Treatment of postoperative cerebellar mutism with fluoxetine

Abstract

Dear Editor: This 13-year-old boy presented with a 4-month history of progressive headaches, vertigo, and blurred vision. At the initial presentation, he showed minor cerebellar ataxia with bilateral papillary edema. There were no further neurological deficits. The cranial MRI scan revealed a vermian fourth ventricular space-occupying lesion consistent with a medulloblastoma causing obstructive hydrocephalus. He had a right ventriculoperitoneal shunt with a medium-pressure valve inserted. The postoperative course was uneventful. One month later, a suboccipital median craniectomy approach was performed (in prone position) to remove the tumor. The histological examination revealed a medulloblastoma. The patient was asymptomatic for the first 2 days. However, on the third postoperative day, he developed significant reduced spontaneous speech and voluntary activity, concentration deficits, and drooling. These symptoms were in agreement with the diagnosis of cerebellar mutism. Laboratory examination revealed no abnormalities related to these symptoms. The postoperative CT scan demonstrated some edema without residual tumor, infarction, or bleeding in the primary site.

Posterior fossa syndrome in children following tumor resection: Knowledge update

“…Several groups have reported single patient trials of pharmaceutical therapies for CMS, including steroids, fluoxetine, bromocriptine, or zolpidem. [ 1 3 11 30 ] While each had reported a positive result, the gradual improvement of the syndrome with time makes it difficult to attribute therapeutic effect to these medications.…”

Cerebellar Mutism Treated Successfully With Zolpidem in a Patient With Learning Difficulties

“…However, following treatment with zolpidem, the urinary retention disappeared within one day, unlike reported cases which can improve up to two months with natural history as reported in case series. Another observation was that the patient was fully dependent on an NGT; however, after 2.5-3 months, she was free from the NGT, and there are no reported cases of NGT dependent that underwent successful weaning in the literature [4][5][6]. She regained motor function by extensive physiotherapy daily, while neurocognition was achieved by increasing quality time with family members through phone calls, messages, video chatting, and in-person visits [8].…”

“…In addition to the technicality of the surgery, some medications have shown efficacy in case reports. Fluvoxamine resulted in improvement of language in patients with no depressive symptoms with unknown mechanism [ 6 ]. However, zolpidem and aripiprazole have resulted in improved speech and motor disorders within days of initiation in children with normal learning abilities, which can be explained by stimulation of corticostriatopallidal-thalamocortical pathway as seen also in alleviating negative psychiatric symptoms [ 7 ].…”

“…The tumors, edema, hypoperfusion, and axonal injury in the vermis are postulated to cause disruption of the dento-thalamo-cortical pathway, especially in cases with high-grade tumors and in young patients with language impairment [ 4 ]. Some therapies such as corticosteroid, fluvoxamine, zolpidem, aripiprazole, and lorazepam have been tried, although only in case reports, favorable outcomes are reported for zolpidem and fluvoxamine [ 5 , 6 ].…”

Cerebellar mutism

“…Gordon 35 has proposed the use of similar treatment for CM as for the elective type (when no organic causes for CM can be found), especially with drugs such as fluoxetine, bromocriptine, and phenelzine. There is a case report of the favorable results of fluoxetine (a selective serotonin reuptake inhibitor) on a child with CM, 3 but more clinical trials should take place for further information.…”