"Tiger Country"

Brain stem is the part of central nervous system that connects the cerebrum and cerebellum to the spinal cord. Its diameter is about the size of a thumb. Nerve fibers communicating between the cerebrum, cerebellum and rest of the body traverse this area. It also contains nuclei that regulate respiratory and cardiac functions. The center that keeps us awake and alert resides in the brain stem as well. Because so many vital structures are packed into such a tiny space, surgical interventions in this area are very technically challenging. Many neurosurgeons consider the brain stem as the "tiger country" because one mistake here can have devastating results.

This patient is a 65 year-old female presented with headaches, nausea and vomiting. CT, MRI and angiogram revealed a very vascular cystic lesion in the posterior fossa, which is most likely hemangioblastoma given its hypervascularity, appearance and location. This case went on for 11 hrs yesterday. It was a very tricky resection because the feeding artery of the tumor was actually hiding underneath the draining vein. The patient's blood pressure was very unstable (going from 90/50 to 160/120 in just a few seconds) during the last part of resection because the tail of the tumor was very close to the medulla. In the last photo you are actually looking into the 4th ventricle at the posterior aspect of brain stem (medulla). The patient was awake, alert and followed command this morning. This is pretty amazing since many patients with this type of surgery would be left unable to breath on their own (damage to respiratory center) or in a permanent unconscious state.

Lee
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