Advertisement

Bilateral Dilated Pupil in Dorsal Midbrain Syndrome

  • An-Guor Wang
Chapter

Abstract

A 19-year-old female presented with complaints of eyestrain and a self-reported abnormally dilated pupil for 1 month. She suffered from major depression managed with regular psychiatric visits. Her vision was 6/6 in both eyes. Intraocular pressures were normal. A pupil examination showed mild dilated pupils with vermiform movements bilaterally. She was diagnosed with bilateral Adie’s pupil and began 1% pilocarpine treatment. One month later, her pupils remained dilated with poor light reflexes. Pupil sizes were 5.5 mm OD and 5.0 mm OS and constricted to 5.0 mm OD and 4.5 mm OS 40 min after conducting a 0.1% pilocarpine test. Extraocular movements revealed limited upgaze in both eyes (Fig. 50.1). Her upgaze palsy was accompanied by convergent retraction nystagmus when she looked upward (Video 50.1). Neuroimaging studies were performed under the impression of dorsal midbrain syndrome. A CT scan revealed a soft tissue lesion over the pineal region (Fig. 50.2). An MRI showed a lesion that was isointense on T1-weighted and mildly hyperintense on T2-weighted images, which enhanced well after contrast injection (Fig. 50.3). She underwent a craniotomy at another hospital, and the pathological report revealed a germinoma.

Supplementary material

Video 50.1

(MOV 35,466 kb)

References

  1. 1.
    Penn A, MEM J, Nicholson JC. Germ cell tumours in children and adolescents. Paediatrics Child Health. 2014;24(4):148–54.CrossRefGoogle Scholar
  2. 2.
    Nagasawa DT, Lagman C, Sun M, Yew A, Chung LK, Lee SJ, Bui TT, Ooi YC, Robison RA, Zada G, Yang I. Pineal germ cell tumors: two cases with review of histopathologies and biomarkers. J Clin Neurosci. 2017;38:23–31.CrossRefPubMedGoogle Scholar
  3. 3.
    Hoffman HJ, Otsubo H, Hendrick EB, Humphreys RP, Drake JM, Becker LE, Greenberg M, Jenkin D. Intracranial germ-cell tumors in children. J Neurosurg. 1991;74(4):545–51.CrossRefPubMedGoogle Scholar
  4. 4.
    Wong AME. Eye movement disorders. New York: Oxford University Press; 2008. p. 140–1.Google Scholar
  5. 5.
    Shams PN, Bremner FD, Smith SE, Plant GT, Matthews TD. Unilateral light-near dissociation in lesions of the rostral midbrain. Arch Ophthalmol. 2010;128(11):1486–9.CrossRefPubMedCentralPubMedGoogle Scholar
  6. 6.
    Kilgore DP, Strother CM, Starshak RJ, Haughton VM. Pineal germinoma: MR imaging. Radiology. 1986;158(2):4358.CrossRefGoogle Scholar
  7. 7.
    Liang L, Korogi Y, Sugahara T, Ikushima I, Shigematsu Y, Okuda T, Takahashi M, Kochi M, Ushio Y. MRI of intracranial germ cell tumours. Neuroradiology. 2002;44(5):3828.CrossRefGoogle Scholar
  8. 8.
    Wolden SL, Wara WM, Larson DA, et al. Radiation therapy for primary intracranial germ-cell tumors. Int J Radiat Oncol Biol Phys. 1995;32:943–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Haas-Kogan DA, Missett BT, Wara WM, et al. Radiation therapy for intracranial germ cell tumors. Int J Radiat Oncol Biol Phys. 2003;56:511–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Jensen AW, Laack NN, Buckner JC, et al. Long-term follow-up of dose-adapted and reduced-field radiotherapy with or without chemotherapy for central nervous system germinoma. Int J Radiat Oncol Biol Phys. 2010;77:1449–56.CrossRefPubMedGoogle Scholar
  11. 11.
    Calaminus G, Bamberg M, Jurgens H, et al. Impact of surgery, chemotherapy and irradiation on long term outcome of intracranial malignant nongerminomatous germ cell tumors: results of the German Cooperative Trial MAKEI 89. Klin Padiatr. 2004;216:141–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Kochi M, Itoyama Y, Shiraishi S, et al. Successful treatment of intracranial nongerminomatous malignant germ cell tumors by administering neoadjuvant chemotherapy and radiotherapy before excision of residual tumors. J Neurosurg. 2003;99:106–14.CrossRefPubMedGoogle Scholar
  13. 13.
    Balmaceda C, Finlay J. Current advances in the diagnosis and management of intracranial germ cell tumors. Curr Neurol Neurosci Rep. 2004;4:253–62.CrossRefPubMedGoogle Scholar
  14. 14.
    Matsutani M, Sano K, Takakura K, et al. Primary intracranial germ cell tumors: a clinical analysis of 153 histologically verified cases. J Neurosurg. 1997;86:446–55.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2018

Authors and Affiliations

  • An-Guor Wang
    • 1
  1. 1.Department of OphthalmologyTaipei Veterans General Hospital, National Yang-Ming University School of Medicine, Yun-San Ophthalmology Education Research FoundationTaipeiTaiwan

Personalised recommendations