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Moderator / ICU: Jeremy Barnett MD
ED: Amy Gutman MD
Neurology: Janet Tamai MD
• 8 yo male presents to the
ED with the complaint of
weakness and dizziness
• 8 yo M, JS, presents at 0840 to room 19 via private vehicle
• Nurse immediately came to Core 1 asking me to see patient rather than
wait for 0900 MD
• Patient laying limp on the stretcher, with mother at bedside.
Maintaining airway, but clearly struggling to move & communicate
• Mother states that he had been diagnosed with an ear infection, but
today “was dizzy, couldn’t walk & was wobbly”
• Mother reports 4 days ago child vomited once, dry heaving yesterday but otherwise
acting / eating “normally” except for complaining of dizziness
• Mother called PCP yesterday, who advised them to start antihistamines due to
history of similar episodes with ear infections / congestion
• Mother also called child’s neurologist / autism specialist who stated “don’t worry
about JS’s symptoms”, but would see him in the office if he worsened
• Last night child having difficulty walking, unable to stand unassisted, & unable to
stand this am due to “dizziness”
• Social:
• Non-smoking home
• 2nd grade
• Family History
• No pertinent family history
• Allergies
• NKDA
• Medications
• Risperdal, lorazepam
• PMH
• Full-term
• Autism, OM
• General: Anxious, toxic, ill appearing & unable to communicate
• HEENT:
Ear “fullness”, nasal congestion, no visual complaints
• Pulm:
(-) SOB, DOE, PND
• CV:
(-) CP, palpitations
• GI:
(+) vomited once yesterday
• Skin:
(-) rashes, lesions
• Neuro:
Cannot ambulate, “can’t move or feel” left side, “dizzy”
• General:
• Awake & interactive. Appears “scared”,
responds to staff, maintains airway
• Vitals:
• T 98.3 oral, HR 98, Resp 16, Wt 35.7kg BP
124/71, Pulse Ox 100% ra
• Skin:
• Warm, dry, (-) rash, (-) temp differential
• HEENT:
• (-) swelling, tenderness, LAD, tongue
deviation. TMs unremarkable
• Pulm:
• CTA AF BL, no distress
• CV:
• S1S2 RRR (-) MRG
• GI:
• Soft NT ND (+) BSAQ
• Neuro:
• Mild right eye deviation which corrects to
center. PERRLA at 3 mm = BL & briskly
reactive; otherwise CN 2-12 intact
• LUE grip 3/5, LE BL 5/5
• (-) Babinski BL
• Falls to left side when tries to ambulate
• (+) vertical nystagmus BL 5 beat
What Is Your Differential?
• CBC:
Unremarkable
• CMP:
Unremarkable
• Coags:
Unremarkable
• Urinalysis:
Ordered, Not collected
• Cardiacs:
Unremarkable
• ESR:
Pending at time of transfer; slight elevation
• Lactic Acid:
22 (elevated)
• ED Lyme:
Ordered, not sent
Midline Falx
3rd Ventricle
Frontal Horns of Lateral
Ventricles
Basal Cistern
Midline Falx
Diffuse low density in left
cerebellum consistent with
acute infarct.
Slight deviation of 4th
ventricle to the right side.
No acute hemorrhage.
Supratentorial area,
brainstem unremarkable,
calvarium intact.
Impression: Acute infarct in
left cerebellum
• Case discussed with Dr P, pediatric neurologist at Albany Medical
Center who advised on acute ED management
• Suspected underlying cerebellar mass due to CT appearance
• Asked us to not wait for MRI, & rapidly transport
• Interventions:
• Oxygenation & airway protection
• NS IVF pediatric bolus
• Keppra 250 IV
• Signal 9 transfer
• Notified patient’s pediatric neurologist & pediatrician
• “JS is an 8 yo male admitted from an outside
hospital for neurosurgical evaluation in regards to
left cerebellar infarct, hydrocephalus & swelling of
the posterior fossa.”
• “The patient was taken emergently to the OR for
suboccipital craniectomy & partial resection of the
left cerebellum and dural augmentation, as well as
a external ventricular drain for hydrocephalus. The
patient tolerated the procedure well.”
• Pathology: Glioblastoma
• “The most recent CT scan re-demonstrated
the evolving infarct within the left cerebellum
with slightly improved areas of trace
pneumocephalus and hemorrhage.”
• “No new hemorrhage identified…there was
noted to be a slight decrease in the size of
the anterior 3rd ventricle in comparison to the
prior CT scan 1 month earlier”.
