Cerebral venous sinus thrombosis (CVST) is an uncommon type of venous thromboembolism whose diagnosis is often difficult due to its vague and non-specific clinical findings. Sometimes, the diagnosis is delayed as the symptoms were considered to be attributable to the underlying etiology, especially in patients with brain tumors such as high-grade glioma (HGG). We described the case of a 60-yearold male patient who presented with headache, generalized seizures, and right hemiparesis soon after receiving brain radiation and temozolomide therapy for HGG of the left thalamus. Initially, his symptoms were considered to be due to his underlying tumor but the subsequent imaging revealed left transverse, left sigmoid, and superior sagittal sinus thrombosis with venous hemorrhagic infarct of the left occipitoparietal lobe. The patient was started on anticoagulant therapy and symptoms resolved completely within a month. Clinicians should always consider CVST in the differential diagnosis of non-specific neurological symptoms, especially in patients with underlying brain tumors.
Germinomas involving non-midline structures such as thalamus and basal ganglia are relatively uncommon contributing up to 5-10% of all intracranial germ cell tumors. Here, we describe a case of thalamic germinoma in a 16-year-old boy who presented with recurrent episodes of headache and blurry vision for 2 months. Magnetic resonance imaging revealed heterogenous mass in the left thalamus with contrast enhancement causing mass effect and obstructive hydrocephalus. Total excision of the tumor was done by suboccipital craniotomy. Histopathology showed poorly differentiated round cells with vacuolated cytoplasm, round nuclei with prominent nucleoli which were separated by thin fibrovascular stroma infiltrated by lymphocytes. Immunohistochemistry showed diffuse immunoreactivity for placental alkaline phosphatase and octamer-binding transcription factor 3/4, and negative for glial fibrillary acidic protein, cluster of differentiation (CD)-45, and CD-30, confirming it to be a pure germinoma. With a combined approach of surgery, chemotherapy, and radiotherapy, these patients have better long-term survival rates.
A 9-year-old boy was admitted to our institution with acute onset of bilateral blurry vision. Physical examination revealed bilateral papilledema. Cerebrospinal fluid analysis and comprehensive metabolic panel were normal. Magnetic resonance imaging (MRI) of the brain showed extensive bilateral optic nerve inflammation with post-contrast gadolinium enhancement on T1-weighted sequence. The involvement was limited to the anterior segments of the optic nerves sparing chiasma and optic tracts. Anti-aquaporin-4 antibody (AQP4) was negative while anti-myelin oligodendrocyte glycoprotein antibody (MOG) was positive. After intravenous methylprednisolone, his vision dramatically improved. The patient was discharged with only mildly impaired visual acuity, 2 weeks after admission. Follow-up brain MRI and MOG assay after 3 months were within normal limits.
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