New York Association of Neuropathologists
Chief complaint:
Headache, Gait disturbance and falls
History of present illness:
The patient is a 61-year-old bus driver with untreated hypertension and hypercholesterolemia.
Since November of 2004 he has been experiencing burning pain in the back of the head following
non-localized headaches. The burning sensation typically lasts a few minutes and is relieved with
Excedrin®. His primary care physician suspected a stroke and prescribed antihypertensive
medication and cholesterol lowering agents, which the patient discontinued. Since December of
2004 the patient has also been complaining of gait changes, namely' festinating gait'. The patient
remembers five to six falls In January of 2005, but is able to walk unassisted and continues to
drive his bus.
The patient has lost five Ibs since the onset of symptoms, but denies night sweats, fevers or chills.
He does not complain of visual, cognitive or personality changes. Also, he declines cardiac,
pulmonary, or renal disease.
He went to the emergency room of an outside institution, where a magnetic resonance
imaging study was performed. It revealed a mass in the vermis cerebelli. The patient was
transferred to CUMC for further management.
Physical examination:
The patient's systemic exam was unremarkable. The neurological evaluation was remarkable for
moderate bilateral dysmetria and gait disturbances.
Operative impression:
The mass was seen along the superior medial portion of the cerebellum in the inter-hemispheric
fissure. The tumor was well demarcated from the adjacent parenchyma. It was sharply dissected
along its pia arachnoid and then removed en bloc.