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Medulloblastoma, case 2

CLINICAL HISTORY:
This 58-year old man complains of one month of progressively increasing vertigo with nausea and vomiting, worse on left lateral gaze and forward bending. He also notes gait instability.

NEUROLOGICAL EXAMINATION: There is a tendency to fall to the left with positive Romberg test. The gait is broad-based. A horizontal nystagmus at left lateral gaze is noted.

MRI:
a) TRANSAXIAL T2-WEIGHTED (5400/119/1) SPIN-ECHO SEQUENCE (IMAGES 1 AND 2): Ill-defined abnormality (arrow) at the level of the brainstem, predominantly located in the medulla oblongata, with edema extending into the pons.

b) TRANSAXIAL T1-WEIGHTED (600/14/1) SPIN-ECHO SEQUENCE (IMAGE 3): Anatomic relations are better seen, with evidence of a mass within the medulla, somewhat enlarging the left part of the brainstem (arrow).

c) TRANSAXIAL (IMAGE 4), CORONAL (IMAGE 5) AND SAGITTAL (IMAGE 6) GADOLINIUM-ENHANCED SPIN-ECHO SEQUENCES: The mass (arrow) is intensely enhancing and appears bilobar. The majority of the lesion is situated within the medulla oblongata, but with extension into the fourth ventricle and protrusion into the cisterna magna. Predominant extension is to the left.

RADIOLOGICAL DIFFERENTIAL DIAGNOSIS is ependymoma, choroid plexus papilloma or metastasis, considering the age of the patient.

SURGICAL FINDINGS: At surgery the tumor protruded out of the foramen of Magendie. The tumor aggressively infiltrated the brainstem and extended into the left inferior cerebellar peduncle and into the fourth ventricle. Resection was limited to the exophytic component. Complementary radiotherapy was incomplete, due to the patient's poor general condition.

ANATOMOPATHOLOGY reveals a medulloblastoma (PNET of the posterior fossa).

FOLLOW-UP: The patient died within 2 months after operation.

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Fig. 1

Medulloblastoma, case 2, Fig. 1
Medulloblastoma, case 2, Fig. 2
Medulloblastoma, case 2, Fig. 3
Medulloblastoma, case 2, Fig. 4
Medulloblastoma, case 2, Fig. 5
Medulloblastoma, case 2, Fig. 6