two days later and he passed away after failed attempts at resuscitation. Chest radiograph showed right upper lobe collapse, and brain magnetic resonance imaging showed metastatic lesion in the left cerebellum extending to the right cerebellum. Post-mortem findings revealed small cell lung cancer with cerebellar metastases. Conclusion: Small cell lung cancer patients with brain metastases deteriorate very rapidly, and the management is mainly supportive. Primary prevention through education is the best way to reduce the incidence of lung cancer. In addition, secondary prevention and screening should be undertaken at earlier stages of the disease, as some studies have shown that combined chemotherapy and radiotherapy improve prognosis of malignancies detected at early stage

Remote Supratentorial Hemorrhage After Posterior Fossa Surgery: A Brief Case Report

Abstract The supratentorial hemorrhage after posterior fossa surgery is an unusual but delicate complication that carries high mortality and morbidity. A 50 year old woman presented vertigo 6 months of evolution, which worsened in the last 2 months accompanied by ataxia. She showed left cerebellar signs, had no focal motor or sensory deficits. A brain MRI identified cerebellopontine angle lesion with mass effect. The patient was treated on suboccipital craniectomy and resection of right posterior fossa tumor, the histopathological diagnosis was consistent with typical meningioma. (WHO Class I). The postoperative period was satisfactory. A month later, presented clinical symptoms of right-sided hemiparesis, brain CT revealed left frontal supratentorial hematoma, receiving conservative management. Patient was discharged after 10 days. Reports in the literature on this rare complication, detailed cases where the hematoma was presented in hours to days. To our knowledge this is the first report in the literature of supratentorial hemorrhage and posterior fossa surgery one month after the surgical procedure has been performed.

Extra axial adult cerebellopontine angle medulloblastoma: An extremely rare site of tumor with metastasis

Dear Sir, Medulloblastomas are rarely seen in the adult population, accounting to less than 1% of primary adult brain tumors.[6] It commonly arises from the cerebellar vermis.[5,6] There are only a few cases of cerebellopontine (CP) angle medulloblastomas. Most of them are intra-axial. Extra-axial site of this tumor is extremely rare.[2] Ours is the first case of metastasis from CP angle medulloblastoma. A 22-year-old male patient presented with headache, vomiting, ataxia, and left facial weakness of one-month duration. Vision was normal. Fundus examination showed papilloedema. He had left lower motor neuron facial paresis, left IX and X cranial nerve paresis, and left cerebellar signs. Computed tomography scan of the brain showed a left CP angle mixed-density nonenhancing lesion (5.4 × 2.8 cm) with broad-based tentorial attachment and displacement of the fourth ventricle causing obstructive hydrocephalus [Figure 1]. Findings were confirmed by magnetic resonance imaging (MRI) [Figure 2]. He had previously undergone right ventriculo peritoneal shunt for obstructive hydrocephalus elsewhere. He underwent left retromastoid craniectomy and gross total excision of the lesion. There was clear plane between the tumor and cerebellum, whereas it was adherent to tent laterally. Histopathology showed a highly cellular tumor composed of rosettes of small round cells, with high nucleus-cytoplasm ratio and increased mitotic figures—suggestive of classical medulloblastoma—WHO grade IV [Figure 3]. Postoperatively, he improved. He was advised craniospinal radiotherapy which he failed to receive and presented 15 months later with progressive quadriparesis and sensory impairment of five-month duration with bladder and bowel involvement. On examination, he had 3/5 motor power in the upper limbs and 2/5 in lower limbs and sensory impairment below D4 dermatome. All deep tendon reflexes were brisk with bilateral extensor plantar reflexes. All superficial reflexes were absent. MRI of the brain and spine showed recurrent left CP angle medulloblastoma and intramedullary lesion at cervical level and intradural extramedullary lesion at sacral level, suggestive of drop metastasis in the spine from CP angle medulloblastoma [Figure 4]. Figure 1 Contrast Computed tomography scan of the brain axial and coronal reconstruction showed a left CP angle mixed-density nonenhancing lesion with broad-based tentorial attachment Figure 2 MRI of the brain axial T1, T2 and coronal sections showed a left CP angle lesion with broad-based tentorial attachment Figure 3 Microphotograph of the histopathology slide. (H and E, ×20). showed a highly cellular tumor composed of rosettes of small round cells, with high nucleus-cytoplasm ratio —suggestive of medulloblastoma Figure 4 Saggital MRI of the cervical and sacral region showing drop metastasis (shown by arrows) Medulloblastoma usually occur in inferior medullary velum in the midline.[6] However, rarely they may occur laterally in the cerebellar hemisphere in adults.[3] Origin of medulloblastoma may be either from germinal cells or their remnants situated at the end of posterior medullary velum or from remnants of the external granular layer.[5,7] Their development in the CPA may be from the remnants of the external granular layer in the cerebellar hemisphere, including the flocculus which faces the CP angle.[5] In CP angle medulloblastomas, though fifth, sixth, and eighth cranial nerves are frequently involved,[4] these nerves were spared in this patient. CP angle medulloblastomas are rare with nearly 35 cases published in the literature,[2,5] of which only 9 are in adults.[2,5] The lack of association with any cerebellar tissue and extra-axial location in the region of CP angle is an extremely rare phenomenon.[2] Medulloblastomas are known to metastasize through CSF to the spinal canal, leptomeninges, and supratentorial regions. Metastasis in medulloblastomas vary between 38 and 60% in various series,[1,6] with the spinal canal being the commonest site with approximately 58%.[6] Kumar et al. have reported a case of vermian medulloblastoma with metastasis to the CP angle.[5] To the best of authors’ knowledge, spinal metastasis from CP angle medulloblastoma has not been reported till date. Extra-axial site of this tumor is extremely rare but must be considered in the differential diagnosis of extra-axial CP angle lesions. Any neurological deterioration seen in follow-up patient must be evaluated for metastasis.

