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Medulloblastoma, hemispheric with drop metastasis

CLINICAL HISTORY:
This 15-year old boy complains of paresthesias in the left arm, increasing bifrontal headache and vomiting.

NEUROLOGICAL EXAMINATION reveals torticollis. There is deviation of the gait to the right with a tendency to fall to the right on Romberg testing. There is left hemiparesis and hypoesthesia. There is severe dysmetria and dysdiadochokinesia on the left side. Furthermore radicular signs in the C7-C8 territory on the left are present, with atrophy of the muscles of the left arm.

CT:
a) NON-CONTRAST SCAN (IMAGE 1): An inhomogeneous lesion is seen (arrowheads) in the left cerebellar hemisphere with displacement of the fourth ventricle (arrow), anteriorly and to the right. The mass is somewhat hyperdense, and surrounded by edema.

b) CONTRAST-ENHANCED SCAN (IMAGE 2): There is moderate enhancement of the lesion (arrowheads).

MRI:
a) TRANSAXIAL T2-WEIGHTED (2500/90/1) SPIN-ECHO SEQUENCE (IMAGES 3 AND 4): A huge mass is confirmed (arrowheads) in the left cerebellar hemisphere with an overall slightly hyperintense appearance. Anteriorly the lesion is ill-defined and surrounded by some edema. There is displacement of the fourth ventricle (arrow).

b) TRANSAXIAL (IMAGES 5 AND 6) AND CORONAL (IMAGE 7) T1-WEIGHTED (600/20/1) SPIN-ECHO SEQUENCE: The lesion now is only slightly hypointense to grey matter. The tumor (arrowheads) appears to occupy the majority of the posterior part of the left cerebellar hemisphere. Notice again the substantial mass effect.

c) TRANSAXIAL (IMAGES 8 AND 9), CORONAL (IMAGE 10) AND SAGITTAL (IMAGE 11) GADOLINIUM-ENHANCED SPIN-ECHO SEQUENCES: There is intense enhancement of the lesion. At the inferior and anterior aspect the enhancement is inhomogeneous and irregularly infiltrates the white matter of the left cerebellar hemisphere.

d) TRANSAXIAL (IMAGE 12) AND SAGITTAL (IMAGE 13) GADOLINIUM-ENHANCED MR OF THE CERVICAL SPINAL CANAL: An extra-axial enhancing lesion (arrowheads) at C7-T1 on the left side is appreciated.

e) SAGITTAL (IMAGE 14) AND CORONAL (IMAGES 15 AND 16) GADOLINIUM-ENHANCED MR OF THE LUMBAR SPINAL CANAL: Multiple small rounded enhancing lesions are seen at the surface of the cauda equina.

RADIOLOGICAL DIAGNOSIS is medulloblastoma with ependymal spread.

SURGICAL FINDINGS: At surgery, a huge tumor was found in the left cerebellar hemisphere. The lesion was ill-defined and diffusely infiltrated the white matter. The tumor was purple-grey, predominantly soft, but with focal firmer components.

ANATOMOPATHOLOGY was consistent with medulloblastoma Grade IV.

Adjuvant total cranial and spinal radiotherapy was performed. The child is alive 3 years after treatment.

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Medulloblastoma

 

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Fig. 1

Medulloblastoma, hemispheric with drop metastasis, Fig. 1
Medulloblastoma, hemispheric with drop metastasis, Fig. 2
Medulloblastoma, hemispheric with drop metastasis, Fig. 3
Medulloblastoma, hemispheric with drop metastasis, Fig. 4
Medulloblastoma, hemispheric with drop metastasis, Fig. 5
Medulloblastoma, hemispheric with drop metastasis, Fig. 6
Medulloblastoma, hemispheric with drop metastasis, Fig. 7
Medulloblastoma, hemispheric with drop metastasis, Fig. 8
Medulloblastoma, hemispheric with drop metastasis, Fig. 9
Medulloblastoma, hemispheric with drop metastasis, Fig. 10
Medulloblastoma, hemispheric with drop metastasis, Fig. 11
Medulloblastoma, hemispheric with drop metastasis, Fig. 12
Medulloblastoma, hemispheric with drop metastasis, Fig. 13
Medulloblastoma, hemispheric with drop metastasis, Fig. 14
Medulloblastoma, hemispheric with drop metastasis, Fig. 15
Medulloblastoma, hemispheric with drop metastasis, Fig. 16