Case Presentation

OBJECTIVESOBJECTIVES

CASE

LETRETURE REVIEW

CaseCase

ON 16/2/2010 @ 08:30 hrs

S. A , 2 y.o boy H/O Vomiting

24/11/2009

HX PRIMARY SURVEY

VOMITINGABCDE

VITAL SIGNSHR 64/minBP 110/60RR 24/minTemp 37.2SPO2 100% RBS 5.8

MONITER,O2, IV LINES, ECG

MORE HXHPCAMPLE

HxHx

Intermittent , started 2 wks agoDx = AGEThis time: started middle of night 10 hrs agoThis is the 3rd episode h/o low appititeh/o loss of wt

HxHx

NORMAL BOWEL MOVEMENT , NO BLOOD OR MALENA

NO URINARY SYMPTOMS

NO H/O FEVER

NO COUGH OR SOB

NO H/O FITS

HxHx

PMHx:

1. 3/12 ago, had similar episode lasted for a wk

2. Unremarkable antenatal Hx3. Immunization = upto date

HxHx

Not on any drugs

No h/o allergy

No h/o travel

No similar Hx in family

24/11/2009

HX PRIMARY SURVEY SECONDARY SURVEY

VOMITINGABCDEMONITER,O2, IV LINES, ECG

MORE HXHPCAMPLE

HEAD & NECKRESPCVSABDCNSMSKSSKIN

VITAL SIGNSHR 64/minBP 110/60RR 24/minTemp 37.2SPO2 100% RBS 5.8

SECONDRYSECONDRY SURVEYSURVEY

H&NNO ABNORMAL FEATURESMODERATELY DEHYDRATEDNO PALLORNO JAUNDICENO L.NSUPPLE NECKNO MENINGEAL SIGNS

SECONDRY SURVEYSECONDRY SURVEY

R.SGOOD A.E, CLEAR

CVSPULSES= REGULAR RATE & RHYTHMS1 S2 NORMAL, NO MURMERS

SECONDRY SURVEYSECONDRY SURVEY

P/A

SOFT, NON TENDERNO ORGANOMEGALYNORMAL B.SHERNIAL ORIFICES = INTACTPR = NOT DONEGENETALIA = NORMAL

SECONDRYSECONDRY SURVEYSURVEY

CNS :

• AWAKE• FOLLOWING COMMANDS• MOVING ALL EXTREMITIES• CN INTACT

SECONDRYSECONDRY SURVEYSURVEY

EXTREMITIES:

WELL PERFUSED, NO CLUBBING OR CYANOSIS OR EDEMA

CAP REFIL = 3 SEC

24/11/2009

HX PRIMARY SURVEY SECONDARY SURVEY

DDX

VOMITINGABCDEMONITER,O2, IV LINES, ECG

MORE HXHPCAMPLE

HEAD & NECKRESPCVSABDCNSMSKSSKIN

VITAL SIGNSHR 64/minBP 110/60RR 24/minTemp 37.2SPO2 100% RBS 5.8

24/11/2009

HX PRIMARY SURVEY SECONDARY SURVEY

DDX LAB RX

DISPOSTION

VOMITINGABCDEMONITER,O2, IV LINES, ECG

MORE HXHPCAMPLE

HEAD & NECKRESPCVSABDCNSMSKSSKIN

RADIOLOGY

VITAL SIGNSHR 64/minBP 110/60RR 24/minTemp 37.2SPO2 100% RBS 5.8

INVESTIGATIONSINVESTIGATIONS

CBC,, Hb= 11.0 (LOW MCV & MCH) Plt= 388 WBC= 6.6LFT,, WNRU/E,, WNRURINE,, NADAMYLASE ,, WNR

INVESTIGATIONSINVESTIGATIONS

CHEST/ ABDOMEN X-RAY:

NORMAL MEDIASTINUM NO CARDIOMEGALY CLEAR CHEST NO SIGNS OF BOWEL OBSTRUCTION NO A.U.D

ECG:

SINUS BRADY.

