A 15-year-old boy was brought to the ER due to headache and vomiting for one week. On examination, he was awake, but was unable to look up to the ceiling. He also had trouble focusing on objects, had double vision, and was unsteady when he tried to stand up and walk. 

Brain MRI showed hydrocephalus (water in the brain) caused by blockage from a tumor in the pineal area, near the center of the brain. Tumor markers (alpha feto protein, B-Hcg) in the blood were negative. 

The patient underwent endoscopic third ventriculostomy (ETV) and endoscopic biopsy of the tumor. The endoscope is used not only in general surgery but also for brain surgery, and is very helpful in cases like this. ETV involves connecting the fluid pathways inside the brain to bypass the tumor and treat the hydrocephalus. A biopsy is necessary because many types of tumors are found in this area, and the treatment for each is different. The patient improved after the surgery. His headache disappeared and his double vision improved. The biopsy result was a germinoma, a type of germ cell tumor. He underwent chemotherapy and radiation therapy with good results.