Objective: To provide a case of subclinical symptoms including motor tics in a child found to have a large craniopharyngioma with post surgical parkinsonism.

Background: A 12 year old child with a history of concentration issues in school and occasional involuntary motor movements presented to the hospital due to intractable headache with emesis after papilledema was noted on an ophthalmologic exam. MRI imaging was notable for a heterogenous multicystic mass centered in the suprasellar cistern. There was supratentorial ventriculomegaly /w rightward 1.8cm shift and mass effect on midbrain structures. The patient was taken for right sided craniotomy fenestration of cystic components of the mass. Post surgery the patient developed left sided neglect, with increased tone of extremities. In recovery, was noted to have right greater than left rigidity, primarily resting tremor of right sided extremities, bradykinesia, and spasticity with weakness of left sided extremities. He was already receiving Baclofen and Diazepam, but noted great improvement with the start of Carbidopa/Levodopa. He was eventually weaned off all agents as his tremors improved. He was taken for proton radiation therapy and continues to be monitored in a multidisciplinary clinic.

Method: NA

Results: NA

Conclusion: Craniopharyngioma may often be seen as asymptomatic early in the course, however there may be clinical findings to alert us. This patient did have remote issues with concentration determined by family later fitting diagnosis for ADHD, in addition to repetitive undesired motor movements with later suspicion for motor tics. Based on the location and size of his tumor there was likely involvement of his cortical-striatal-thalamic-cortical circuits suggested to play a role in tic disorders. In addition to these pathways, there was asymmetric displacement of the midbrain structures involving substantia nigra likely resulting in post surgical parkinsonism. Therefore, it is important to maintain clinical suspicion for craniopharyngioma in patients with movement disorders including tics.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/from-subclinical-symptoms-to-post-surgical-challenges-a-pediatric-case-of-craniopharyngioma/