Presentation
The patient presented with chief complaints of headache and vomiting. Brain CT was performed for the patient which advised MRI. Based on the CT report VP shunt was placed for the patient and an MRI was done after 6 months.
Patient Data
An ill-defined isodense lesion is noted in the midline posterior fossa with obliteration of the fourth ventricle and proximal triventricular acute hydrocephalus -evident by trans ependymal CSF leakage-.
MRI advised for further workup.
A large well-defined, lobulated outlined, mass is seen centered in the fourth ventricle and herniating inferiorly through the foramen magnum to the spinal canal. There is also an expansion of the right foramen of Luschka by the lesion. The lesion is mostly isointense to the adjacent cerebellum on T1WI, hyperintense on T2WI (with some foci of higher signal-cystic change), and without significant restricted diffusion. Post-contrast images demonstrate relatively heterogeneous enhancement of the lesion. There is no surrounding edema.
Superiorly the lesion is reaching the level of the Sylvian aqueduct and obstructing it.
Inferiorly the lesion is herniating through the foramen magnum to the spinal canal posterior to the spinal cord to the level of C2/3 intervertebral disc.
Anteriorly it is compressing the brain stem.
The right side VP shunt is seen with its end in the atrium of the right lateral ventricle. Lateral and third ventricles are still dilated with trans-ependymal CSF leakage.
Case Discussion
Based on the patient's age and imaging characteristics; the lesion is more likely to be a posterior fossa ependymoma.
Unfortunately, due to economic problems, the patient was not treated. At Clinical follow-up four years later, the patient became blind and paraplegic.
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