Cerebellopontine angle tumor

Shanthi Helan Sophia1, Subathra Devi. M2, Maha Lakshmi3

1Nursing Incharge, Kauvery Hospital, Cantonment, Trichy

2Nurse Educator, Kauvery Hospital, Cantonment, Trichy

3Nursing Superintendent, Kauvery hospital, Cantonment, Trichy

Abstract

Cerebellopontine angle is a triangular space in the posterior cranial fossa that is bounded by the tentorium superiorly, brainstem posteromedially and petrous part of the temporal bone posterolaterally. It is an important landmark anatomically and clinically and is occupied by the CPA cistern, which houses the cranial nerves V, VI, VII and VIII along with the anterior inferior cerebellar artery. the clinical significance of CPA stems from the variety of tumors that may involve this region and present with a myriad of non-specific symptoms, the most common of which are sensorineural hearing loss, tinnitus and dizziness.

CPA tumours can be classified into two types:

  • Those arising from structures located in the CPA.
  • Those extending from adjacent regions into the CPA.

Background

Cerebellopontine angle tumours are the most common neoplasms in the posterior fossa. Most CPA tumours are benign, with 80-94% being vestibular schwannomas (acoustic neuromas), lipo vascular malformations and hemagiomas. Treatment options include observation, radiosurgery and microsurgery.

Case Presentation

A female patient of 59 years of age was admitted with H/O low back ache radiating to right lower limb since September 2024, Intermittent to begin with worsening during last October with, difficulty in walking and altered gait.

  • No h/o paraesthesia lower limb
  • No h/o claudication

She was evaluated for the above symptoms in an outside hospital. MRI Spine suggestive of diffuse disc bulge advised conservative management.

MRI brain with MRA and MRV was suggestive of left CP angle? meningioma SOL? Schwanomma and she was suggested surgery.

No H/o vertigo/ataxia/speech or swallowing disturbance

H/o chronic tension-type headache >10-15 years’ mild to moderate pain, global, relieves with analgesics.

Social History

She did not have any social history of cigarette smoking, or alcohol addiction.

Not known medicine or environmental allergies.

Past Medical History

She was known to have DM /HT, on treatment

Diabetic peripheral neuropathy symptoms present

Past Surgical History:  Not known surgical history.

Physical Examinations

Vital signs:

  • Temp: 97’F, HR: 84beats /min, BP: 120/70mmhg, SpO2:98%
  • GCS: E4V5M6, Moves all limbs, Mild difficulty in tandem walking
  • EOM-full, No nystagmus, No cranial nerve palsy
  • No focal neurological deficit

Investigations – Pre Op

MRI of Brain, plain and contrast (12.12.2024)

Left CP angle Meningioma causing indentation /compression over the adjacent 8th nerve and brain stem.

Echo (13.12.2024)

Normal Chambers dimensions, No RWMA, Good LV function, Valves normal, No MR /TR

Intact septate, No pericardial effusion/clot

Surgery Notes

  • On 13.12.2024, Left sub occipital craniotomy and excision of SOL were done under IONM under GA
  • Left retro mastoid S incision was made
  • 2×13 cm sub occipital; craniotomy done and Transverse sigmoid junction exposed
  • CSF released from cisterna magna – cerebellum became lax.

Findings

The lesion was vascular/firm in consistency with attachment to tentorial dura and compressing 5th/7th/8th nerve complex.

Procedure

Tentorial attachment cauterized and cut, lesion was separated from 7th, 8th complex 5th nerve under IONM.

Internal debulking done with WSA

Lesion excised totally/ preserving all cranial nerves

Hemostasis secured.

Gel form placed – epidural blood patch placed. Bone replaced 7 fixed with single plate screw

Wound closed in layers

Multiple CT brain -14.12.24 (post op)

Post sub-occipital craniotomy status on left side with parenchymal changes in the left cerebellum. No residual lesion.

Post-op follow-up treatment

  • Antibiotics, analgesics, PPI, & antiemetics.
  • Patient GCS stable, E4V5M6
  • Vital signs improved.
  • Able to recognize relatives.
  • The patient was discharged and advised to come for regular follow up.

Skilled Nursing Care

Regular monitoring of the overall condition and reporting deviations in the health status.

  • Nutritional needs: oral feeding given.
  • Positioning: the head elevation from 30° up to 45° to prevent swelling on the face and edema.to frequently change the position done to prevent pneumonia.
  • Early ambulation: ambulated the patient to a chair to improve his muscle strength.
  • Pressure ulcer risk assessment measures taken to prevent bed sore.
  • Sequential compression device applied in order to prevent DVT.
  • Educated facial exercises and eye care
  • Hygiene and grooming measures taken.
  • Physiotherapy exercise given to evaluate the muscle strength balance and mobility.as physiotherapist will train the family the exercise to continue at home.
  • Clinical nutrition: the nutritional requirements of the patient, types of feed, frequency and quantity of feed, supplements etc are decided and monitored by dieticians daily. Diet charts are prepared and given.

Condition at Discharge

  • Conscious, oriented, obeying commands
  • Moving all limbs
  • Afebrile
  • Left LMN facial palsy – Grade III
  • GCS: E4 V5 M6,HR: 86/min, BP: 120/80 mm/hg, SpO2:98% room air

Conclusion

In conclusion, CPA tumors are extremely rare and commonly occur in adults. Adult patients with CPA tumors usually have a good prognosis, while a poor outcome is observed in pediatrics patient. The findings could help develop a subsequent management plan when treating this rare disease.

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