Pineal cyst presenting with intracystic and subarachnoid haemorrhage: report of a case and review of the literature

Pineal Apoplexy: Highlighting the Causes, Treatment, and Outcome

BACKGROUND

 Pineal apoplexy, alternatively referred to as pineal hemorrhage or pineal gland hemorrhagic stroke, is an infrequent pathologic condition characterized by bleeding within the pineal gland. In this review, we encompass the primary factors contributing to this uncommon ailment.

METHODS

 The retrieval of pertinent research, including patients with pineal apoplexy, was conducted through PubMed, Google Scholar, and Scopus databases. This study exclusively incorporated comprehensive articles written in the English language. The search encompassed the MeSH terms "pineal apoplexy" and "pineal hemorrhage."

RESULTS

 A total of 41 articles were identified, encompassing a collective sample size of 57 patients. The median age of the patients in the study was 30 years, with a range spanning from 1 to 73 years. There were 27 males, representing 47.4% of the participants. The study identified the most often reported symptoms as headache (49; 86%), nausea/vomiting (19; 33.3%), and Parinaud's syndrome (16; 28.1%). The treatment options encompass several approaches, including open resection, shunting, ventriculostomy, endoscopic aspiration, and conservative care. In the conducted study, a notable number of patients, amounting to 45 cases (78.9%), indicated an amelioration of their symptoms upon their discharge.

CONCLUSION

 Data from a cohort of 57 cases provide insights into symptoms, lesions, treatments, and outcomes. Management approaches range from conservative measures to surgical interventions, with prognosis hinged on timely intervention. This investigation serves as a valuable resource for clinicians and researchers, underscoring the need for early diagnosis before permanent neurologic dysfunction happens and tailored treatments for optimal outcomes in pineal apoplexy cases.

Sudden death in patients with pineal cyst: Evidence from autopsy studies

Pineal cysts are usually benign, fluid-filled sacs and most pineal cysts are asymptomatic. Sudden death specifically related to pineal cysts is extremely uncommon. A literature review of the pertinent databases, including PubMed, Google Scholar, Scopus, and Web of Science, was carried out to review the existing literature describing sudden death in patients with pineal cysts. In the evaluation of 49 articles, it was found that four reports discussed the unexpected death of patients who had pineal cysts. A total of four cases of sudden death and a pineal cyst were reported. There were 75% females and a mean age of 29 (range: 20-45). Cyst size on average was 1.3 cm (1.2-1.5). In each case, the cause of death and the involvement of important brain structures were confirmed by autopsy results. A pathological analysis of the pineal region and the surrounding brain tissue revealed a variety of lesions. Vascular malformation was found in one case, adding another layer of complexity to the study of sudden death syndrome. In this research, the authors highlight the fact that patients with pineal cysts can experience serious, even fatal, complications. Increased vigilance and early detection through neuroimaging and neurological assessments are required due to the wide variety of clinical manifestations and underlying mechanisms. To explain the mechanism and enhance the management and prevention of sudden deaths associated with pineal cysts, additional research with larger sample sizes is required.

An Unusual Presentation of Hearing Impairment in an Adult with Pineal Region Germinoma: A Case Report

Tumors of the pineal region typically present with symptoms and signs of mass effect and increased intracranial pressure. However, although rare and can be overlooked, hearing impairment is a potential clinical finding in these cases. The authors describe a 24-year-old male who presented to the emergency room complaining of bilateral hearing impairment. Brain computed tomography showed a pineal region tumor. Histopathological examination demonstrated features consistent with germinoma. This case reports a rare presentation rarely seen in the literature and in practice as evident by the conducted literature review. Therefore, we highlight the importance of considering hearing impairment as a presenting symptom of pineal region tumors since prompt recognition and intervention, as demonstrated in this case, can lead to successful outcomes.

Pineal cyst apoplexy and memory loss: a novel complication

An 8-year-old boy presented to our hospital complaining of a bilateral headache associated with episodes of anterograde amnesia. He had a road traffic accident 3 years ago when a computed tomography (CT) scan revealed traumatic brain injury. In addition, a small pineal cyst (PC) was noted with minor intramural calcifications. A follow-up CT a day later demonstrated increased density in the pineal gland of 60 Hounsfield Units, suggestive of apoplectic changes in the PC. However, the patient was lost to follow-up and presented with memory loss a year and a half later, upon which CT and magnetic resonance imaging revealed enlargement of the PC. PC apoplexy is a very rare occurrence usually affecting young adult women; cases in children are rarely reported. Furthermore, PC apoplexy secondary to severe craniofacial trauma manifesting as memory loss has not yet been reported in the literature to the best of our knowledge.

Exclusively endoscopic management of complicated pineal cysts in young children: Definitive treatment through single burr-hole technique

Background:

The management of complicated symptomatic pineal cysts in the pediatric population is challenging and variable. Surgical management may include treatment of hydrocephalus alone, or direct treatment of the cyst with or without direct hydrocephalus management. This is typically done through craniotomy-based microsurgical approaches to the pineal region or an endoscopic transventricular approach.

