Presentation
1-2 year history of worsening balance and 10+ year history of hearing loss.
Patient Data
Stable size of the homogeneously enhancing left cerebellopontine angle mass which displaces the adjacent pons and causes mild effacement of the fourth ventricle. This mass extends into and expands the left internal auditory meatus.
Codominant transverse sinuses communicate across the midline. This mass lies in direct contact with the left sigmoid sinus and intracranial internal jugular vein. No definite venous sinus invasion. No sinus compression or stenosis. No filling defect within either venous structure to suggest the presence of thrombosis.
Gliosis/encephalomalacia in the region of left cerebellopontine angle meningioma is stable. The left cerebellar infarction region has reduced in size, consistent with expected evolution. No intracranial hemorrhage or evidence of new territorial infarction. The ventricles are stable in size. No new findings.
Case Discussion
Rehabilitation notes
This person had an unusually large CPA tumor that compressed the pons, medulla, cerebellum and the jugular foramen. The tumor was resected successfully and histopathology confirmed transitional meningioma (WHO grade 1). Post operatively left cerebellar infarction was observed.
Clinically the client experienced dense left facial palsy, dysarthria, dysphonia (requiring left vocal augmentation), severe dysphagia (requiring PEG), immobility due to poor balance and vertigo. It is unusual to observe this extent of impairments after CPA tumor resections 1-3, unless the tumors are large enough to compress the brain stem and cranial nerves 4. In this case, the likely reasons for the extensive impairments were the impact of the tumor of the medulla and pons (swallow) as well as CNs VII (dysarthria and drooling), VIII (balance and vertigo), IX and X in the jugular foramen (swallow). The cerebellar infarct may have also contributed to the swallowing difficulties5 and disturbances in balance and vertigo.
Despite the significant impairments and slow gains, the client was able to achieve meaningful functional recovery. After 8 months of intensive inpatient and outpatient rehabilitation, the PEG was removed and normal diet/fluids were re-established. Dysarthria was mostly resolved, left facial palsy persisted and dysphonia was mild. The client was mobilizing independently with a gait aid and with improved endurance.
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Co author: Ettie Ben-Shabat PhD MAPT (neurological physiotherapy), B.App.Sci (physiotherapy)
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