Central Hypoventilation Syndrome in Posterior Circulation Stroke Treated by Respiratory Rehabilitation: a Case Report

Central hypoventilation syndrome is a rare and fatal condition resulting from various central nervous system disorders that is characterized by a failure of automatic breathing. We report a case of central hypoventilation syndrome following posterior circulation stroke whose pulmonary function was improved by respiratory rehabilitation. A 59-year-old woman with a history of hemorrhagic stroke of the bilateral cerebellum was hospitalized due to pneumonia. A portable ventilator was applied via tracheostomy, recurrent episodes of apnea and hypercapnia impeded weaning. A respiratory rehabilitation program including chest wall range of motion exercise, air stacking exercise, neuromuscular electrical stimulation (NMES) on abdominal muscles, upper extremity ergometer, locomotor training, high-frequency chest wall oscillator, mechanical insufflation, and exsufflation was employed, as spirometry showed a severe restrictive pattern. A spontaneous breathing trial was started, and a portable ventilator was applied for 8 hours, only during nighttime, to prevent sudden apneic event. After 4 weeks of treatment, follow-up spirometry showed much improved respiratory parameters. This case suggests that respiratory rehabilitation can improve pulmonary function parameters and quality of life in central hypoventilation syndrome.

Hemorragia cerebelosa a distancia. Presentación de un caso y revisión bibliográfica / Cerebellar hemorrhage a distance. Presentation of a Case and literature review

La hemorragia cerebelosa a distancia y, en su principal forma de presentación, los hematomas cerebelosos remotos constituyen una complicación poco frecuente de las cirugías que involucran el sistema nervioso central y la columna vertebral. Algunas publicaciones estiman su frecuencia entre el 0,2 y el 4,9%. Este porcentaje quizás esté subestimado, debido, por una parte, al gran abanico de manifestaciones clínicas que incluyen los casos asintomáticos y, por otra parte, al desconocimiento de esta inusual patología. Su fisiopatología no ha sido del todo definida; sin embargo, la teoría con más fuerza involucra el papel preponderante de la pérdida de líquido cefalorraquídeo durante el acto quirúrgico. La sintomatología puede incluir cefalea, síntomas cerebelosos y alteración del estado de conciencia. El tratamiento de los hematomas cerebelosos remotos debe ser acorde a la magnitud del sangrado y a las complicaciones asociadas. El pronóstico, en general, es bueno. Aproximadamente una tercera parte de los pacientes no tiene secuelas permanentes y la tasa de mortalidad es de alrededor 12%.(AU)

Remote cerebellar hemorrhage constitutes a rare complication of surgeries involving the central nervous system and the spine. Some publications estimate its frequency between 0.2% and 4.9%. This percentage may be underestimated, due, on the one hand, to the wide range of clinical manifestations that include asymptomatic cases and, on the other hand, to the unknown of this unusual pathology. Its pathophysiology has not been completely defined; however, the main theory involves the predominant role of cerebrospinal fluid loss during surgery. Symptoms may include headache, cerebellar symptoms and altered state of consciousness. Treatment of remote cerebellar hematomas should be commensurate with the magnitude of bleeding and the associated complications. Prognosis, in general, is good. Approximately one third of patients do not have permanent sequelae and mortality rate is around 12%.(AU)

Neuroendoscopic hematoma evacuation in patients with hypertensive cerebellar hemorrhage / 中国神经精神疾病杂志