Methods:

We present a stepwise minimally invasive technique to treat complicated pineal cysts in young children associated with an obstructive hydrocephalus in a single procedure through third ventriculostomy combined with an intraventricular marsupialization of the pineal cyst through a single burr-hole using stereotactic navigation.

Results:

Two young patients with over 2 years of follow-up have done well without complication using this technique. Other literature reports for complex pineal cysts in pediatric patients are reviewed and this technique is not previously described for this population.

Conclusion:

Endoscopic third ventriculostomy and cyst marsupialization using a single burr-hole and stereotactic navigation for symptomatic or enlarging pineal cysts in children allow for minimally invasive management, a rapid recovery, short hospital stay, and durable outcome owed to redundant CSF flow pathways.

Surgical treatment of symptomatic pineal cysts without hydrocephalus-meta-analysis of the published literature

Background

To examine published data and assess evidence relating to safety and efficacy of surgical management of symptomatic pineal cysts without hydrocephalus (nhSPC), we performed a systematic review of the literature and meta-analysis.

Methods

Following the PRISMA guidelines, we searched Pubmed and SCOPUS for all reports with the query ‘Pineal Cyst’ AND ‘Surgery’ as of March 2021, without constraints on study design, publication year or status (PROSPERO_CRD:42,021,242,517). Assessment of 1537 hits identified 26 reports that met inclusion and exclusion criteria.

Results

All 26 input studies were either case reports or single-centre retrospective cohorts. The majority of outcome data were derived from routine physician-recorded notes. A total of 294 patients with surgically managed nhSPC were identified. Demographics: Mean age was 29 (range: 4–63) with 77% females. Mean cyst size was 15 mm (5–35). Supracerebellar-infratentorial approach was adopted in 90% of cases, occipital-transtentorial in 9%, and was not reported in 1%. Most patients were managed by cyst resection (96%), and the remainder by fenestration. Mean post-operative follow-up was 35 months (0–228). Presentation: Headache was the commonest symptom (87%), followed by visual (54%), nausea/vomit (34%) and vertigo/dizziness (31%). Other symptoms included focal neurology (25%), sleep disturbance (17%), cognitive impairment (16%), loss of consciousness (11%), gait disturbance (11%), fatigue (10%), ‘psychiatric’ (2%) and seizures (1%). Mean number of symptoms reported at presentation was 3 (0–9). Outcomes: Improvement rate was 93% (to minimise reporting bias only consecutive cases from cohort studies were considered, N = 280) and was independent of presentation. Predictors of better outcomes were large cyst size (OR = 5.76; 95% CI: 1.74–19.02) and resection over fenestration (OR = 12.64; 3.07–52.01). Age predicted worse outcomes (OR = 0.95; 0.91–0.99). Overall complication rate was 17% and this was independent of any patient characteristics. Complications with long-term consequences occurred in 10 cases (3.6%): visual disturbance (3), chronic incisional pain (2), sensory disturbance (1), fatigue (1), cervicalgia (1), cerebellar stroke (1) and mortality due to myocardial infarction (1).

Conclusions

Although the results support the role of surgery in the management of nhSPCs, they have to be interpreted with a great deal of caution as the current evidence is limited, consisting only of case reports and retrospective surgical series. Inherent to such studies are inhomogeneity and incompleteness of data, selection bias and bias related to assessment of outcome carried out by the treating surgeon in the majority of cases. Prospective studies with patient-reported and objective outcome assessment are needed to provide higher level of evidence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-021-05054-0.

Pineal Apoplexy: A Case Series and Review of the Literature

BACKGROUND

 Pineal apoplexy is a rare condition, with unknown incidence and clinical significance. To elucidate this clinical condition, we analyzed our own case series and performed a review of the literature.

METHODS

 We enrolled all patients with a hemorrhagic pineal apoplexy who were referred to our department between January 2000 and January 2020. Hemorrhagic pineal apoplexy was defined as the presence of fluid-fluid levels inside the pineal cyst (PC) on an axial or sagittal magnetic resonance scan. In one patient, after PC apoplexy, we performed a circadian melatonin sampling from peripheral blood to determine the function of the pineal gland. The PubMed database was searched for publications using the terms "pineal" and "apoplexy."

RESULTS

 Eight patients were enrolled, of which three patients underwent surgical treatment and five patients were managed conservatively. One patient was tested for circadian melatonin secretion. Results confirmed melatonin secretion with preserved physiologic circadian rhythm.Our search of the literature led us to 31 studies that comprised 30 patients with apoplectic PC, 9 with apoplectic pineal tumor, and 1 with bleeding into the normal pineal gland. Most patients presented with headache, nausea, and vomiting, less frequently with acute hydrocephalus and gaze palsy. Twenty patients with a PC underwent resection or aspiration. Two patients underwent shunt placement as the only procedure and five received both shunt and surgical removal. Six patients with a PC were observed without surgical treatment. All the nine patients with a pineal tumor were operated on. In indicated cases, four patients received radiation therapy and one received chemotherapy.

CONCLUSION

 Clinical significance of hemorrhagic pineal apoplexy ranges from an asymptomatic course to rapid deterioration and death. In patients with mild symptoms, observation is indicated, whereas surgical treatment is reserved for severe cases presenting with obstructive hydrocephalus and includes cerebrospinal fluid diversion, resection of apoplectic pineal lesions, or both.

