# Bilateral extramidline involvement in intracranial germinoma: diagnostic lessons from a complex presentation

## TL;DR

A rare case of intracranial germinoma with unusual bilateral brain involvement is described, emphasizing the importance of early diagnosis for effective treatment.

## Contribution

Highlights a rare presentation of intracranial germinoma with bilateral extramidline lesions and non-specific symptoms.

## Key findings

- The patient exhibited multifocal lesions in bilateral basal ganglia, fornices, and pineal region.
- Brain biopsy confirmed intracranial germinoma despite normal tumor markers and unremarkable cerebrospinal fluid studies.

## Abstract

A 25-year-old man presented with subacute progressive anxiety, cognitive deficits, hypernatremia, and left hemiparesis. Magnetic resonance imaging demonstrated multifocal lesions in bilateral basal ganglia (globus pallidus and putamen), fornices, pineal region, along with Wallerian degeneration of the right corticospinal tract with right brainstem atrophy. Serum B-hCG, alpha-fetoprotein, alkaline phosphatase, and placental alkaline phosphatase were normal. Cerebrospinal fluid studies were unremarkable. Brain biopsy revealed intracranial germinoma. The case herein presented highlights a rare presentation of an uncommon neuro-oncological condition that often demonstrates excellent treatment response but is often diagnosed late due to its non-specific presenting symptoms.