Recovery From Surgery for Infratentorial Hemangioblastomas in Children

Postoperative Orders 

• Admission to PICU: Typically the patient is admitted to an intensive care unit for close monitoring of vital signs and neurological examination, serial laboratory tests, neurological evaluations, and possible ICP monitoring. Prolonged intubation and sedation may be indicated when there has been intraoperative brainstem/cranial nerve manipulation; ICP monitoring is advised if neurological examination is not possible.

• ICP monitoring: Continued ICP monitoring may be considered if persistent hydrocephalus is suspected.

• Steroids: Steroids may be administered for 5–7 days or longer depending upon the patient’s status and the results of radiological examinations.

• Imaging: MRI should be performed within 72 hours of surgery to look for possible tumor remnants. An urgent CT scan should be obtained in case of neurological deterioration and/or sudden increase in ICP.

• ETV or CSF shunting: Signs of persistent hydrocephalus (enlarged ventricles on early neuroimaging examinations with progressive pseudomeningocele or elevated ICP and/or large amount of CSF through EVD) may necessitate consideration of a permanent treatment.

Postoperative Morbidity

• Headache (frequent): Headache may result from intracranial manipulation (edema, subarachnoid hemorrhage, pneumocephalus) or from postoperative hydrocephalus. Analgesic drugs are used for treatment in the first instance, possibly associated with specific therapy (e.g., steroids for edema); an ETV or shunt is used for the second instance.

• Neck pain (frequent): Neck pain may result from the skin/muscle incision and/or the craniotomy or, less commonly, from postoperative cerebellar downward herniation (severe edema, postoperative hemorrhage). Analgesic/anti-inflammatory drugs are used in the first case; aggressive steroid/diuretic therapy or surgical decompression should be used in the second case.

• Neck stiffness (frequent): Neck stiffness is usually due to neck pain. Treatment is with analgesic/anti-inflammatory drugs plus early but soft physiotherapy.

• Nausea and vomiting (quite frequent): Nausea and vomiting result from manipulation of the floor of the fourth ventricle. Treatment consists of antiemetic drugs, steroids, and adequate hydration and calorie-intake.

• Consciousness disturbances (rare): Disturbances of consciousness result from severe cerebellar or brainstem edema. Treatment is with steroids/diuretic therapy or surgical decompression.

• Cerebellar mutism (very rare): Cerebellar mutism is still of unknown origin and is typical of a malignant tumor. It is best to take a wait-and-see approach and provide psychological support.