Recurrent Medulloblastoma Case Study

Recurrent Medulloblastoma, brainstem compression and occurrence of refractory essential hypertension: a case report
ABSTRACT
Brainstem compression1-5 leading to systemic hypertension has been reported in case reports and series. This is a case report of a 4 year old male child previously operated for medulloblastoma. He was readmitted with tumour recurrence with leptomeningeal spread involving the brainstem leading to severe refractory hypertension with raised intracranial pressure and finally succumbing to it. A tentative conclusion can be made regarding occurrence of hypertension and fatality in recurrent medulloblastoma.
INTRODUCTION
Medulloblastoma arise from embryonic medullobastic cells located in the anterior and posterior medullary

The patient had been previously operated 3 months back for sub-occipital craniotomy with a right sided ventriculoperitoneal (VP) shunt prior to the definitive surgery. Tumour marker studies showed a high level of MIB1 (an antibody against a protein called Ki-67, expressed in proliferating cells) of 35%.
Examination revealed the patient was febrile but conscious and oriented with normal movements of all 4 limbs but a positive kerning’s sign. The hematological investigations showed leucocytosis (count of 15,700) and cerebrospinal fluid examination was consistent with the picture of bacterial meningitis. Intravenous antibiotics vancomycin and meropenem were started after verifying renal status. The shunt was initially exteriorized followed by removal under anesthesia. When the patient became afebrile a left sided medium pressure VP shunt was inserted. In the postoperative period in the neurointensive care unit (NICU) the patient became drowsy and had to be intubated and put on mechanical ventilator support. During the NICU stay the patient had multiple episodes of generalized tonic clonic seizures for which clobazam and levetiracetam were administered. An elective tracheostomy was done in view of persistent low GCS and poor respiratory effort. The patient subsequently developed high blood pressure

The first series to appear was from Janetta and Gendell9 in which they found out those patients who had vascular compression of the medulla between 9th and 10th cranial nerve and the inferior olive had essential hypertension. There are studies to voice the fact that medullary compression leads to hypertension regardless of laterality of pressure10. Also corollary evidence exists in form of reports of resolution of hypertension after decompression of the posterior fossa, as in craniovertebral junction anomaly type-1 where the pressure was exerted at the junction by the herniated cerebellar tonsils11. One of the possible areas of stimulation intraoperatively producing systemic hypertension rise is the rostral ventrolateral medulla (RVLM). Similarly levy and colleagues reported a series of 12 patients who underwent microvascular decompression of the left RVLM for severe medically refractory hypertension as a primary indication without underlying cranial nerve compression syndromes with good