Objective The aim of our study was to examine the clinical value of neuroendoscopic surgery in hypertensive cerebellar hemorrhage.Methods The clinical data from 38 patients with cerebellar hemorrhage were retrospectively analyzed.Thirty-eight patients included 18 cases with neuroendoscopic hematoma evacuation (neuroendoscopic group) and 20 cases with craniotomy hematoma evacuation (craniotomy group).The perioperative parameters and clinical outcome were statistically analyzed.Results Compared with craniotomy group,the mean operative time was shorter [(82.9±17.0)min vs.(177.9±28.8)min,t=12.545,P=0.000],the loss of mean blood volume was smaller [(45.1±15.6)mL vs.(197.9±29.5)mL,t=20.237,P=0.000]ml,ventricle drainage time [(3.5±1.5)d vs.(5.3±1.4)d,t=3.751,P=0.001],ICU stay time [(2.9±1.0)d vs.(4.7±1.5)d,t=4.146,P=0.000] and hospital stay time [(7.4±1.5)d vs.(9.9±2.8)d,t=3.348,P=0.002] were shorter (P＜0.05).Two weeks after surgery,1 cases died in neuroendoscopic group and 2 cases died in craniotomy group (P=1.000,P＞0.05).Three months after surgery,GOSE was greater than 4 in 14 cases in neuroendoscopic group and in 13 cases in craniotomy group and the difference was not significant (2=0.752,P=0.386,P＞0.05).Conclusion Although there are no differences in mortality and clinical outcomes between neuroendoscopic hematoma evacuation and occipital craniotomy hematoma evacuation for hypertensive cerebellar hemorrhage patients,neuroendoscopic hematoma evacuation can significantly reduce the mean operative time,the loss of mean blood volume,ventricle drainage time,ICU stay time and hospital stay time.Thus,neuroendoscopic hematoma evacuation in hypertensive cerebellar hemorrhage is safe and effective,which has a great value of application in the future.

Neuroendoscopic hematoma evacuation in patients with hypertensive cerebellar hemorrhage / 中国神经精神疾病杂志

Objective The aim of our study was to examine the clinical value of neuroendoscopic surgery in hypertensive cerebellar hemorrhage.Methods The clinical data from 38 patients with cerebellar hemorrhage were retrospectively analyzed.Thirty-eight patients included 18 cases with neuroendoscopic hematoma evacuation (neuroendoscopic group) and 20 cases with craniotomy hematoma evacuation (craniotomy group).The perioperative parameters and clinical outcome were statistically analyzed.Results Compared with craniotomy group,the mean operative time was shorter [(82.9±17.0)min vs.(177.9±28.8)min,t=12.545,P=0.000],the loss of mean blood volume was smaller [(45.1±15.6)mL vs.(197.9±29.5)mL,t=20.237,P=0.000]ml,ventricle drainage time [(3.5±1.5)d vs.(5.3±1.4)d,t=3.751,P=0.001],ICU stay time [(2.9±1.0)d vs.(4.7±1.5)d,t=4.146,P=0.000] and hospital stay time [(7.4±1.5)d vs.(9.9±2.8)d,t=3.348,P=0.002] were shorter (P＜0.05).Two weeks after surgery,1 cases died in neuroendoscopic group and 2 cases died in craniotomy group (P=1.000,P＞0.05).Three months after surgery,GOSE was greater than 4 in 14 cases in neuroendoscopic group and in 13 cases in craniotomy group and the difference was not significant (2=0.752,P=0.386,P＞0.05).Conclusion Although there are no differences in mortality and clinical outcomes between neuroendoscopic hematoma evacuation and occipital craniotomy hematoma evacuation for hypertensive cerebellar hemorrhage patients,neuroendoscopic hematoma evacuation can significantly reduce the mean operative time,the loss of mean blood volume,ventricle drainage time,ICU stay time and hospital stay time.Thus,neuroendoscopic hematoma evacuation in hypertensive cerebellar hemorrhage is safe and effective,which has a great value of application in the future.

Cerebellar Hemorrhage due to a Direct Carotid–Cavernous Fistula after Surgery for Maxillary Cancer

Infratentorial cerebral hemorrhage due to a direct carotid–cavernous fistula (CCF) is very rare. To our knowledge, only four such cases have been reported. Cerebellar hemorrhage due to a direct CCF has not been reported. We describe a 63-year-old female who presented with reduced consciousness 3 days after undergoing a maxillectomy for maxillary cancer. Computed tomography showed a cerebellar hemorrhage. Magnetic resonance angiography showed a left-sided direct CCF draining into the left petrosal and cerebellar veins through the left superior petrosal sinus (SPS). Her previous surgery had sacrificed the pterygoid plexus and facial vein. Increased blood flow and reduced drainage could have led to increased venous pressure in infratentorial veins, including the petrosal and cerebellar veins. The cavernous sinus has several drainage routes, but the SPS is one of the most important routes for infratentorial venous drainage. Stenosis or absence of the posterior segment of the SPS can also result in increased pressure in the cerebellar and pontine veins. We emphasize that a direct CCF with cortical venous reflux should be precisely evaluated to determine the hemodynamic status and venous drainage from the cavernous sinus.

