Treated suprasellar germ cell tumor complicated by radiotherapy induced leukoencephalopathy with a stroke

Case contributed by Dr Andrei Tsoriev

Presentation

Since 2008 being observed for diabetes insipidus. Now presents with right hemiparesis and speech disorders. Imaging revealed suprasellar mass, with infiltration of nearby structures, and the tumour was considered inoperable. Typical imaging and clinical features allowed the diagnosis of germinoma to be suggested, Whole brain radiotherapy was administered, which proved to be effective with complete and sustained tumor response. Now the tumor is completely calcified and lacks contrast enhancement.

Patient Data

Age: 20
Gender: Female
CT

June, 2015. Acute onset of right sided hemiparesis and speech disorders

Symmetric suprasellar, basal ganglia, pons and temporal lobes calcifications. Symmetric hypodense areas within temporal lobes and both centrum semiovale.

Ventricular system is not dilated, no shift. No fluid collections or hematomas. Bone structures are within normal ranges.

Symmetric white mater T2 hypersignal within temporal lobes and both centum semiovale, more on the left.

Multiple dilated perivascular spaces at the basal ganglia.

Symmetric T1-hypersignal from suprasellar region, basal ganglia, temporal lobes, pons and dentate nuclei bilaterally best seen on 3D T1 sequence reflecting multiple calcifications

No abnormal enhancement after Gd administration.

Diffusion restriction at the left centrum semiovale posteriorly with corresponding ADC values confirms acute infarction.

There are no significant changes since last imaging excluding cystic changes at the left centrum semiovale depicting chronic post infarct changes.

Case Discussion

Germ cell brain tumors are very rare, accounting for less than 5% of all brain tumors in children. This is a case of cured suprasellar germ cell tumor by whole brain radiotherapy complicated by leukoencephalopathy, radiation angiopathy and further stroke.

Note an absolutely symmetric changes (both calcifications and leukoencephalopathy, there are a few published similar cases) even if you don't know the patient's history you can to find a key a priori - it could be post-treatment changes as we see in this case. 

Childhood stroke is another entity, it can be an outcome of paraneoplastic syndrome, chemo- and/or radiotherapy, vast majority of infections, varicella zoster more frequently including in the context of immunosuppression. We think the cause of stroke in this patient was a post-radiotherapy leukoencephalopathy and angiopathy because chemotherapy was not performed.

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Case information

rID: 44885
Case created: 7th May 2016
Last edited: 17th May 2016
Inclusion in quiz mode: Excluded

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