MRI showed a cerebellar infarct,
appearing as a bright signal on the
diffusion-weighted image
Differential diagnosis in children
• Definition:
• A sensation of movement when there is none. Commonly a spinning sensation,
but can be any type of movement
• Need to differentiate between
• “Dizziness”
• Ataxia
• Weakness
• Confusion
• 1st reported by Harrison in 1962
• Uncommon pediatric complaint
• >560,000 pediatric encounters over a 4-year period showed prevalence of
0.4% (dizziness), 0.03% (peripheral vertigo), & 0.02% (central vestibulopathy)
• History & exam challenged by vocabulary, distractibility & compliance
• Common impression that symptoms secondary to lack of coordination or
behavioral
• Remarkable compensation for vestibular deficits that in adults results in
disequilibrium and / or ADL limitations
• True vertigo present?
• PMH?
• Onset pattern?
• Medications?
• Symptom duration?
• Social?
• Auditory symptoms?
• Family?
• Associated neurological
symptoms?
• Associated symptoms?
• Keep a look out for red flags!
• Inspection for alertness, GCS, AVPU
• Developmental: cognitive, behavioral, dysmorphia
• Cranial nerves, especially III, IV, VI
• Eyes: nystagmus, diplopia
• Hearing: tinnitus, hearing loss
• Coordination:
• Gait, limb ataxia, cerebellar signs
• Motor / Sensory:
• Focal weakness or sensory changes
• Peripheral Nerves
• Internuclear ophthalmoplegia:
• Medial longitudinal fasciculus (MLF)
Lesion
• Cranial nerve 3, 4 or 6 palsy
• Cn 3: Oculomotor
• Cn 4: Trochlear
• Cn 6: Abducens
• Gaze palsy:
• Pontine lesion
• Ophthalmoplegia
• Fast uncontrollable eye movements
• Vertical vs horizontal/rotatory nystagmus
• Congenital nystagmus
• Acquired
• Brainstem lesion
• Peripheral lesion
• Other (i.e. medication)
• Migraine
• Seizures
• Aura
• Infection
• Peripheral: otitis media, labyrinthitis
• Central: meningitis, encephalitis
• Head trauma
• Structural lesions
• AVMs, Tumors, Arnold-Chiari
• Drug overdose
• i.e. NSAIDs, anticonvulsants
• Benign paroxysmal vertigo of
childhood
- Recurrent vertigo, normal in between
episodes, self limited after years
• Benign paroxysmal positional
vertigo
• Rare in children
• Stroke:
• Hypercoagulable state, i.e. Sickle cell
disease, genetic/inherited conditions,
elevated homocysteine
• Trauma (i.e. dissection)
• Congenital heart disease
Symptom
Central
Peripheral
Nausea
Mild-Moderate
Severe
Imbalance
Moderate-Severe
Moderate
Hearing Loss
Rare
Common
Tinnitus
Rare
Possible
Oscillopsia
Severe
Mild
Neurological
Common
Rare
Compensation
Slow
Rapid
Nystagmus
Pure vertical
Unchanged with fixation
No fatigability
No latency
Mixed torsional, vertical/horizontal
Dampens with fixation
Fatigability (BPPV)
Latency post maneuver (BPPV)
• Diversity of etiologies present with complaint of
“vertigo” or “dizziness”
• Detailed history & otoneurological exam
essential
• Most common etiology is migraine
• Accompanies vertigo, but dominates clinical picture
• Migraine in 35% of vertigo pediatric pts vs 6% adults
• Though 10% children meet International Headache
Society criteria for migraine, vestibular symptoms occur
in about 25%
• Family history
• Car sickness
• Imaging normal
• Can occur even in 1-2 year olds,
but difficult to diagnose until
older
• Symptoms
• Throbbing head pain
• Nausea, vomiting
• Photophobia
• Sonophobia
• Visual aura
• Focal symptoms
• Vertigo
• Demyelinating CNS disorder
• Most commonly in young adults,
but can occur in children
• 2-5% of adult patients had
symptoms prior to age 18
Google, fine art America; imagesofdisease.blogspot.com
Google, fine art America; imagesofdisease.blogspot.com
• ~70% occur in posterior fossa
• Brainstem or cerebellum
• Astrocytoma
• Ependymoma
• Medulloblastoma or primitive
neuroectodermal tumor (PNETs)
Imgarcade.com
• Three types of normal glial cells
can produce tumors
• Astrocytes produce astrocytomas
(including glioblastomas)
• Oligodendrocytes produce
oligodendrogliomas
