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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Teratomas&#44; a common form of non-germinomatous germ cell tumor&#44; are composed of multiple tissues foreign to the organ or site from which they arise with a histological representation of all three germ cell layers &#40;ectoderm&#44; mesoderm&#44; and endoderm&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> Teratomas commonly present during infancy and childhood with males being affected more often than females&#46; Teratomas account for 3&#37; of all pediatric tumors with the major site affected being the sacrococcygeal regions and the gonads&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> In this study&#44; we report three cases of intracranial teratomas with an interesting clinical course&#44; neuroradiology&#44; and outcome&#46; In addition&#44; we review the literature and convey important messages to the neuroscience community regarding issues related to the management of these rare tumors&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report 1 &#40;pineal gland teratoma&#41;</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 10-year-old male presented to our hospital with a 7-month history of headache&#44; vomiting&#44; and decreased vision in the left eye&#46; The course was progressive&#44; and a few days prior to seeking medical advice&#44; he experienced a decrease in the level of consciousness&#46; The patient was a product of a full term pregnancy and uncomplicated vaginal delivery&#46; At birth&#44; his Apgar score&#44; head circumference&#44; weight&#44; and fontanels were all normal&#46; His milestones were normal with no remarkable medical and surgical abnormalities&#46; He completed all scheduled vaccinations&#46; There was a family history of a brain tumor in the paternal grandmother&#46; CT of the brain &#40;without contrast&#41; revealed a mass in the pineal region measuring 1&#46;3<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1&#46;5<span class="elsevierStyleHsp" style=""></span>cm with calcification and possible fat components&#46; The ventricular system was prominent representing hydrocephalus mainly affecting the lateral and third ventricles &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Magnetic Resonance Imaging &#40;MRI&#41; of the brain was done&#44; which revealed a heterogeneous pineal region mass measuring 1&#46;4<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1&#46;3<span class="elsevierStyleHsp" style=""></span>cm with internal fat signal intensity and calcifications&#46; He was diagnosed with pineal region tumor with obstructive hydrocephalus&#46; Tumor markers in both serum and cerebrospinal fluid &#40;CSF&#41; were negative&#46; A right ventriculoperitoneal shunt was inserted with an improvement of both headache and vision&#46; He was discharged home and recommended to follow up and repeat the MRI in three months&#46; Unfortunately&#44; he missed his appointment&#44; and a few months later&#44; he was presented again to the hospital with a chronic headache that increased during the day with fatigue&#46; His overall performance at school was deteriorating with associated sleep disturbance&#46; He had a history of marked weight loss&#44; polyphagia&#44; morning sickness&#44; and vomiting with intermittent ptosis&#46; There was no history of seizures or weakness&#46; On examination during this admission&#44; fundus examination showed papilledema&#46; He was clinically fully conscious&#44; oriented&#44; with full extraocular movements and normal motor and gait examinations&#46; MRI of the brain showed interval increase in the size of the tumor measuring 5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>cm with extensive venous congestion and cerebellar swelling with no hydrocephalus observed &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; He was admitted for craniotomy and tumor debulking&#44; but the surgery was limited to bony decompression and duroplasty due to severe cerebellar engorgement&#44; which made it impossible to reach the pineal region using the supracerebellar infratentorial approach&#46; All measures to reduce tension during surgery did not help the engorgement&#44; which was related to venous compression of the deep veins by the tumor&#46; He recovered well postoperatively and treated with a course of steroid and Mannitol&#44; which made resection of the tumor by endoscopic third ventriculostomy achievable&#46; The pediatric oncology department was involved for follow-up and adjuvant radiotherapy&#46; He received six cycles of chemotherapy&#59; Ifosfamide and Etoposide &#40;VP-16&#41;&#46; He is still alive and receiving treatment&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case report 2 &#40;hemispheric cerebral teratoma&#41;</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 2-year-old male&#44; a case of cow milk allergy and Rickets&#44; presented to the emergency department with a 2-day history of vomiting associated with a decreased oral intake and progressive right eye squint for two weeks&#46; During the initial physical examination&#44; he was awake and alert with a Glasgow Coma Scale &#40;GCS&#41; of 15&#47;15 and was found to have bradycardia with a heart rate of 60&#8211;70 beats per minute&#46; The pupils