Presentation
Headache and syncope. Recent history of hydrocephalus and shunt tube insertion.
Patient Data
Small pineal gland lesion of abnormal signal and enhancement. It measures 10 x 10 x 7 mm. It elicits a low signal on T1 WI and a high signal on T2 WI and shows vivid enhancement on the post-contrast series.
Right V/P shunt. No hydrocephalic changes.
Left frontoparietal small subdural collection with engorged dural venous sinuses and diffuse smooth dural enhancement likely attributed to overshunting and hypotension.
Right frontal periventricular small patch of abnormal signal with no contrast enhancement.
A CSF sample revealed elevated β-hCG levels (121 IU/L) and normal AFP levels.
Post therapeutic-follow up
Follow-up MRI post-chemo and radiotherapeutic treatment showed:
regression regarding the size of the previously noted pineal lesion
newly developed diffuse periventricular subependymal and leptomeningeal metastatic spread of the tumor
complete resolution of the subdural collections and the diffuse smooth dural enhancement
Case Discussion
Germinomas tend to occur in the midline, either at the pineal region (majority) or along the floor of the third ventricle/suprasellar region. They are the most common tumor in the pineal region.
Yolk sac tumors and choriocarcinomas often present with AFP and β-hCG elevation.
Germinomas with malignant characteristics, as in our case, will infiltrate into the subependymal lining of the ventricular systems, spreading in a periventricular pattern. Differential diagnoses of diffuse subependymal lesions include lymphoma, metastasis, or less likely inflammatory lesions.
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