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

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.