Surgical management of brainstem hydatid cyst—an unusual site

Background The authors describe their surgical experience of a hydatid cyst in the brainstem, which is an unusual site. The cyst was internally decompressed and totally excised. Although the Dowling technique has been described to be the ideal method for removal of hydatid cysts, it may not be possible when the cyst is in a deep-seated, vital, and eloquent location. We report the use of internal decompression by aspiration followed by total excision as an alternative method when the cyst is located in vital areas of the brain. Case Description A 40-year-old female presented with headache, progressive right-sided weakness, double vision, and unsteadiness of gait of 1-month duration. On examination, she had left one-and-a-half syndrome, right hemiparesis of 3/5, and left cerebellar signs. Computed tomographic and MRI scans of the brain revealed a solitary, stenciled-out cystic lesion in the brainstem more toward the left side with features suggestive of hydatid cyst. A left retromastoid craniectomy followed by left middle cerebellar peduncle approach, aspiration of the cyst, and total excision of the cyst was performed. Postoperatively, the patient improved progressively and was asymptomatic with minimal left cerebellar signs at 1-year follow-up. Conclusion Hydatid cyst is a benign lesion. Appropriate management is mandatory for reducing the morbidity. Although the Dowling technique with its modifications is appropriate for cerebral parenchymal surfacing or superficial hydatid cysts, in deep-seated cysts located in eloquent and vital areas such as the brainstem, management by internal decompression by aspiration followed by extirpation of the cyst wall, protecting the surrounding cisterns and CSF spaces, is an alternative option.

Acoustic Neurinoma with Early Venous Drainage and Caput Medusae-like Vasculature on Angiogram

It has been considered that acoustic neurinomas are hypovascular tumors on angiogram. Recent angiographical analysis, however, revealed that some of them showed tumor stain, capsular stain, and even arteriovenous shunt. The problem with operation on the acoustic neurinoma with a peculiar vasculature on angiogram has not been discussed in previous reports. In this paper, the neuroradiological findings of a unique case are described, in conjunction with the operative problem. A case of huge acoustic neurinoma with early venous drainage and caput medusae-like vasculature on angiogram is presented. The patient was a 46-year-old woman suffering from dizziness and gait disturbance. On admission, she had bilateral choked disc, left fifth and seventh nerve palsy, and left cerebellar signs. The audiogram showed scale out on the left, carolic test and auditory brain stem response were nil on the left side. On computed tomography, a huge, heterogeneously enhanced mass was detected in the left cerebellopontine angle. Vertebral angiography revealed that the tumor was supplied by the anterior inferior cerebellar artery and ascending pharyngeal artery. Caput medusae-like vasculature was visualized in arterial and capillary phases, and abnormal draining veins were also opacified in these phases. They were considered to be an arteriovenous fistula. At operation, the abnormal vasculature looked like an arteriovenous malformation on the tumor capsule, which made the surgical procedure of dissecting the tumor from the pons extremely difficult.

Ｓｕｐｅｒｉｏｒ ｏｂｌｉｑｕｅ ｍｙｏｋｙｍｉａの発生機序について

Superior oblique myokymia is an intermittent uniocular microtremor caused by uncontrolled contractions of the superior oblique muscle, termed by Hoyt and Keane. As all the previously reported cases were healthy individuals, its lesion and mechanism have not been clarified. In this report, I introduced a patient with a cerebellar tumor who presented with superior oblique myokymia.A 41-year-old woman was admitted to the Nihon University Hospital with complaints of headache, dizziness and diplopia. A right cerebellar cyst was observed on computerized tomography and partial resection of this tumor was performed. Two months after this operation, she complained of oscillopsia and torsional diplopia. At that time, rapid, smallamplitude, intorted movements, that is superior oblique myokymia, were noted only in the right eye. This abnormal eye movement disappeared in one week. Thereafter, left cerebellar signs became apparent and visual suppression of nystagmus was reduced on both sides. Therefore, it was suspected that the tumor had already extended to the left cerebellum.From this clinical course and the experimental data of Ito, it was suggested that when the left flocculus was stimulated, the left superior vestibular nucleus was inhibited. Disinhibition of the right superior oblique muscle and disfacilitation of the right inferior oblique muscle resulted and the intorted movement appeared in the right eye.From these results, it seemed that the lesion responsible for superior oblique myokymia was the contralateral flocculus and this characteristic eye movement was produced when this region was stimulated temporarily.

Posterior Fossa Mass in a 60-Year-Old Woman

Dr. Richard Steckel: A 60-year-old woman entered the hospital with dizziness and difficulty in walking which had progressively worsened for three months. She had had an attack of vertigo, accompanied by tinnitus and nausea, ten years ago. A diagnosis of labyrinthitis had been made and her symptoms subsided spontaneously after three months. On the present admission her general physical examination was not remarkable. There was a fine rotary nystagmus on lateral gaze, and mild left cerebellar signs were present. Her speech was slow and slurred. She was unable to stand with her feet closer together than six inches, and she walked very cautiously. Plantar responses and deep tendon reflexes were normal. Urinalysis revealed 80 white blood cells. The twohour postprandial blood sugar was elevated slightly at 120 mg/100 cc. The blood bromide and barbiturate levels were within normal limits. The skull roentgenograms were within normal limits. A pneumoencephalogram was performed