were reacting briskly to light with mild abducens nerve palsy on the right side&#46; Computed Tomography &#40;CT&#41; of the brain revealed a left hemispheric mass with an internal area of calcification and hemorrhage &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; MRI showed that the mass measured 9&#46;9<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>7&#46;2<span class="elsevierStyleHsp" style=""></span>cm with extensions into the left side and posteriorly occupying the cranial-caudal diameter&#46; There was a significant mass effect and midline shift of around 1&#46;4<span class="elsevierStyleHsp" style=""></span>cm and hydrocephalus &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The patient developed vomiting and was electively intubated&#44; and an emergency mass excision was performed&#46; The mass was showing changes consistent with left hemispheric teratoma with an internal area of calcification and hemorrhage&#46; During surgery and while debulking the tumor&#44; the patient bled profusely which necessitated the administration of several blood units&#46; Unfortunately&#44; the patient developed cardiac arrest&#44; and cardiopulmonary resuscitation &#40;CPR&#41; was performed&#46; CPR continued for about one hour with no success&#46; The cardiac arrest and unsuccessful CPR were then found to be due to the increased potassium level up to 13&#46;8<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case report 3 &#40;posterior fossa teratoma&#41;</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 5-year-old male presented one year ago to a local hospital with a three months history of headache&#44; vomiting&#44; and irritability that was progressive in course&#46; One month prior to seeking medical advice&#44; he became obtunded and stopped responding to questions and verbal commands&#46; A CT scan was performed and revealed a cystic posterior fossa lesion &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; The patient was then urgently referred to our hospital&#46; He was a product of a full term pregnancy and uncomplicated vaginal delivery&#46; His Apgar score&#44; head circumference&#44; weight&#44; and fontanels at birth were all normal&#46; His milestones were normal until the time of presentation&#46; His medical&#44; surgical&#44; and family history were unremarkable&#44; and vaccinations were all up to date&#46; His vital signs were normal on examination in our emergency department&#46; His level of consciousness was altered&#44; but he was able to open his eyes spontaneously and obey simple commands&#46; His pupils were equal and reactive&#44; and extraocular muscle and gaze examination revealed paralysis of upward gaze&#46; The remaining cranial nerves&#44; motor functions&#44; and coordination were normal&#46; He was admitted to the pediatric intensive care unit&#44; and an emergency extraventricular drain was inserted&#46; On the 2nd day&#44; he developed a generalized tonic&#8211;clonic seizure before his surgery and was started on lorazepam and phenytoin therapy&#46; Three days later&#44; a suboccipital craniotomy and resection of the posterior fossa tumor were carried out with no complications&#46; Intraoperatively&#44; the tumor was found to be composed of a large loop of intestine with teeth and hair-like structures and was removed completely&#46; The pathology department diagnosed him as a case of mature posterior fossa teratoma&#46; Eight days later from his admission&#44; a ventriculoperitoneal shunt was inserted due to the hydrocephalus and high intracranial pressure on monitoring&#46; 6 weeks later&#44; in the outpatient department&#44; his parents reported no significant complaints&#44; and the neurological examination was normal&#46; The parents expressed their satisfaction regarding his progress and management plan&#46; One year later&#44; an MRI of the brain showed significant improvement of the communicating hydrocephalus with no evidence of tumor recurrence&#46; Six years later&#44; a brain CT was performed and showed significant improvement with no evidence of tumor recurrence &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Germ cell tumors are uncommon pediatric brain tumors accounting for 1&#8211;3&#37;&#44; but for unknown reasons&#44; they are more common in Japan and South East Asia &#40;around 10&#37;&#41;&#46; Although rare in infancy and adulthood&#44; teratomas are the commonest congenital brain tumors and also in the first two years of life&#46; They account for up to 50&#37; of fetal brain tumors&#44; 33&#37; of neonatal intracranial tumors&#44; and only 2&#8211;4&#37; of intracranial tumors in people less than 15 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Of all the germ cell tumors&#44; only the mature teratoma is considered to be benign&#46; Although intracranial teratomas may occur anywhere in the neuroaxis&#44; they are usually located in the midline region&#44; in or around the pineal gland&#44; third ventricular region&#44; and suprasellar region&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The presenting signs and symptoms of teratoma are variable and related to the size and localization of the tumor&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> Tumors in the pineal region typically present with signs of obstructive hydrocephalus