• Ependymal cells produce
ependymomas
• Tumors that display a mixture of
different cells are “mixed gliomas”
Normal astrocytes
comminfo.rutgers.edu
• Most common Grade 1 astrocytomas
• Typically do not spread
• Considered “most benign” (noncancerous) of all
the astrocytomas
• Other Grade 1 astrocytomas:
• Cerebellar astrocytoma
• Desmoplastic infantile astrocytoma
• Based on pathology
Pathologyoutlines.com
• Commonly see solid & cystic
components
Neuropathology-web.org
• Also called Low-Grade or Astrocytoma Grade II
• Types:
• Fibrillary
• Gemistocytic
• Protoplasmic
• Tend to invade surrounding tissue and grow at a relatively slow rate
• More common in the cerebral hemispheres
• Fibrillary astrocytoma is the
most common diffuse low grade
astrocytoma
• Cystic appearance
• Grade III tumor
• These rare tumors require more
aggressive treatment than lower grade
tumors
Brain.mgh.harvard.edu; Emedicine.medscape.com
 Previously called “Glioblastoma
Multiforme,” “Grade IV Glioblastoma,”
and “GBM”
• Two types of astrocytoma Grade IV
• Primary, or de novo
• Most common form, very aggressive
• Secondary
• Originate as a lower-grade tumor &
evolve into a grade IV tumor
Radiologyteacher.com
• Named for location, not tissue
type from which they originate
• Glioblastoma
• Astrocytoma
• Hemorrhage and necrosis (seen
in the bottom image) indicates
Grade IV
Brain tumor foundation of canada website;
Neuropathology-web.org
• Arise from ependymal cells that line the
ventricles of the brain and the center of the
spinal cord
• 30% diagnosed in children under age 3
• Grades 1-3
• Grade 1: Subependymomas
• Grade 1: Myxopapillary ependymomas
• Grade 2: Ependymoma
• 4 subtypes
• Grade 3: Anaplastic ependymoma
abta.org
• Always located in the cerebellum
• Unusual to spread outside brain & spinal cord
• However, as CSF “seeding” common, need to image
entire neuroaxis to identify drop metastasis and
leptomeningeal spread
• >70% of all pediatric medulloblastomas are
diagnosed in children under age 10
cancerwall.com//nature.com
• Pathology identical to
medulloblastoma, but occurs
primarily in cerebrum
• Pineoblastoma, polar spongioblastoma,
medulloblastoma, medulloepithelioma
• Very rare
• Treatment
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Biopsy & resection/debulking if possible
Radiation
Chemotherapy
Supportive care
• Performed to remove a tumor or hematoma from
beneath the skull
• Suboccipital approach allows exploration of
posterior fossa & associated cranial nerves
• 5th CN cut to treat trigeminal neuralgia
• 8th CN (vestibular branch of the vestibulocochlear) cut
to surgically treat Ménière's disease
• 9th CN cut to treat glossopharyngeal neuralgia
• Remove acoustic neuromas from auditory canal
• Duraplasty provides additional room for cerebellar tonsils at
craniocervical junction, to close dura & prevent CSF leakage
• Primary dural closure difficult in many neurosurgical cases
• Options for dural grafting include monolayer collagen &
bilayer collagen sponges
• CSF circulates around brain & spinal cord
then reabsorbed via arachnoid villi
• Pediatric ventricular system produces CSF
at ~0.35mls/kg/hr via choroid plexus of
lateral ventricles
• Normal ICP is 0-20 mmHg
• EVD is a temporary system allowing CSF
drainage from ventricles to an external
system
• EVD pressure transducer maintained at
the same horizontal level as the
ventricles for reliable interpretation
• Laser level device should be in line with
the patient's Foramen of Monro
• If patient supine, level EVD system to the
ear tragus
• If the patient upright, level EVD to the mid
sagittal line (between eyebrows)
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Cohen-Kerem MR et al. Vertigo in Children and Adolescents: Characteristics and Outcome. ScientificWorldJournal. 2012; 2012: 109624. ePub 2012 Jan 3.
Tintinelli. Emergency Medicine – A comprehensive Study Guide. “Pediatric Neurological Emergencies”. 2010.
