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Ganglioglioma of the Pineal Gland: Clinical and Radiographic Response to Stereotactic Radiosurgical Ablation

Case Report This 10-year-old, right-handed male third grader presented with a 3month history of behavioral changes followed by abulia, &dquo;dizziness,&dquo; ataxia, and urinary incontinence. His apathy and inactivity were initially attributed to a grief reaction after the death of a great-grandfather. However, a week before admission, his ataxia worsened, impairing safe ambulation. He had urinary incontinence for 1 to 2 days before admission. He did not complain of headache or double vision. His medical history was otherwise noncontributory. On examination, he was afebrile and normotensive. Abnormal findings were confined to the neurologic examination. He was inattentive, with flat affect and no spontaneous movements. Although disoriented to date and place, memory was intact. The cranial nerve examination revealed swollen optic discs. His color vision was significantly impaired bilaterally, and he had no stereopsis (by Titmus test). Confrontation fields showed a generalized constriction bilaterally, worse nasally. Regarding ocular motility, he was orthotropic but had impaired pursuit bilaterally. He had normal horizontal and vertical saccades, with no impairment of upgaze. Convergence was present but a little slow. His pupils reacted briskly to light. There was a limited upward gaze, and gaze evoked nystagmus in all directions. Cerebellar signs revealed severe axial ataxia with a positive Romberg sign. The sensory examination was indeterminate. There was no corticospinal tract deficit. Visual acuity, without correction, was 9/200 and 6/200, there was no improvement with pinhole, and his near vision was worse than J14 OU. Analysis of the cerebrospinal fluid revealed no cells or elevations in a-fetoprotein, #-human choriogonadotropin, chorioembryonic antigen, the lactate dehydrogenase 5 isoenzyme, or placental alkaline phosphatase. Neurodiagnostic imaging demonstrated a 2.7-cm mass in the