LAUSR

A 28-year-old woman presented with generalized tonic– clonic seizures of 8 months duration. Gadolinium-enhanced MRI of brain revealed multiple, parenchymal ring enhancing lesions suggestive of neurocysticercosis. The suprasellar and third ventricular region was normal (Fig. 1A). She was started on anti-epileptics and albendazole. Six months later, she developed painless progressive visual loss with behavioral changes. A repeat MRI brain showed a new T1 hypointense, T2 iso-hyperintense, heterogenously enhancing lesion in the third ventricle which was not present in the earlier scan (Fig. 1B-F). In view of progressive visual loss, she was operated upon and gross total excision of tumor was achieved. Intra-operatively the lesionwas grayish-white, mildly vascular with variegated consistency. Postoperatively, her vision improved. Histopathological study showed mixed germ cell tumor (MGCT) which stained positive for placental alkaline phosphatase (PLAP), negative for α-fetoprotein (AFP) and β-human chorionic gonadotropin (β-HCG). Cerebrospinal fluid (CSF) cytology performed was negative for malignant cells. Serum AFP and β-HCG levels measured were normal. MRI screening of craniospinal axis showed no evidence of disseminated disease. The patient underwent adjuvant chemoradiotherapy (CRT) (36 Gy in 20 fractions with six cycles of three weekly Cisplatin-based chemotherapy). Post-treatment, she was followed up with periodic assessment of serum AFP and β-HCG levels along with brain imaging. About 5 months after CRT, serial serum AFP levels showed a rising trend. A new MRI of the brain revealed no recurrent lesion. However, in view of elevated AFP levels, she was planned for spinal MRI to rule out metastatic disease. In the meantime, she presented with low backache and rapidly progressive paraparesis. Gadoliniumenhanced MRI of spine demonstrated a mildly enhancing intradural extramedullary lesion at D12-L1 level with cord compression. Unfortunately she succumbed soon after initiation of radiotherapy.