as a result of increased intracranial pressure&#46; About 25&#8211;50&#37; of patients with pineal region tumors have ophthalmological abnormalities and somnolence and 25&#37; have ataxia&#44; seizures&#44; and behavioral changes&#46; Parinaud&#39;s syndrome &#40;vertical gaze palsy&#41; that is caused by involvement of the adjacent midbrain structures&#44; specifically the rostral interstitial nucleus of medial longitudinal fasciculus&#44; affects about 50&#37;&#46; Other less common manifestations include endocrinopathies and disturbances in the sexual development&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> Tumors of the suprasellar region typically present with hypothalamic&#47;pituitary axis dysfunction including diabetes insipidus&#44; delayed sexual development&#44; isolated growth hormone deficiency&#44; hypopituitarism&#44; and precocious puberty&#46; Other less common signs include ophthalmological abnormalities &#40;e&#46;g&#46; bilateral temporal hemianopsia due to compression of the optic chiasm&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnosis of intracranial teratomas is based on clinical signs and symptoms&#44; neuroimaging&#44; tumor markers&#44; CSF cytology&#44; and histological assessment&#46; Assay of serum and CSF for &#945;-fetoprotein and beta human chorionic gonadotropin are currently routine in the assessment of suspected teratoma prior to surgery and typically show an elevation of either oncoproteins&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> Both CT and MRI are sensitive in intracranial teratomas&#46; The CT or MRI features of teratomas in the intracranial cavity are non-specific&#44; but a diagnosis can be suspected if the lesion shows intratumoral cysts admixed with calcified regions&#44; heterogeneous density&#44; and foci of low-attenuation similar to fat&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> Although the tumors in our cases were located in the pineal gland&#44; posterior fossa&#44; and cerebral hemisphere&#44; other reported sites of origin include the hypothalamus&#44; ventricles&#44; cavernous sinus&#44; suprasellar region&#44; and cerebellum&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The management of teratomas usually depends on the histological findings from the biopsy&#46; Total surgical resection is considered the gold standard for the treatment of intracranial teratomas&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> Management of teratomas in the pineal glands includes ventriculoperitoneal shunts and endoscopic third ventriculostomy&#46; Performing endoscopic third ventriculostomy may be the treatment of choice of obstructive hydrocephalus&#44; and some experts would argue that endoscopic third ventriculostomy and biopsy should be performed as the initial management for a pineal mass&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> The follow-up period after resection may be as long as ten years due to a possible metachronous occurrence&#46; In addition&#44; a combination of chemotherapy and radiation therapy are often used&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> Mature teratoma is more resistant to chemotherapy and radiotherapy than any other germ cell tumor&#46; It is not unusual to operate in a &#8220;second look&#8221; surgery for a mature teratoma because residual tumor is frequent after chemotherapy and radiotherapy&#46; The prognosis is dependent on location&#44; size&#44; and surgical experience&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="par0045" class="elsevierStylePara elsevierViewall">The present cases in our series are interesting examples of intracranial teratoma in terms of location of the tumor and neuroimaging findings&#46; Total surgical resection is the treatment of choice for intracranial teratomas&#46; However&#44; preoperative&#44; intraoperative&#44; and postoperative medical care and good preparation for surgery are of paramount importance&#46; This includes acid&#8211;base balance&#44; electrolyte disturbances&#44; and preparation for an unexpected large amount of blood loss&#46; Surgical experience is a prerequisite for a good clinical outcome&#46; Delay in surgical intervention may complicate the course of the disease with progressive enlargement of tumors and development of complication including hydrocephalus&#46; Using endoscopic surgical techniques may emerge as the preferred intervention option as compared to other traditional methods&#46; We recommend the establishment of a national and international registry for intracranial tumors&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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            0 => array:2 [
              "identificador" => "sec0010"
              "titulo" => "Case report 1 &#40;pineal gland teratoma&#41;"
            ]
            1 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Case report 2 &#40;hemispheric cerebral teratoma&#41;"
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            2 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Case report 3 &#40;posterior fossa teratoma&#41;"
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        5 => array:2 [
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          "titulo" => "Discussion"