Remote Cerebellar Hemorrhage due to Cerebrospinal Fluid Leakage or Meningitis after Spinal Surgery: Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a rare case of remote cerebellar hemorrhage (RCH) as a complication of spinal surgery. SUMMARY OF LITERATURE REVIEW: Remote cerebellar hemorrhage is rare but lethal as a complication of spinal surgery. Interestingly, dural tears and cerebrospinal fluid (CSF) leakage are reported in all published cases of RCH. MATERIALS AND METHODS: A 67-year-old man had posterior lumbar decompression and posterolateral fusion for spinal stenosis at L4/5/S1. Intraoperatively, the dura was torn and there was a loss of CSF. The dural tear was sutured immediately in a water-tight manner. After surgery, the patient complained of headache and dizziness. On postoperative day 44, brain magnetic resonance imaging (MRI) showed meningeal enhancement suggesting meningitis. On postoperative day 54, brain computed tomography (CT) showed cerebellar edema and hemorrhage, and external ventricular derivation was performed. RESULTS: The patient died. CONCLUSIONS: Special attention should be paid to prevent dural damage during spinal surgery or minimize CSF leakage in the case of dural damage and tears during spinal surgery, and CT and MRI should be promptly performed for symptomatic patients.

Infrequent Hemorrhagic Complications Following Surgical Drainage of Chronic Subdural Hematomas

Chronic subdural hematomas mainly occur amongst elderly people and usually develop after minor head injuries. In younger patients, subdural collections may be related to hypertension, coagulopathies, vascular abnormalities, and substance abuse. Different techniques can be used for the surgical treatment of symptomatic chronic subdural hematomas : single or double burr-hole evacuation, with or without subdural drainage, twist-drill craniostomies and classical craniotomies. Failure of the brain to re-expand, pneumocephalus, incomplete evacuation, and recurrence of the fluid collection are common complications following these procedures. Acute subdural hematomas may also occur. Rarely reported hemorrhagic complications include subarachnoid, intracerebral, intraventricular, and remote cerebellar hemorrhages. The causes of such uncommon complications are difficult to explain and remain poorly understood. Overdrainage and intracranial hypotension, rapid brain decompression and shift of the intracranial contents, cerebrospinal fluid loss, vascular dysregulation and impairment of venous outflow are the main mechanisms discussed in the literature. In this article we report three cases of different post-operative intracranial bleeding and review the related literature.

Cerebellar Hemorrhage after Posterior Lumbar Decompression and Interbody Fusion Complicated by Dural Tear: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: To report a rare case of remote cerebellar hemorrhage (RCH), which was a complication after posterior decompression and lumbar interbody fusion (PILF). SUMMARY OF LITERATURE REVIEW: Remote cerebellar hemorrhage (RCH) after spinal surgery is a rare complication, and its cause is known to be due to a loss of cerebral spinal fluid (CSF) through the dural tear. Most of the literature has disclosed that early diagnosis and treatment of RCH is very important in the patient with suspicious symptoms. MATERIALS AND METHODS: A 57-year-old woman had posterior lumbar decompression and interbody fusion for the severe spinal stenosis at L4-5. During surgery, an accidental dural tear with CSF leakage occurred. The torn dura was sutured. Postoperatively, she developed nausea and a severe headache. Hypotension developed at postoperative 2 hours. A brain CT showed RCH. The patient was conservatively managed with clamping of the wound drainage. RESULTS: The nausea and severe headache were controlled and normal blood pressure could be maintained without dopamine therapy at postoperative day 2. The patient was discharged without any neurological deficit, and her consciousness was clear at postoperative 2 weeks. CONCLUSIONS: Persistent postoperative nausea, headache, and hypotension after repair of the torn dura may suggest that the treating surgeons pay careful attention due to the possibility of RCH, even though the amount of CSF leakage is small.

