- Division of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, R. O. C.
- Department of Pathology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, R. O. C.
Division of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, R. O. C.
DOI:10.4103/2152-7806.134815Copyright: © 2014 Yip C This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Yip C, Tseng H, Hsu S, Liao W, Chen J, Chen C, Chang C. Dyspnea and choking as presenting symptoms in primary medulla oblongata germinoma. Surg Neurol Int 19-Jun-2014;5:
How to cite this URL: Yip C, Tseng H, Hsu S, Liao W, Chen J, Chen C, Chang C. Dyspnea and choking as presenting symptoms in primary medulla oblongata germinoma. Surg Neurol Int 19-Jun-2014;5:. Available from: http://sni.wpengine.com/surgicalint_articles/dyspnea-and-choking-as-presenting-symptoms-in-primary-medulla-oblongata-germinoma/
Background:The medulla oblongata is the lower half of the brainstem. It contains the cardiac, respiratory, vomiting, and vasomotor centers and deals with autonomic functions such as breathing, heartbeat, and blood pressure. Primary medulla oblongata germinoma is very rare and less than 20 cases have been reported in the English literature.
Case Description:A 22-year-old female without any particular past medical history presented to us in October 2012 with the chief complaint of dyspnea and frequent choking for 1 month. Neurological examination revealed lower cranial nerve palsies and nystagmus. Her brain computed tomography (CT) and brain magnetic resonance imaging (MRI) demonstrated a mass lesion at the dorsal surface of medulla oblongata with extension into the inferior fourth ventricle and foramen magnum. She underwent bilateral suboccipital craniotomy and C1 laminoplasty with the grossly total resection of the tumor. The histological examination of the tumor proved germinoma. Postoperative adjuvant radiotherapy was arranged. The latest brain MRI and whole spine MRI done 1 year after surgery showed neither residual nor recurrent tumor in the whole axis. She is regularly followed-up at our outpatient department and is doing well except having left vocal cord palsy, which occurred before surgery.
Conclusion:Medulloblastoma, ependymoma, glioma, hemangioblastoma, and cavernous angioma are common intraaxial tumors in the medulla oblongata and fourth ventricle. Intracranial germ cell tumors originate from extragonadal seminal cells and have been found in 0.4-3.4% of patients with primary central nervous system (CNS) tumors in Western countries, while the incidence is reported to be 5-8 times greater in Japan and the Far East. Although germinoma of medulla oblongata is rare and difficult to diagnose preoperatively, it should be included in the differential diagnosis of medulla masses with fourth ventricle extension, especially in Asian population.
Keywords: Fourth ventricle, germinoma, medulla oblongata
Germ cell tumor is a neoplasm of germinal origin. It occurs in the gonads and extra-gonadal sites such as sacrococcygeum, retroperitoneum, mediastinum, intracranial, and rarely in nasopharynx and orbit.[
A 22-year-old female without any particular past medical history presented to us in October 2012 with the chief complaint of dyspnea and frequent choking for 1 month. Traced back her clinical course, she had suffered from suboccipital pain, dizziness, and blurred vision for 6 months; about 2 months prior to the visit, she experienced dysarthria and intermittent swallowing disturbance. On admission, she was clear and ill-looking. Her neurological examination revealed left vocal cord palsy, weak gag reflex, tongue fasciculation, and horizontal nystagmus in the right side gaze. She had neither motor nor sensory disorder of her extremities and her Babinski's sign was negative on both sides. Magnetic resonance imaging (MRI) of brain was performed, which demonstrated a mass lesion about 3.2 × 3 × 2.6 cm in size located in the inferior fourth ventricle with extension to foramen magnum, causing mild dilatation of fourth ventricle. This tumor showed heterogeneous enhancement with several foci of cystic change in postgadolinium enhancement study [
Preoperative brain MRI. T1-weighted postcontrast image, sagittal (a), axial (b), coronal (c) views revealed a heterogeneous enhancing mass lesion with several foci of cystic change over inferior fourth ventricle, about 3.2 × 3 × 2.6 cm, and extension to foramen magnum, causing mild dilatation of fourth ventricle
Under general anesthesia, she was put in prone position and underwent a bilateral suboccipital craniotomy and C1 laminoplasty with the removal of the tumor. A midline longitudinal incision was made from external occipital proturbance to the spinal process of C2, then a Y shape incision was made on the exposed dura of cerebellum and upper cervical spinal cord. Reflected the dural flaps to expose the cerebellar hemisphere and upper cervical cord. After the arachnoid membrane was opened and the cerebrospinal fluid (CSF) was drained, bilateral tonsils and the superficial part of the tumor was exposed. Grossly, the tumor was soft and gray-red [
She is doing well except having left vocal cord palsy, which occurred before surgery. Her dyspnea and choking were much resolved after the operation. The latest brain and whole spine MRI done 12 months after the surgery showed no abnormal enhancing tumor in the whole axis [
The medulla oblongata is the lower half of the brainstem. It contains the cardiac, respiratory, vomiting, and vasomotor centers and deals with autonomic functions such as breathing, heartbeat, and blood pressure. Surgery on this vital area remains a challenge to most neurosurgeons. Medulloblastoma, ependymoma, glioma, hemangioblastoma, and cavernous angioma are common intraaxial tumors in the medulla oblongata and fourth ventricle.[
Intracranial germ cell tumors originate from extragonadal seminal cells and frequently arise in the midline brain structures, such as pineal and suprasellar regions, floor of the third ventricle; they also happen in the basal ganglia and thalamus.[
To the best of our knowledge, from 1991 to 2013, there were 17 cases of pure primary medulla oblongata fourth ventricle germinoma, which have been reported in the English literature.[
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