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        6 => array:2 [
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          "titulo" => "Conclusion"
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    "fechaRecibido" => "2017-02-07"
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            0 => "Teratoma"
            1 => "Germ cell tumor"
            2 => "Brain tumor"
            3 => "Pineal gland"
            4 => "Cerebral hemisphere"
            5 => "Posterior fossa"
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            0 => "Teratoma"
            1 => "Tumor de c&#233;lulas germinales"
            2 => "Tumor cerebral"
            3 => "Gl&#225;ndula pineal"
            4 => "Hemisferio cerebral"
            5 => "Fosa posterior"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Teratoma is a common form of germ cell tumors composed of multiple tissues foreign to the site in which arise with a histological representation of all three germ cell layers&#46; Intracranial teratomas are very rare&#46; In this study&#44; we report three cases of intracranial teratomas with an interesting clinical course&#44; neuroradiology&#44; and outcome&#46; In addition&#44; we review the literature and convey important messages to the neuroscience community regarding issues related to the management of these rare tumors&#46; The present cases are interesting examples of intracranial teratoma in terms of location of the tumor and neuroimaging findings&#46; Delay in surgical intervention may complicate the course of the disease with progressive enlargement of tumors and development of complication including hydrocephalus&#46; Using endoscopic surgical techniques may emerge as the preferred intervention option as compared to other traditional methods&#46; We recommend the establishment of a national and international registry for intracranial tumors&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El teratoma es un tipo frecuente de tumor de c&#233;lulas germinales compuesto por m&#250;ltiples tejidos ajenos a la zona en que aparecen con una representaci&#243;n histol&#243;gica de las 3 capas de c&#233;lulas germinales&#46; Los teratomas intracraneales son muy poco frecuentes&#46; En este estudio&#44; se presentan 3 casos de teratomas intracraneales con una evoluci&#243;n cl&#237;nica&#44; neurorradiolog&#237;a y resultado interesantes&#46; Adem&#225;s&#44; se revisa la bibliograf&#237;a y se difunde un mensaje importante a la comunidad de las neurociencias respecto a los problemas relacionados con el tratamiento de estos tumores raros&#46; Estos casos son ejemplos interesantes de teratoma intracraneal en t&#233;rminos de localizaci&#243;n de los hallazgos tumorales y de neuroimagen&#46; El retraso en la intervenci&#243;n quir&#250;rgica puede complicar la evoluci&#243;n de la enfermedad con la ampliaci&#243;n progresiva de los tumores y el desarrollo de complicaciones&#44; especialmente hidrocefalia&#46; El uso de t&#233;cnicas quir&#250;rgicas endosc&#243;picas aparece como la opci&#243;n de intervenci&#243;n preferida en comparaci&#243;n con otros m&#233;todos tradicionales&#46; Se recomienda el establecimiento de un registro nacional e internacional de tumores intracraneales&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CT of the brain &#40;without contrast&#41; showing a mass in the pineal region measuring 1&#46;3<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>1&#46;5<span class="elsevierStyleHsp" style=""></span>cm with calcification and possible fat components&#46; The ventricular system is prominent representing hydrocephalus mainly affecting the lateral and third ventricles&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Axial and sagittal MRI of the brain showing a large supratentorial pineal area heterogeneous lesion measuring 4&#46;2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3&#46;1<span class="elsevierStyleHsp" style=""></span>cm that demonstrates cystic and solid components&#46; This lesion is causing a mass effect on the midbrain&#44; especially on the tectum with evidence of narrowing of the cerebral aqueduct&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">CT scan of the brain showing a cystic posterior fossa lesion causing acute hydrocephalus preoperatively &#40;the upper raw&#41; and significant improvement with no evidence of tumor recurrence six years postoperatively &#40;the lower raw&#41;&#46;</p>"
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                      "titulo" => "Alphafetoprotein and human chorionic gonadotropin determination in cerebrospinal fluid&#46; An aid to the diagnosis and management of intracranial germ-cell tumors"
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                          "etal" => false
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Case Report
Teratoma of the nervous system: A case series
Teratoma del sistema nervioso: serie de casos
Hussein Algahtania,
Autor para correspondencia
halgahtani@hotmail.com

Corresponding author.
, Bader Shirahb, Ahad Abdullahc, Abdulrahman Bazaidc
a King Abdulaziz Medical City/King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
b King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
c Batterjee Medical College, Jeddah, Saudi Arabia

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