DrVirgo
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23. A 6-year-old girl is brought to the physician because of a 1-day history of vomiting, headache, and weakness. One month ago, she underwent resection of an astrocytoma and placement of a ventriculoatrial shunt for residual hydrocephalus, her postoperative course had been uncomplicated. Currently, she is drowsy and irritable. Her temperature is 37.5°C (99.5°F), blood pressure is 126/54 mm Hg, pulse is 82/min, and respirations are 24/min. Funduscopic examination shows papilledema. Reflexes are brisk with hypertonia in the lower extremities.
Which of the following is the most likely underlying mechanism for these symptoms?
O A) Carcinomatous infiltration of cerebrospinal fluid
O B) Malfunction of ventriculoatrial shunt
O C) Overproduction of cerebrospinal fluid from a choroid plexus papilloma
O D) Recurrence and extension of the astrocytoma
O E) Thrombosis of the superior sagittal sinus
B. malfunc of shunt or
D. recur. Of astrocytoma
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| Aashi
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Malfunction of ventriculoatrial shunt
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| godfather1212m
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go with b,
recuurence will take longer time
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WE MIGHT HAVE COME FROM DIFFERENT PLACES, BUT WE ARE HEADING IN THE SAME DIRECTION
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| DrVirgo
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B is probably the best answer, but do shunts usually manfunction so soon? Strange Q... Couldn't find answer anywhere in notes.
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| Oussama77
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I go with B.
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| Sayulita
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Ok I can see the clinical thinking going on here
Yes I agree with the malfuntion of the shunt,but there is something else that needs to be seen here,and that is that hydrocephaly ( overproduction of CSF ) Cerebral spinal fluid
is the main ethiology of the pathology
so it is either a mechanical or physyiological problem..........
also there is evidence of papilledema sign of intracraneal pressure going up
age of the patient
I will go with C
but I can understand and respect the B answer.
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| DrVirgo
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How can you rule out D?
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| Sayulita
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http://en.wikipedia.org/wiki/Astrocytoma
Yes it does has recurrenceut the timelime does not check out
and you would need a CT scan to prove it.
it is a good question
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| DrVirgo
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"To date, complete resection of high grade astrocytomas is impossible because of the diffuse infiltration of tumor cells into normal parenchyma. Thus, high grade astrocytomas inevitably recur after initial surgery/therapy and are usually treated similarly as the initial tumor."
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| falcon
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Hi, DrVirgo
what is the final answer B OR D
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| DrVirgo
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falcon wrote:
Hi, DrVirgo
what is the final answer B OR D
Still not sure... Depends on which can occur in a month... failure of shunt or recurrence of astrocytoma.
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| falcon
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hi, Drvirgo, could u please see the answers of some NBME Qs, which I posted
Thanks
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| DrVirgo
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falcon wrote:
hi, Drvirgo, could u please see the answers of some NBME Qs, which I posted
Thanks
Umm... I posted a LOT of questions... you'll have to be more specific; I have no idea which ones you answered. 
And by the way, there are NO given answers to these questions... We can only assume a right answer as we all come to a final conclusion. If we are all undecided then the question is still debatable... unless some person gives an incredible explanation which we all agree with, then we can say case closed so to speak. 
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| DrVirgo
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Aashi wrote:
Malfunction of ventriculoatrial shunt
I think the shunt takes LONGER to malfunction...
Please see:
1. Median survival of a shunt (before need for revision) in a child under 2 years of age is 2 years; over two years of age is 8 - 10 years.
2. Signs and symptoms include headache, malaise, general not feeling well, vomiting, mental status alterations, increased blood pressure, head circumference increase, Cushings triad, bulging fontanel, sixth nerve palsy signs, Macewen's sign, changes in gait, and personality changes. There may also be an increase of seizures and a complaint of neck pain. The parents often know that something is wrong. Teachers may state that there has been a change of school performance
3. Obstruction- most often the proximal tip is obstructed with cells, choroid plexus, or debris. May also have kinking of the tubing and migration of the distal end.
a. Diagnosis by suspicion based on signs and symptoms and confirmed by CT scan of the head or shunt tap or lumbar puncture for CSF pressure elevation (ALWAYS RECORD A PRESSURE WHEN DOING AN LP!!!!).
4. Infection-
a. signs include fever, meningeal signs, vomiting, signs and symptoms of shunt malfunction, abdominal pain, and peritonitis.
b. There may be evidence of purulent material around the shunt insertion site and redness along the shunt tract
c. Most common organisms are S. epidermidis and S. aureus. Also gram negative organisms.
d. Diagnosis by positive blood cultures, shunt fluid cultures, or lumbar puncture cultures. Also the presence of greater than 10 cells in the fluid is suggestive of infection.
Infection peaks in the first few weeks after a shunt insertion. Infection years after shunt placement is rare unless the skin is broken over the tubing.
ANY other thoughts?
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| ngaybinhyen
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I don't have a good answer for this. I would go for my best guess which is B. It sounds like this is the diffuse type of the tumor in which patient has a very progressive course. Hydrocephalus already occured when pt underwent surgery. Pappilledema and possible Cushing triad indicate a very high ICP. Pappilledema may be an evidence of long-standing elevated ICP.
Please comment
-t.
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| ngaybinhyen
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Sorry I mistakenly wrote B. It should have been D
My guess is D
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| Oussama77
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1 month is not enough for recurrence to occur " The delayed occurrence of hydrocephalus signified recurrence of tumor"
Recurrence may take place in childhood cerebellar gliomas and may develop many years after initial treatment. Disease can be at the primary tumor site or, especially in malignant tumors, at noncontiguous central nervous system sites. Systemic relapse is rare, but may occur.
At the time of recurrence, a complete evaluation to determine the extent of relapse is indicated for all patients .
Biopsy or surgical resection may be necessary for confirmation of relapse because other entities such as secondary tumor and treatment-related brain necrosis may be clinically indistinguishable from tumor recurrence.
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| ngaybinhyen
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So, which one would you pick, Oussama77?
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| Oussama77
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Hello Dear ngaybinhyen
I am still with answer B, but also still suspicious about if the answer could be that simple?
I still wonder about C, but not aware of the cause of papilloma in such case.
I hope some friends will give additional comments.
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| nightflight1945
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MAlfunction of the shunt is the correct answer .
for example it may get blocked or obstructed.
IT is the most probable cause.
Astrocytoma is a slow growing tumor and also if it were the answer there would be some other clues like Focal neurological defect or seizure or ... in the question.
still it can be the cause however the most probable answer is SHUNT.
regards
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