2 days PTA, started walking funny (like a drunk person), loses balance when standing, has been worsening

When he talks, his mouth turns to the L side, once yesterday, twice today

No seizures No LOC No fevers

No staring spells (+) frontal headache this morning No vomiting Last week, (+) belly pain and NBNB

emesis for 6 days No diarrhea No rash

No incontinence Able to move neck No head trauma No known sick conracts Mom takes anti-anxiety meds (no

missing meds.) No sick contacts

Went to CA 4 months ago. Usually “hyper” but has been more

calm the past 2 days

Dental surgery at 3 yo Surgery for trigger thumb at 2 yo No seizures No asthma

FT via NSVD; no complications

Immunization History• Up to date

Walked before 12 mns of age In SPED; has an IEP- 1st grade but

failing his classes

Mom has anxiety d/o. No seizures No mental retardation No schizophrenia No malignancies

Lives with mom No pets or smokers at home

VS Temp 99.8 HR 88 RR 20 BP 100/60 100%RA

Gen awake, alert, oriented x 3, speech slurred mildly

HEENT PERRLA, EOMI, (+) vertical and horizontal nystagmus, clear OP, no LAD

CHEST CTA b/lHEART N S1/S2, no murmursABD soft, (+) BS, no HSMEXT FEP, CRT < 2 secs

Cranial nerves: I grossly intactII PERRLA, visual field testing normalIII, IV, VI EOMI; (+) vertical and

horizontal nystagmusV intactVII depressed RNLF with smile, weak eye

closure and eye wrinkling on the R

VIII grossly intactIX, X no gagXI able to shrug shouldersXII no tongue fasciculation, tongue midline

Motors 5/5Sensory no deficitsReflexes 1+, L toes upgoingCerebellar ataxic gait, R dysmetria

Brain Tumor Drug Ingestion Encephalitis (Brainstem) Genetic Disorders

› Dominant recurrent ataxia› Episodic ataxia› Hartnup Disease› MSUD› Pyruvate dehydrogenase deficiency

Migraine› Basilar› BPPV

Postinfectious- immune› Acute postinfectious cerebellitis› Miller Fisher Syndrome› MS› Neuroblastoma

Pseudoataxia (epileptic)

Trauma› Hematoma› Postconcussion› Vertebrobasilar

occlusion

Vascular DisordersCerebellar hemorrhageKawasaki disease

Ataxia R facial palsy Upgoing toes on the L R dysmetria

MRI CBC Lyme titers ESR/ CRP Urine toxicology

Axial mass in the R posterior brainstem, R middle cerebellar peduncle with surrounding vasogenic edema compressing the 4th ventricle with 2 separate areas of cystic changes

Primary malignant CNS tumors are the second most common childhood malignancies (after hematologic malignancies.)

Most common pediatric solid organ tumor

Headache Nausea and vomiting Abnormal gait or coordination Papilledema Seizures Squint Change in behavior or school performance Macrocephaly Cranial nerve palsies

Lethargy Abnormal eye movements Hemiplegia Weight loss Unspecified visual or eye abnormalities Altered level of consciousness

MRI*Compared to CT, it provides more detailed images of parenchymal lesions*More sensitive in detecting lesions within the posterior fossa, subarachnoid spaces, and leptomeninges

CT Scan

Fluorodeoxyglucose PET imaging or 11C-methionine PET may indicate foci of higher grade within a predominantly low-grade tumor. 

11C-methionine PET may also be able to differentiate astrocytic from oligodendroglial tumors. 

Histology

Occur in the brain stem, which is the area between the aqueduct of Sylvius and the fourth ventricle.

Originate from glial cells or their stem cell precursors and include astrocytoma, oligodendroglioma, and ependymoma.

Brainstem gliomas are divided into 3 distinct anatomic locations—diffuse intrinsic pontine,1 tectal, and cervicomedullary. 

With tectal lesions- hydrocephalus may occur as a result of fourth ventricular compression.

With pontine and cervicomedullary lesions, cranial nerve or long tract signs are observed commonly.

Histopathologically, brainstem gliomas can range from WHO Grade 1 to 4. Based on nuclear atypia, vascular proliferation, mitoses, necrosis

Grade 1 - juvenile pilocytic astrocytoma

Grade 2 - diffuse astrocytoma Grade 3 - anaplastic astrocytoma Grade 4 - glioblastoma multiforme.

Low-grade astrocytomas, which include Grade 1 (juvenile pilocytic astrocytomas) and Grade 2 (diffuse astrocytomas) astrocytomas

Complete surgical resection. If additional treatment is required, radiation therapy is usually used for the older children and chemotherapy is used for the younger children.

High-grade astrocytomas include Grade 3 (anaplastic astrocytomas) and Grade 4 (glioblastoma multiforme) astrocytomas

Surgery, radiation therapy, and chemotherapy are usually recommended.

Fenichel, G. Clinical Pediatric Neurology. 1997: WB Saunders Company, USA.

Rowland, LP et al. Merrit’s Neurology. 2010: Lippincott and Williams, USA.

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