PMC8248242_01
Initial presentation of non-germinatous germ cell tumor causing obstructive hydrocephalus. Gadolinium-enhanced T1-weighted head MRI in the axial (a), coronal (c), and sagittal (d) axes performed at presentation showed a pineal region tumor compressing the tectum and causing obstructive hydrocephalus. The FLAIR image in the axial plane (b) revealed some edema in the midbrain.
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F1
Gadolinium-enhanced head MRI revealed a pineal region mass causing 10 mm of midline shift and compressing the cerebral aqueduct, the left thalamus, and the midbrain [Figure 1], requiring an immediate ventriculoperitoneal shunt for treatment of obstructive hydrocephalus.
Rapid growth of non-germinatous germ cell tumor displacing the left substantia nigra and rostral-caudal fibers from midbrain. Gadolinium-enhanced T1-weighted head MRI in the axial (a), coronal (e), and sagittal (f) axes performed before initiation of treatment showed a heterogeneously enhancing mass arising from the pineal region and measuring 34 x 28 x 23 mm. It caused 10 mm of midline shift and extended anteriorly into the left thalamus. The tumor extended caudally into the midbrain on the left exerted pressure medially and anteriorly (c). Diffusion tensor imaging showed that the rostral-caudal fibers (blue color) from the midbrain were displaced anteriorly and laterally on the left and laterally on the right at the pineal (b) and midbrain (d) levels.
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F2
The tumor grew quickly and nearly doubled in size in 3 weeks [Figure 2].
Second-look neurosurgical resection achieved additional cytoreduction. Gadolinium-enhanced T1-weighted head MRI obtained 1 day after surgery in the axial (a), coronal (c), and sagittal (d) axes, as well as T2-weighted image in the axial plane (b), demonstrated tumor cytoreduction and relief of compression on the tectum and the midbrain.
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F3
His Parkinsonism improved further after second-look neurosurgery, which achieved near total cytoreduction [Figure 3] and revealed residual yolk sac tumor.