0:00

So, we're here with a 27-year-old gal

0:03

who's had prior surgery for a mass

0:05

in the left cerebellar hemisphere.

0:07

We've got an axial T2,

0:09

an axial T1 without contrast,

0:11

and an axial T1 with contrast.

0:13

The mass is cystic,

0:14

although not quite CSF,

0:16

similar to CSF,

0:18

with a hypervascular nodule.

0:20

Could be a pilocytic but kind of old,

0:22

you know, 27 years of age.

0:24

More likely, the most common,

0:26

posterior fossa,

0:27

primary tumor of the adult,

0:29

and that is hemangioblastoma.

0:31

Of course, the most common tumor in the posterior fossa

0:34

in the adult would be mets. But for primary,

0:37

it's hemangioblastoma.

0:38

So as we look at this lesion,

0:41

it's got a fair amount of mass

0:43

effect on the fourth ventricle.

0:44

What would be the next move for you

0:46

if you're on call at 9 o'clock at night and you see this?

0:49

So looking at this case,

0:50

the fact that there's mass effect

0:52

upon the fourth ventricle,

0:53

that the pons and everything

0:55

is pushed forward.

0:57

Neurosurgical consult has to be your next move.

1:00

So, acute neurosurgical consult.

1:02

So in other words,

1:03

you don't read this case and they go

1:05

home for the night, and then find out

1:07

the next morning that the patient herniated.

1:08

You pick up the phone and you call

1:10

the neurosurgeon, if you're a general

1:12

radiologist or a neuroradiologist,

1:13

right then and there.

1:15

And look at the sagittal.

1:17

Look at the effacement of the cerebellum.

1:19

Where are the folia?

1:20

Where are the sulci?

1:21

I don't see them.

1:21

The inferior aspect of the fourth,

1:23

the inferior recess? Gone.

1:25

The obex? Effaced.

1:26

The clava? Effaced.

1:28

The fourth ventricle fastigium,

1:29

which should be a fastigial point.

1:32

We don't see a point.

1:33

It's flattened.

1:34

It's cut off right there.

1:35

Even the upper portion of the fourth

1:37

in the aqueduct are difficult to see.

1:39

So this patient has some serious mass effect going on.

1:42

Yes, even the prepontine cistern is effaced.

1:44

The pons is bowed towards the clivus.

1:47

Pushed forward.

1:48

So this patient is again at risk for herniating.

1:50

Look at the temporal horns.

1:51

They're big.

1:51

So, what's the treatment for this condition?

1:53

Because you can see they already did

1:56

an occipital craniectomy

1:57

and it didn't do a heck of a lot of good,

1:59

so what are some ways you can manage this?

2:02

So, I think the most important

2:04

take-home point is surgical

2:05

resection of the actual enhancing nodule.

2:07

If you drain the cystic component,

2:09

it typically recurs.

2:11

So taking out the enhancing nodule,

2:13

if it's a large lesion,

2:14

you'd want to do a preoperative embolization.

2:16

If it's a lesion that is so large

2:19

you can't resect the whole thing,

2:20

then adjuvant radiotherapy would be the next step.

2:23

So emboling this, I think,

2:25

with the current mass effect might be dangerous.

2:27

I'm not sure about that,

2:29

but certainly you wouldn't want to wait

2:30

to radiate this particular one.

2:32

So this one probably requires, you know,

2:34

as we said,

2:35

an acute, right then and there,

2:37

neurosurgical consult,

2:38

come down and look at the patient.

2:40

Pomeranz and Laser out.

2:42

Out.