Protection of the superior petrosal vein in microneurosurgery for acoustic neuroma / 中南大学学报(医学版)

Objective:To explore the clinical signiifcance of the protection of superior petrosal vein (SPV) in the microneurosurgery for acoustic neuroma. Methods:From January 2009 to July 2011, 149 cases of acoustic neuroma microsurgery were observed. hTe difference in hematoma in surgical area, cerebellar hematoma and cerebellar edema were compared between a SPV without protection group (SPVWP group, n=8) and a SPV protection group (SPVP group, n=141). Results:In the 149 patients with acoustic neuroma, the SPV was reserved in 141 patients. In the SPVWP group (8 patients), hematoma in the surgery area occurred in 4 patients, cerebellar edema in 5, and cerebellar hemorrhage in 3. In the SPVP group (141 patients), hematoma in the surgery area occurred in 40 patients, cerebellar edema in 56, and cerebellar hemorrhage in 12. hTere was signiifcant difference in the incidence of cerebellar hemorrhage (χ2=3.84, P=0.05), no signiifcant difference in the incidence of hematoma in the surgical area (χ2=0.646, respectively, P=0.422), and no significant difference in the incidence of cerebellar edema (χ2=0.611, P=0.434) between the SPVWP group and the SPVP group. Conclusion:In acoustic neuroma surgery, the SPV should be protected, which may reduce the risk of cerebellar hemorrhage.

The Clinical Characteristics and the Neurodevelopmental Outcomes of the Neonates with Cerebellar Hemorrhage

PURPOSE: We present our experience of 14 neonates with cerebellar hemorrhage and describe the clinical characteristics and the neurodevelopmental outcomes. METHODS: Fourteen neonates were identified as having cerebellar hemorrhage, based on the brain MRI findings at the two university hospitals from January 2007 to July 2011. Twelve preterm infants with the brain MRI taken before the discharge, and 2 term infants having taken the brain MRI with birth asphyxia were enrolled. The electronic medical records of the infants were reviewed. RESULTS: Ten (71.4%) infants were found to have multifocal or lobar cerebellar hemorrhage involving both hemispheres. Three infants had unilateral lesions in the right hemisphere, and one infant had a left hemisphere lesion. Six infants (42%) had co-existing high grade IVH (> or =grade III); 6 infants (42%) had periventricular leukomalacia (PVL); and 6 infants (42%) had posthemorrhagic hydrocephalus (PHH). After discharge, 12 infants (85.7%) were followed at the outpatient clinics for at least 6 months. Two out of 9 infants (22.2%) with other neurological co-morbidities (IVH> or =grade III, PVL, or PHH) had cerebral palsy, and 5 infants (55.6%) had developmental delay assessed by the Bayley scales. None of the infants without other neurological co-morbidities had cerebral palsy or developmental delay. CONCLUSION: Neonatal cerebellar hemorrhage is often diagnosed incidentally on the brain MRI in the preterm infants. If there is no concomitant high-grade IVH, PVL or PHH, cerebellar hemorrhage seems to hardly accompany its own specific symptoms, and the neurodevelopmental outcomes seem to be favorable as well. However, further long-term, large scale studies are necessary.

Remote Cerebellar Hemorrhage after Intradural Disc Surgery

We report a rare case of remote cerebellar hemorrhage after intradural disc surgery at the L1-2 level. Two days after the spine surgery, patient complained unexpected headache, dizziness, nausea and vomiting. From the urgently conducted brain CT, it was reported that the patient had cerebellar hemorrhage. Occipital craniotomy and hematoma evacuation was performed, and hemorrhagic lesion on the right cerebellum was effectively removed. After occipital craniotomy, the patient showed signs of improvement on headache, dizziness, nausea and vomiting. He was able to leave the hospital after two weeks of initial operation without any neurological deficit. Remote cerebellar hemorrhage following spinal surgery is extremely rare, but may occur from dural damage of spinal surgery, accompanied with cerebrospinal fluid leakage. Early diagnosis is particularly important for the optimal treatment of remote cerebellar hemorrhage.

Stereotactic Burr Hole Aspiration Surgery for Spontaneous Hypertensive Cerebellar Hemorrhage