UpToDate.com. “Vertigo”, “Pediatric Dizziness”, “Pediatric Stroke”
Yang WC, Chen CY, Wu KH, Wu HP. Acute onset of dizziness caused by a cavernous malformation lateral to the fourth ventricle: a case report. Pediatr Neonatol 2011 Apr;52(2):113-6.
Reed Group MDGuidelines. “Suboccipital Craniectomy”. 2013.
Litvack ZN, West GA, Delashaw JB, Burchiel KJ, Anderson VC. Dural augmentation: part I-evaluation of collagen matrix allografts for dural defect after craniotomy. Neurosurgery. 2009
Nov;65(5):890-7; discussion 897.
Albanese, J; Leone M; Alliez JR; Kaya JM; Antonini F; Alliez B; Martin C (2003). "Decompressive craniectomy for severe traumatic brain injury: Evaluation of the effects at one
year". Critical Care Medicine 31 (10): 2535–2538.
Hejazi, N; Witzmann A; Fae P. "Unilateral decompressive craniectomy for children with severe brain injury. Report of seven cases and review of the relevant literature". European
Journal of Pediatrics 161 (2): 99–104.
Agannathan, J; Okonkwo DO; Dumont, AS. "Outcome following decompressive craniectomy in children with severe traumatic brain injury: a 10-year single-center experience with longterm follow up". Journal of Neurosurgery Pediatrics. April 2007. 106 (4): 268–275.
Adelson. P., et al. Intracranial pressure monitoring. Paediatric Critical Care. 4(3) (suppl.):S28-S30. 2003.
Tippett N. Intracranial pressure (ICP) monitoring and extraventricular drains (EVD). Bayside Health, Alfred ICU: 1-19. 2006.
Photo Search: wikipedia, google, bing
Muralidharan R.External ventricular drains: Management and complications. Surg Neurol Int. 2015 May 25;6(Suppl 6):S271-4.
Lau T, Reintjes S, Olivera R, van Loveren HR, Agazzi S. C-shaped Incision for Far-Lateral Suboccipital Approach: Anatomical Study and Clinical Correlation. J Neurol Surg B Skull Base.
2015 Mar;76(2):117-21.
Klimo P Jr, Nesvick CL, Broniscer A, Orr BA, Choudhri AF. Malignant brainstem tumors in children, excluding diffuse intrinsic pontine gliomas.J Neurosurg Pediatr. 2015 Oct 16:1-9.
Hopkinsmedicine.org
Medscape.com
Klimo P Jr, Nesvick CL, Broniscer A, Orr BA, Choudhri AF. Malignant brainstem tumors in children, excluding diffuse intrinsic pontine gliomas.. J Neurosurg Pediatr. 2015 Oct 16:1-9.
PDQ Pediatric Treatment Editorial Board. Childhood Central Nervous System Germ Cell Tumors Treatment (PDQ®): Health Professional Version. PDQ Cancer Information Summaries
[Internet]. Bethesda (MD): National Cancer Institute (US); 2002-2015 Sep 24.
Aghayan Golkashani H, Hatami H, Farzan A, Mohammadi HR, Nilipour Y, Khoddami M, Jadali F. Tumors of the Central Nervous System: An 18-Year Retrospective Review in a
Tertiary PediatricReferral Center. Iran J Child Neurol. 2015 Summer;9(3):24-33.
Assina R, Meleis AM, Cohen MA, Iqbal MO, Liu JK. Titanium mesh-assisted dural tenting for an expansile suboccipital cranioplasty in the treatment of Chiari 1 malformation. J Clin
Neurosci. 2014 Sep;21(9):1641-6.
Robertson SC, Lennarson P, Hasan DM, Traynelis VC. Clinical course and surgical management of massive cerebral infarction. Neurosurgery. 2004 Jul;55(1):55-61; discussion 61-2.
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Tomita T, Grahovac G. Cerebellopontine angle tumors in infants and children. Childs Nerv Syst. 2015 Oct;31(10):1739-50.
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• EVD removed 2 weeks after initial surgery
• As of 3 months after the initial presentation, patient with improved
speech, motor function and ambulation
• No evidence of metastatic spread
• Weaned off TPN, tolerating po
• Unclear if any long-term cognitive insults, but is able to ambulate & has
regained strength on his left side
• Pediatric brain tumor is a rare cause of dizziness, but needs to be
considered if the history & exam suggestive of a significant or focal
neurological deficit
• A through history & physical exam is often a better diagnostic “tool”
than any radiologic testing
• Thank you for your attention today ~ any questions?