Brainstem ganglioglioma in an infant: Case report and review of literature
An 8-month-old boy presented with complaints of incessant cry and vomiting. A computed tomography (CT) scan brain at a local hospital revealed a posterior fossa tumor and obstructive hydrocephalus. In view of raised intracranial pressure (ICP), a ventriculoperitoneal shunt was performed, and the child was referred to our hospital for further management. On admission, the child was alert and did not have any clinical features suggestive of increased ICP. The child′s neurological examination was normal. Magnetic resonance imaging revealed a heterogeneously enhancing large solid-cystic tumor in the fourth ventricle compressing the cervicomedullary junction dorsally []. A well-defined plane from the floor of the fourth ventricle or inferior cerebellar vermis could not be discerned. Differential diagnosis of exophytic cervicomedullary glioma or a vermian astrocytoma was considered. The child underwent a midline suboccipital craniectomy. The tumor was a moderately vascular grey tissue that was variably soft to firm, and was dorsally exophytic from the medulla into the fourth ventricle. A near total excision of the tumor was attempted to spare the medullary tissues, which had no clear plane from the tumor.\nHistopathological examination [] revealed a combination of neoplastic ganglion cells mixed with neoplastic astrocytic cells. Immunohistochemical staining demonstrated that the pleomorphic glial cells were positive for glial fibrillary acid protein, and the neoplastic ganglion cells and the intervening stroma were intensely positive for neurofilament protein and synaptophysin.\nAfter surgery, the child had no new neurological deficits but developed high grade fever from the third post-operative day. A cerebrospinal fluid (CSF) study confirmed meningitis and the child were started on intravenous antibiotics based on sensitivity pattern. In view of persistent fever, it was decided to remove the shunt. Following shunt removal, fever subsided, and the child was continued on oral antibiotics. Ten days after surgery, the child became irritable. Examination revealed a tense anterior fontanelle and CT scan showed gross hydrocephalus with periventricular lucency. Suspecting raised ICP; the child underwent a repeat ventriculoperitoneal shunt. After this procedure, the child had an uneventful course in the hospital and was discharged 2 weeks after admission. Post-operative imaging showed minimal enhancement in the left side of the medulla bordering the cerebellomedullary fissure, and it was decided to keep the child on imaging follow-up.