• An 18 year old previously healthy right handed male presented with a one month history of double vision. He was seen by ophthalmology and scheduled for a head CT (Figure 1 below).

    On exam, the patient was afebrile with normal vital signs. He was alert and oriented to person, place and time. Speech was fluent. Comprehension and higher integrative functions were normal. Pupils were 5 mm bilaterally and minimally reactive to light. Extraocular motions were grossly intact. Cranial nereve 5, 7-12 were all intact. Strength was 5/5 in upper and lower extremities, no drift was present. Reflexes were normal and toes were down going bilaterally.

    The patient was admitted to the hospital and an MRI was obtained.

    Figures 2-5 (Below) Serum AFP and b-hCG were normal.

    The patient underwent an endoscopic third ventriculostomy and biopsy uneventfully. Pathologic diagnosis was germinoma. The patient was referred for chemotherapy with cisplatin and etoposide as well as radiotherapy.

    Figure 1.

    Figure 2.

    Figure 3.

    Figure 4.

    Figure 5.

    1. What in your opinion is the appropriate next step in the management of this patientÂ’s tumor?

    2. What in your opinion is the appropriate next step in the management of this patientÂ’s hydrocephalus?

    3. If you were to offer surgery for both would you do it at the same session, or stage the procedures (e.g. shunt first and stereotactic biopsy on another day)?

    4. If you were to perform an open biopsy / resection what approach would you utilize?

    5. Please add any suggestions or comments regarding this case:

    If the tumor revealed to be germinoma, it will be better to do radiotherapy and avoid open surgery.

    I would also sample CSF for tumor marker analysis / cytology as part of the endoscopic procedures.

    If pt has h/aches, symptoms of hydrocephalus then in answer to #2, I would proceed with Bx and 3rd Ventric, and if not technically feasible, shunt at the same time.

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