Introduction: Ependymomas are slow-growing neuroectodermal tumors that may arise from various parts of the central nervous system. Anaplastic ependymoma represents 3-5% of ependymomas, and it is rarely found in adults and the infratentorial area, particularly the cerebellum. This paper discusses the first reported case of an adult female with anaplastic cerebellar ependymoma who underwent surgery and was treated with chemotherapy for tonsillar herniation.

Case Presentation: This is a case of a 58-year-old Filipino female with a five-month history of dizziness, headache, nausea, and vomiting. Cranial computed tomography (CT) scan revealed the presence of hydrocephalus with enhancing lesions at the right cerebellum. The patient underwent ventriculoperitoneal shunting (VPS) with sub-total excision and biopsy of the right cerebellum. Histology and immunochemistry were consistent with a high-grade anaplastic ependymoma (WHO Grade III). Cerebrospinal fluid and spinal magnetic resonance imaging (MRI) were negative for tumors. The initial plan was to undergo limited field external beam radiation therapy to the cerebellum. However, the patient was lost to follow-up. Two months after surgery, she presented with similar symptoms. MRI revealed tonsillar herniation and interval progression of the mass compressing the fourth ventricle, pons, and medulla oblongata; thus, medical decompression urgent chemotherapy with cisplatin and etoposide were started. After four chemotherapy sessions, repeat cranial MRI revealed resolution of tonsillar herniation and interval regression of the mass.

Conclusion: This paper presented a rare case of anaplastic cerebellar ependymoma with tonsillar herniation, successfully treated with chemotherapy. Radiotherapy is the standard of care following surgical resection. Still, our case management showed that in a patient with tumor progression presenting with tonsillar herniation, alternative management is to give systemic chemotherapy instead of radiotherapy.

Anaplastic Cerebellar Ependymoma ; Chemotherapy ; Herniation

Introduction: Lung cancer is the leading malignancy metastatic to the central nervous system with approximately 20% to 44% of all cases developing brain metastasis. Immunotherapy using pembrolizumab, an anti-PD1monoclonal antibody, is a novel method in lung cancer treatment and has shown favorable results in patients with metastatic brain lesions from non-small cell lung carcinoma (NSCLC). However, the cost of the recommended treatment dose limits its use especially in developing countries like the Philippines. Case Presentation: The authors report two patients with lung cancer with brain metastasis upon diagnosis. The first patient is a 65-year-old male, non-smoker with PD-L1 expression of 60%. He was started on pembrolizumab 100 mg IV every three (3) weeks and a repeat CT scan after 11 cycles revealed a reduction of the two brain metastatic lesions and no fluoro-D-glucose (FDG) uptake on positron emission tomography (PET) scan even after one year into treatment. The second patient is a 67-year-old female, a previous smoker with PD-L1 expression of 50% with a metastatic solitary solid nodule in the cortex of the right cerebellum. After five cycles of pembrolizumab 100 mg IV every three weeks, there was noted complete resolution of brain metastasis on PET scan even after one year of treatment. Conclusion A lower dose of pembrolizumab (100 mg given every 3 weeks) was found to be effective in the management of advanced NSCLC with brain metastasis in the two patients. Further studies are recommended to investigate lower dose pembrolizumab as monotherapy without radiation therapy or surgery in patients with NSCLC with brain metastasis especially in the setting of a resource-limited country like the Philippines.
Immunotherapy ; Lung Neoplasms ; Developing Countries

Coronavirus disease 2019 (COVID-19) infection primarily affects the respiratory system leading to majority of intensive care unit admissions; nevertheless, neurologic manifestations and complications occur and are now being reported. We present a case of a 19-year-old male who tested positive for COVID-19 and manifested with headache, drowsiness and eventually went into coma. Cerebrospinal fluid analyses during the early course of illness showed predominance of lymphocytes but were negative for COVID-19 and other viral or bacterial organisms. Cranial MRI showed bright signals in the splenium of the corpus callosum. The patient was treated with a combination of antivirals, convalescent plasma therapy and high dose steroid therapy. Progressive improvement in clinical status was observed after the combination therapy including high-dose steroid, suggesting a possible inflammatory mechanism of COVID-19-related encephalitis. The diagnosis of COVID-19 encephalitis can be challenging but it must be considered in any COVID-19 positive patient presenting with symptoms of encephalitis, such as fever, seizures or altered sensorium. Anticipation of long-term care should also be taken into consideration since the long-term sequelae of CNS COVID-19 are largely unknown.