- Admission to an intensive care unit: Postoperatively, children undergoing medulloblastoma surgery require hourly neurological checks, close monitoring of vital signs, and laboratory examinations as needed. This care is best provided in an ICU. End-tidal PCO2 monitoring may be considered.
- Prolonged postoperative intubation: Extended postoperative intubation may be considered for patients who have had long operations, received multiple units of blood, or had extensive manipulation of cranial nerves and may not be able to protect their airways.
- Urgent CT scan for neurological change: A CT scan should be obtained in the event of progressive lethargy or neurological changes in the immediate postoperative period to look for hemorrhage or acute hydrocephalus.
- Postoperative brain MRI: A MRI should be obtained after surgery to document the extent of tumor resection. It is best within 48–72 hours when possible because enhancement thereafter may not represent residual disease (18). Reoperation is considered if more than 1.5 cm2 of tumor remains on postoperative imaging to avoid the adjuvant treatment required for high risk disease.
- Transfer to regular floor: Transfer generally occurs after 24–48 hours in the ICU, about the time that the patient is mobilized.
- Dexamethasone taper: Dexamethasone should be tapered over approximately 7–10 days if the patient is doing well clinically and the postoperative MRI demonstrates complete or near-complete tumor resection.
- Oncology consultation: If not already done, the oncologist is consulted to plan postoperative staging and adjuvant therapy.
Management of Hydrocephalus After Tumor Resection
- Permanent CSF diversion: A drain usually is not required after complete or near-complete tumor resection.
- Concern if progressive ventriculomegaly, CSF leak, pseudomeningocele or signs elevating ICP: Some patients will require management of postoperative hydrocephalus. This possibility is more likely in younger patients and those with large tumors or long-standing ventriculomegaly (11). Elevated ICP in association with large ventricles can compromise recovery as can an infection due to CSF leakage. These are, therefore, generally an indication for early intervention with a shunt or ETV.
- Neck pain: Patients may experience postoperative pain and neck stiffness due to muscle dissection.
- Headache: Headaches may occur due to intraventricular blood or pneumocephalus.
- Nausea and vomiting: Nausea and vomiting may occur due to anesthesia and/or irritation of the area postreme in the floor of the fourth ventricle.
- Ataxia: Transient ataxia may occur due to cerebellar manipulation during surgery.
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