24/11/2009

HX PRIMARY SURVEY SECONDARY SURVEY

DDX

VOMITINGABCDEMONITER,O2, IV LINES, ECG

MORE HXHPCAMPLE

HEAD & NECKRESPCVSABDCNSMSKSSKIN

LAB RADIOLOGY

VITAL SIGNSHR 64/minBP 110/60RR 24/minTemp 37.2SPO2 100% RBS 5.8

OBSERVATIONOBSERVATION

DURING OBSERVATION, CHILD HAD TCS

TREATED WITH IV. LORAZEPAM

NEXTNEXT?? ??

CT BRAIN ( NON CONTRAST) :

OBSTRUCTIVE HYDROCEPHALUS

POSTERIOR FOSSA MASS ? TUMOR

24/11/2009

HX PRIMARY SURVEY SECONDARY SURVEY

DDX LAB RX

DISPOSTION

VOMITINGA&CBCDEMONITER,O2, IV LINES, ECG

MORE HXHPCAMPLE

HEAD & NECKRESPCVSABDCNSMSKSSKIN

RADIOLOGY

VITAL SIGNSHR 64/minBP 110/60RR 24/minTemp 37.2SPO2 100% RBS 5.8

Rx & DISPOSITIONRx & DISPOSITION

CONTINUED TO HAVE SEIZURES ,, Rx WITH LORAZEPAM

INTUBATED

REFERED TO NEUROSURGERY

PT HAD MRI BRAIN,, CONFIRMED TUMOR

TUMOR RESECTED

INTRODUCTIONINTRODUCTION

Tumors in posterior fossa are considered critical brain lesions. This is, primarily, because of the limited space within the posterior fossa and the potential involvement of vital brain stem nuclei.

Some pts should undergo emergency operation, especially if they present with acute symptoms of brain stem involvement or herniation.

INTRODUCTIONINTRODUCTION

Posterior fossa tumors are more common in children than the adults.

Between 54% and 70% of all childhood brain tumors originate in the posterior fossa.

About 15-20% of brain tumors in adults occur in the posterior fossa.

INTRODUCTIONINTRODUCTION

Certain types of posterior fossa tumors, such as medulloblastoma, pineoblastoma, ependymomas, primitive neuroectodermal tumors (PNETs), and astrocytomas of the cerebellum and brain stem, occur more frequently in children.

Some glial tumors, such as mixed gliomas, are unique to children. They are located more frequently in the cerebellum (67%) and are usually benign.

PRESENTATIONPRESENTATION

BRAIN TUMOURS IN PAEDs CHARACTERISTICALY PRESENT WITH SYMPTOMS OF INCREAED ICP CAUSED BY HYDROCEPHALUS

90% OF PTs WITH MEDULLOBLASTOMA OR CEREBELLAR ASTROCYTOMA & 65% WITH EPENDYMOMAS PRSENT WITH HYDROCEPHALUS SYMPTOMS

PRESENTATIONPRESENTATION

SYMPTOMS; HEADACHE, VOMITING, IRRITABILITY , LETHERGY

MORE COMMON IN THE MORNING BECAUSE OF RECUMBENCY & RELATIVELY ELEVATED PaCO2 INCREASES ICP

BRADYCARDIA IS OMINOUS BECAUSE IT SIGNIFIES VENTILATORY ARREST IS IMMINENT

InvestigationsInvestigations

CT is the first to be doneDetect 95% of brain tumors

CT scan of the posterior fossa is inferior to MRI in diagnostic value because of the artifact produced from the surrounding thick bone. However, CT scan is helpful for postoperative follow-up

ManagementManagement

INDICATIONS FOR SURGERY;

To decompress the post. fossa for the purpose of relieving pressure on the brain stem and/or to release ICP & avert the risk of herniation

To diagnose the tumor based on histopathology

To determine further plan of management depending on the nature of the tumor

ManagementManagement

When indicated, to treat hydrocephalus by shunting cerebrospinal fluid (CSF) to the peritoneal cavity