Elsevier

World Neurosurgery

Volume 84, Issue 4, October 2015, Pages 1176.e11-1176.e14
World Neurosurgery

Case Report
Synchronous Subarachnoid Aneurysmal Hemorrhage and Medulloblastoma in a 6-Year-Old Girl

https://doi.org/10.1016/j.wneu.2015.06.058Get rights and content

Background

Hemorrhage in medulloblastoma (MB) is a rare clinical entity with the undeniable potential for catastrophic repercussions. This case report highlights the first incidence of intraoperative subarachnoid hemorrhage (SAH) in a patient with MB secondary to an intracranial aneurysm.

Case Description

A 6-year-old girl with a left cerebellar mass, fourth ventricle effacement, and triventriculomegally had an external ventricular drain inserted, at which time blood stained cerebral spinal fluid was drained. After insertion of an external ventricular drain, imaging showed diffuse SAH. Post tumor resection scans showed a small residuum of tumor. At repeat tumor resection after chemoradiotherapy, a 2-mm internal carotid aneurysm was noted.

Conclusions

Intraoperative hemorrhage in MB is a very rare occurrence. We describe the first case of hemorrhage in MB secondary to an intracranial aneurysm. MB has a predisposition to bleed spontaneously that can have catastrophic repercussions. Sudden clinical deterioration after insertion of external ventricular drainage should be susceptive of intracerebral hemorrhage. In cases of uncertain etiology, investigation of SAH with cerebral angiography is recommended.

Introduction

Hemorrhage in medulloblastoma (MB) is a rare clinical entity with the irrefutable potential for catastrophic repercussions. This case report highlights the first incidence of intraoperative subarachnoid hemorrhage (SAH) in MB secondary to an intracranial aneurysm. Intracranial aneurysms in the pediatric population are uncommon, representing 1%–4% of all intracranial aneurysms in all age groups (10), with a male predominance (1.42:1) (10). The wide internal carotid artery (ICA) bifurcation angle is the most common site for the occurrence of aneurysms, because of greater exposure of the vessel wall to turbulent blood flow 4, 5, 6, 7. The ICA bifurcation is prone to defects of the muscularis layer and internal elastic membrane of the tunica media, resulting in decreased integrity of this site, forming aneurysms that may lead to SAH. MB is a commonly encountered, highly malignant posterior fossa midline cerebellar tumor of children, accounting for 15%–20% of all intracranial neoplasms in children. Spontaneous hemorrhage with, or as a result of, these tumours is rare and often fatal 2, 3, 9.

Section snippets

Case History

A 6-year-old girl presented to a peripheral hospital with a 4-day history of worsening headache, vomiting, lethargy, and ataxia. During the second day of her admission, her Glasgow Coma Scale score decreased from 15/15 to 12/15, and her pupils were equal (size 4) and reactive to light. She became hypertensive 140/90 mm Hg and bradycardic with a heart rate of 50–60 bpm. Mannitol was administered, and an urgent computed tomography (CT) of the brain identified a large heterogeneous left cerebellar

Discussion

Children with posterior fossa MB are predisposed to hydrocephalus, and a significant proportion require CSF diversion (1). However, as has been reported by other authors, serious complications can be associated with CSF diversion such as upward herniation, hemorrhage of the tumor and peritoneal seeding of the intracranial tumor (8). Intratumoural hemorrhage in MB is a rare but a recognized complication of EVD insertion 2, 3. In medulloblastoma, tumor neovascularization is thin walled, weak, and

Conclusion

Synchronous SAH and MB is highly uncommon, and a pathophysiologic relationship between intracranial aneurysm and SAH in this scenario has not been reported previously. CSF diversion in obstructive hydrocephalus due to MB has been implicated in the development of intracranial hemorrhage, and although it is a rare occurrence, one should be aware of this potential complication. In cases of unexplained SAH in MB, angiographic techniques should be used to aid in the detection of previously

References (10)

  • B.J. Jian et al.

    Pediatric intracranial aneurysms

    Neurosurg Clin N Am

    (2010)
  • L. Bognar et al.

    Analysis of CSF shunting procedure requirement in children with posterior fossa tumors

    Childs Nerv Syst

    (2003)
  • E.A. Elgamal et al.

    Fatal haemorrhage in medulloblastoma following ventricular drainage. Case report and review of the literature

    Pediatr Neurosurg

    (2006)
  • J. Fukai et al.

    Intraoperative hemorrhage in medulloblastoma: a case report and review of the literature

    Childs Nerv Syst

    (2002)
  • K. Garg et al.

    Pediatric intracranial aneurysms—our experience and review of literature

    Childs Nerv Syst

    (2014)
There are more references available in the full text version of this article.
View full text
Copyright © 2015 Elsevier Inc. All rights reserved.