Lorazepam for post-operative pediatric cerebellar mutism syndrome: A case report

Case DiagnosisAn 11-year-old male with medulloblastoma underwent gross total resection of a posterior fossa tumor, complicated by post-operative pediatric cerebellar mutism syndrome (ppCMS), exhibiting mutism, emotional dysregulation, impaired volitional movement initiation, and ataxia.Case DescriptionWhile ppCMS's pathophysiology remains incompletely understood, prevailing hypotheses implicate cerebellothalamocortical dysregulation, functional diaschisis, and inhibitory-excitatory network imbalance. This case explores the use of lorazepam, a benzodiazepine that enhances GABA-A receptor activity, as a potential neuromodulator to facilitate recovery in ppCMS.SettingTertiary care children's hospital.Assessments/ResultsPharmacologic trials with bromocriptine, risperidone, and gabapentin yielded minimal benefit. However, administration of intranasal midazolam (5 mg) during radiation simulation resulted in transient resolution of mutism and improved initiation of movement. Based on this response, lorazepam (2 mg daily, 0.06 mg/kg) was initiated, leading to sustained improvements in speech, motor function, and therapy participation. Functional outcome assessments, including the WeeFIM, revealed a 40-unit gain within one week of lorazepam initiation compared to a 1-unit gain in the preceding week. Immediate regression was noted upon medication discontinuation and reintroduction resulted in subsequent recovery.Discussion/RelevanceThe differential response to benzodiazepines compared to other medications suggests potential for inhibitory-excitatory network imbalances. Future research should explore whether less sedating benzodiazepines, such as clobazam, or other GABAergic modulators could provide similar benefits without the cognitive side effects associated with lorazepam.ConclusionsThere is compelling evidence that benzodiazepine-mediated GABAergic modulation may facilitate CMS recovery by restoring cerebellothalamocortical network function. The observed improvements in motor initiation and speech fluency underscore the potential for pharmacologic neuromodulation as an adjunct to traditional rehabilitative therapies.An 11-year-old male with medulloblastoma underwent gross total resection of a posterior fossa tumor, complicated by ppCMS, exhibiting mutism, emotional dysregulation, impaired volitional movement initiation, and ataxia. Amid ongoing neurorehabilitation, a pharmacologic trial with lorazepam led to a reproducible improvement in speech and engagement. Though transient, the response suggested reversible disruption within functional circuits rather than fixed structural damage. This case report uncovers latent functional capacity in ppCMS, which can help distinguish ppCMS from other overlapping neurologic or psychiatric conditions throughout the course of rehabilitation.