David I. Sandberg, M.D.


Table 1: Relative Incidence of the Most Common Infratentorial Brain Tumors by Histology (Excluding Intrinsic Brainstem Tumors) in Children (34)

Tumor Histology | Percentage of Tumors
Medulloblastoma (PNET) | 30-55%
Cerebellar Astrocytoma | 25%
Ependymoma | 20%

Table 2: Uncommon Posterior Fossa Tumors in Children (34)

Choroid Plexus Pappilloma
Atypical Teratoid/Rhabdoid
Acoustic Neuroma
Metastasis (most common: neuroblastoma, embryonal rhabdomyosarcoma, Wilms tumor)


General Management Principles

Preoperative Imaging Studies:

Management of Hydrocephalus Prior to Tumor Resection:

Management of Hydrocephalus After Tumor Resection:

Other Preoperative Considerations:

Postoperative Management:

Surgical Approaches

General Intraoperative Considerations

  1. Extreme caution must be taken when opening the dura in the posterior fossa, particularly in young children who may have enlarged dural venous sinuses.
  2. Tumor bleeding during resection can also be extensive, particularly for malignant tumors such as medulloblastoma.
  3. All patients should have an arterial line and appropriate venous access. In the event of extensive blood loss, coagulopathy and thrombocytopenia should be ruled out and aggressively corrected if diagnosed.
Midline Suboccipital Craniotomy: the common surgical procedure performed for children with infratentorial tumors. The basic surgical steps for a midline suboccipital craniotomy for tumor resection are outlined below: Other Surgical Approaches: Cerebello-pontine angle tumors in children, such as ependymomas, may be approached via a retrosigmoid approach as reviewed by Sanford et al. (61) . Focal brainstem tumors are best approached by the route which provides the shortest trajectory to the tumor. Surgical approaches to various areas within the brainstem are detailed in other references (52).

Complications of Surgery

Classification and Management of Specific Tumor Subtypes


Table 3: High Risk Versus Average Risk Medulloblastoma (42)

Average Risk High Risk


Cerebellar Astrocytoma

Brainstem Gliomas

Diffuse Tumors Dorsally Exophytic Tumors Cervicomedullary Tumors Focal Intrinsic Tumors Tectal Tumors


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