OBJECTIVE: Patients with severe spontaneous cerebellar hemorrhage typically undergo treatment with suboccipital craniectomy and hematoma evacuation. However, this is a stressful procedure for patients due to the long operating time and operation-induced tissue damage. In addition, the durotomy can result in pseudomeningocele. We investigated the efficacy of stereotactic or navigation-guided burr hole aspiration surgery as a treatment for spontaneous hypertensive cerebellar hemorrhage (SHCH). METHODS: Between January 2002 and December 2011, 26 patients with SHCH underwent surgery using the stereotactic or navigation-guided burr hole aspiration and catheter insertion technique in our institution. RESULTS: Mean hematoma volume was 21.8 +/- 5.8 cc at admission and 13.1 +/- 5.4 cc immediately following surgery. Preoperative Glasgow Coma Scale (GCS) score was 12.5 +/- 1.3 and postoperative GCS score was 13.1 +/- 1.2. Seven days after surgery, the mean hematoma volume was 4.3 +/- 5.6 cc, and there was no occurrence of surgery-related complications during the six-month follow-up period. The mean operation time for catheter insertion was 43.1 +/- 8.9 min, and a mean 31.3 +/- 6.0 min was also added for extra-ventricular drainage. The mean Glasgow Outcome Scale (GOS) score after six months was 4.6 +/- 1.0. CONCLUSION: Stereotactic burr hole aspiration surgery for treatment of SHCH is less time-consuming and invasive than other interventions, and resulted in no surgery-related complications. Therefore, we suggest that this surgical method could be a safe and effective treatment option for selected patients with SHCH.

Smart Equitest Balance Master Training for Severe Balance Disorder Caused by Cerebellar Hemorrhage in Children: A Case Report / 中国康复理论与实践

@#ObjectiveTo study the effects and feasibility of Smart Equitest Balance Master training for severe balance disorder caused by cerebellar hemorrhage in children. MethodsA 10-year-old boy with severe ataxia caused by cerebellar hemorrhage were trained with Smart Equitest Balance Master. He was assessed with Smart Equitest Balance Master, Modified Barthel Index and Berg Balance Scale. ResultsAfter 22 weeks of balance training, he improved in equilibrium, gait, posture control, activity of daily living, dysarthria, and return to school to continue his study. ConclusionSmart Equitest Balance Master training can significantly improve balance function，motor function and activities of daily living after cerebellar hemorrhage.

Smart Equitest Balance Master Training for Severe Balance Disorder Caused by Cerebellar Hemorrhage in Children: A Case Report / 中国康复理论与实践

@#ObjectiveTo study the effects and feasibility of Smart Equitest Balance Master training for severe balance disorder caused by cerebellar hemorrhage in children. MethodsA 10-year-old boy with severe ataxia caused by cerebellar hemorrhage were trained with Smart Equitest Balance Master. He was assessed with Smart Equitest Balance Master, Modified Barthel Index and Berg Balance Scale. ResultsAfter 22 weeks of balance training, he improved in equilibrium, gait, posture control, activity of daily living, dysarthria, and return to school to continue his study. ConclusionSmart Equitest Balance Master training can significantly improve balance function，motor function and activities of daily living after cerebellar hemorrhage.

Fulminant neurogenic pulmonary edema developed after spontaneous cerebellar hemorrhage: A case report

Neurogenic pulmonary edema (NPE) was first reported in the literature in 1874. NPE has been described following head injury, subarachnoid hemorrhage (SAH), intracerebral hemorrhage, seizures, brain stem tumor and cervical spinal cord injury. According to the reports in the literature since 1990, the most frequent underlying factor for NPE has been subarachnoid hemorrhage and aneurysm rupture is following. The incidence of NPE was reported to be 6% in a series of 457 patients with SAH. We present here a case of NPE arising from cerebellar hemorrhage, which is a very rare cause of NPE.

Cerebellar hemorrhage after spine fixation misdiagnosed as a complication of narcotics use: A case report / 대한마취과학회지

Cerebellar hemorrhage occurs mainly due to hypertension. Postoperative cerebellar hemorrhage is known to be associated frequently with frontotemporal craniotomy, but quite rare with spine operation. A 56-year-old female received spinal fixation due to continuous leg tingling sensation for since two years ago. Twenty-one hours after operation, she was disoriented and unresponsive to voice. Performed computed tomography showed both cerebellar hemorrhage. An emergency decompressive craniotomy was carried out to remove the hematoma. On the basis of this case, we reported this complications and reviewed related literature.

