Rapid-Growing Intracranial Immature Teratoma Presenting Obstructive Hydrocephalus and Abducens Nerve Palsy: A Case Report and Literature Review

Abstract

Intracranial immature teratoma is an extremely rare disease with poor prognosis and requires complicated treatment. Owing to the deep midline location of the tumor, total surgical resection of the tumor is challenging. We present our experience with a fast-growing pineal gland immature teratoma in a 4-year-old boy, who presented with obstructive hydrocephalus and abducens nerve palsy, which was treated with total surgical resection of the tumor. In addition, we aimed to determine the appropriate treatment modality for intracranial immature teratomas by reviewing the literature and investigating the prognosis.

Keywords: Brain neoplasms; Hydrocephalus; Immature teratoma.

Fig. 1. Initial CT and MRI findings of the patient. A: Sagittal view of initial enhanced CT scan of the patient. A 2.5-cm-sized pineal gland tumor blocking the cerebral aqueduct and obstructive hydrocephalus were seen. B and C: Axial and sagittal views of the enhanced MRI scan after extra-ventricular drainage, showing the pineal gland tumor with heterogeneous enhancement and mixed signals due to different tissues. D: Axial view of T2-weighted image scan after extra-ventricular drainage, showing intratumoral cysts and calcification.

Fig. 2. Preoperative sagittal (A) and axial (B) MRI showing improved hydrocephalus after endoscopic third ventriculostomy but much increased solid portion of the tumor.

Fig. 3. Intraoperative microscopic view and postoperative MRI. A: Intraoperative microscopic image after retracting the right occipital lobe. The tumor (black arrow) anterior to deep venous system (white arrow) was noted. B: Microscopic view after gross total removal of the tumor. Right occipital lobe (black arrow), deep venous system (white arrow), and incised tentorium (white arrowhead). C and D: Postoperative MRI demonstrating no residual tumor.

Fig. 4. Pre- and postoperative eyeball motion of the patient. A: Preoperative eyeball motion of the patient presenting right abducens nerve palsy. B: Postoperative eyeball motion presenting resolution of the palsy.

Fig. 5. Histologic findings of the tumor (H&E stain, ×100). A: Immature cartilage with high cellularity is seen. B: Primitive neuronal epithelial tissue and multilayered neural crest forming tissue are seen, suggesting immature teratoma.