Intended for healthcare professionals

Endgames Case Review

A young woman with headache and vomiting

BMJ 2019; 364 doi: (Published 30 January 2019) Cite this as: BMJ 2019;364:l216
  1. Gareth M Dobson, specialty trainee neurosurgery1,
  2. Craig H Robson, specialty trainee neurosurgery1,
  3. John Williams, consultant in infectious diseases2,
  4. Nitin Mukerji, consultant neurosurgeon1
  1. 1Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
  2. 2Department of Infectious Diseases, James Cook University Hospital, Middlesbrough, UK
  1. Correspondence to G Dobson gareth_dobson{at}

A 31 year old woman of Indian origin, now living in the UK, was admitted to the neurosurgical ward with a two month history of headache and nausea. Her symptoms had progressively worsened over two weeks and she now reported increasingly severe morning headaches, worse on lying down, and episodes of vomiting. On admission her Glasgow coma scale score was 15/15 and she had no ascertainable neurological deficit on either peripheral nerve assessment or cranial nerve assessment.

Her medical history included multidrug resistant pulmonary tuberculosis (TB) diagnosed around five years earlier. She underwent successful treatment for this in the form of a two year course of pyrazinamide, moxifloxacin, linezolid, and azithromycin. She had no history of immunocompromising medical conditions or medications. She also had hypothyroidism.

Blood tests on admission were suggestive of mild neutrophilia: haemoglobin was 111 g/L (reference range 115-160), white blood cell count was 11.3×109/l (4-11), neutrophil count 9.6×109/l (2-7.5) and C reactive protein was <5 mg/L.

Computed tomography showed a posterior fossa lesion with associated hydrocephalus. Magnetic resonance imaging showed a mixed signal mass within the middle of the cerebellar hemispheres (fig 1).

Fig 1

Axial fat suppression T1W magnetic resonance imaging with contrast showing a multilobular, well defined ring enhancing lesion within the posterior fossa


  1. What is the most likely diagnosis?

  2. How is this diagnosis confirmed?

  3. How would you manage …

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