Remote Cerebellar Hemorrhage after Lumbar Spinal Surgery

Remote cerebellar hemorrhage (RCH) is rare but potentially lethal as a complication of spinal surgery. We recently experienced a case of RCH in a 61-year-old man who showed mental deterioration after lumbar spinal surgery. There was dural tearing with subsequent cerebrospinal fluid (CSF) loss during the surgery. Brain computed tomography scan revealed cerebellar hemorrhage, 3rd and 4th ventricular hemorrhage and pneumocephalus. He underwent suboccipital craniectomy and hematoma removal. The most important pathomechanism leading to RCH after spinal surgery has been known to be venous bleeding due to caudal sagging of cerebellum by rapid leak of large amount of CSF which seems to be related with this case. Dural repair and minimizing CSF loss after intraoperative dural tearing would be helpful to prevent postoperative RCH.

Remote Cerebellar Hemorrhage Complicated after Supratentorial Surgery: Retrospective Study with Review of Articles

OBJECTIVE: Remote cerebellar hemorrhage (RCH) is one of the rare complications occurring after supratentorial surgery, and its pathomechanism is poorly understood. We report 10 cases of RCH from our institution and review 154 cases from a database in order to delineate incidence, common presentation, risk factors, and outcomes of this complication. In addition, the means of prevention are discussed. METHODS: We reviewed the medical records of 10 patients who experienced RCH after undergoing supratentorial surgery at our institution between 2001 and 2008. A database search in Medline revealed 154 cases of RCH in the English literature. Characteristic features were analyzed and compared. RESULTS: There were 10 cases of RCH among 3307 supratentorial surgery cases, indicating a 0.3% incidence. All patients had characteristic imaging features of RCH, namely a streaky bleeding pattern in the superior folia of the cerebellum. Seven patients had a history of preoperative hypertension. Four cases were related to cerebral aneurysms, and other four developed after the removal of brain tumors. Cerebrospinal fluid (CSF) drainage apparatuses were installed postoperatively in all cases. Outcomes according to modified Rankin scale (mRS) were good in 7 patients, with 1 fatal case. CONCLUSION: RCH is a rare complication after supratentorial surgery, and the exact etiology still remains uncertain. Hypertension and perioperative loss of CSF seem positively correlated with RCH, but no single risk factor is totally responsible. Patients with RCH should be closely observed to improve their prognosis.

The value of configuration of the fourth ventricle to indicate surgical treatment in patients with spontaneous cerebellar hemorrhage / 中国医师进修杂志

Objective To study the value of configuration of the fourth ventricle to indicate, surgical treatment in patients with spontaneous cerebellar hemorrhage. Methods The data of 52 patients with spontaneous cerebellar hemorrhage were retrospectively analyzed. The relationship between configuration of the fourth ventricle and consciousness, volume of the hematoma, frequence of hydrocephalus and incidence of deterioration of consciousness was investigated. Results The correlations between the degree of the fourth ventricular compression and the consciousness, the volume of the hematoma were strong (r= -0.881,P <0.01; r=0.808,P < 0.01, respectively). The more the degree of the fourth ventricular compression was severe,the more GCS score was low and the volume of the hematoma was large. The incidence of hydrocephalus in patients with composed the fourth ventricle[57.7%(15/26)] was significantly higher than that in patients with normal configuration of the fourth ventricle [16.7% (3/18)] (χ~2= 7.406, P < 0.01). The incidence of deterioration of consciousness in patients with compressed the fourth ventricle who accepted conservative therapy initially [72.7% (8/11)]was significantly higher than that in patients with normal configuration of the fourth ventricle [12.5%(2/16)] (P= 0.003). Conclusions The configuration of the fourth ventricle is an useful indicator for surgical treatment in patients with spontaneous cerebellar hemorrhage. When making decision whether surgical treatment was used or not in patients with spontaneous cerebellar hemorrhage, the configuration of the fourth ventricle should be take into account.

Congenital Cerebellar Mixed Germ Cell Tumor Presenting with Hemorrhage in a Newborn

We report here on a neonate with congenital cerebellar mixed germ cell tumor, and this initially presented as cerebellar hemorrhage. Postnatal cranial ultrasonography revealed an echogenic cerebellar mass that exhibited the signal characteristics of hemorrhage rather than tumor on MR images. The short-term follow-up images also suggested a resolving cerebellar hemorrhage. One month later, the neonate developed vomiting. A second set of MR images demonstrated an enlarged mass that exhibited changed signal intensity at the same site, which suggested a neoplasm. Histological examination after the surgical resection revealed a mixed germ cell tumor.