Pineal Cyst Apoplexy in an 8-Year-Old Girl: Case Report and Literature Review

BACKGROUND

Pineal cysts are common, typically asymptomatic, and are usually found incidentally in adults. In rare cases, pineal cyst apoplexy occurs as a result of an acute cystic hemorrhage. This situation can result in acute onset of severe headaches, acute obstructive hydrocephalus, mass effect on the midbrain, and even death. Pineal apoplexy is most common in women of reproductive age, whereas pediatric cases continue to be less prevalent. Pineal cyst apoplexy remains a rare entity with ≥30 cases presented in the literature to date.

CASE DESCRIPTION

We present the youngest case in the literature (an 8-year-old girl with a pineal cyst that resulted in apoplexy), her diagnostic workup, management, and follow-up. We supplement our case study with a literature review of pineal cyst apoplexy.

CONCLUSIONS

Pineal cyst apoplexy remains a rare clinical event in the pediatric population. Our case details the diagnosis and management of an 8-year-old girl with pineal cyst apoplexy. We also discuss our findings from our literature search for all reported cases of pineal cyst apoplexy.

Pineal Cyst Apoplexy: A Rare Complication of Common Entity

Pineal cysts (PCs) are often encountered as incidental findings in intracranial images. The vast majority of cysts are normally asymptomatic and clinically benign. Bleeding into the cysts, which leads to neurological symptoms and signs, is considered to be quite rare. The authors illustrate a newly identified complication of PC in a 56-year-old woman who characterized by headache of sudden onset and vomiting. MRI disclosed a small hemorrhagic PC without narrowing of the cerebral aqueduct. The patient was managed conservatively without any surgical interventions, and she remained symptom-free over a period of 15-year follow-up. The description of this case adds to the limited literature on the series in which nonsurgical treatments had a role in the care for patients with PC complicated by intracystic hemorrhage.

Sudden and Unexpected Death During Sexual Activity, Due to a Glial Cyst of the Pineal Gland

Cysts of the pineal gland are benign lesions. Often asymptomatic, in the majority of cases they are discovered incidentally during brain magnetic resonance imaging or autopsy. Sporadically, however, they may cause such symptoms as chronic headache, loss of consciousness, corticospinal and sensory impairment, and, in some cases, even sudden death. A 45-year-old woman, in apparently good health, collapsed and died suddenly, after reaching orgasm while engaged in sexual intercourse. According to the circumstantial account of her relatives, the woman suffered from severe headaches, which were exacerbated by certain types of physical strain, such as sexual activity. Postmortem examination revealed no external injuries or internal diseases except for a cystic lesion of the pineal gland. Microscopically, the wall of the cyst consisted of a layer of glial tissue surrounded by an area of pineal elements. A complete forensic approach concluded that the cause of death was fatal cardiorespiratory failure resulting from midbrain compression due to a nonneoplastic pineal gland cyst, exacerbated by sexual activity. In this case, the intracranial pressure increase, secondary to Valsalva maneuver during climax, may further aggravate compression on the brainstem, thus concurring to determine the death.

Epilepsy in patients with pineal gland cyst

OBJECTIVE

The aim of the study is to describe types of epileptic seizures in patients with pineal gland cyst (PGC) and their outcome during follow up period (6-10 years). We wanted to determine whether patients with epilepsy differ in PGC volume and compression of the PGC on surrounding brain structures compared to patients with PGC, without epilepsy.

PATIENTS AND METHODS

We analyzed prospectivelly 92 patients with PGC detected on magnetic resonance (MR) of the brain due to various neurological symptoms during the period 2006-2010. Data on described compression of the PGC on surrounding brain structures and size of the PGC were collected.

RESULTS

29 patients (16 women, 13 men), mean age 21.17 years had epilepsy and PGC (epilepsy group). 63 patients (44 women, 19 men), mean age 26.97 years had PGC without epilepsy (control group). Complex partial seizures were present in 8 patients, complex partial seizures with secondary generalization in 8 patients, generalized tonic clonic seizures (GTCS) in 10 and absance seizures in 3 patients. Mean PGC volume in epilepsy group was 855.93 mm³, in control group 651.59 mm³. There was no statistically significant difference between epilepsy and control group in PGC volume. Compression of PGC on surrounding brain structures was found in 3/29 patients (10.34%) in epilepsy group and in 11/63 patients (17.46%) in control group with no statistically significant difference between epilepsy and control group. All patients with epilepsy were put on antiepileptic therapy (AET). During the follow up period, 23 patients (79.31%) were seizure free, 3 patients (13.04%) had reduction in seizure frequency, whereas 3 patients had no improvement in seizure frequency. Two patients from epilepsy group and 3 patients from control group were operated with histologically confirmed diagnosis of PGC in 4, and pinealocytoma in 1 patient.

CONCLUSIONS

In patients with PGC, epileptic seizures were classified as: complex partial seizures (with or without secondary generalization), GTCS and absance seizures. All patients were put on AET. During follow up period 79.31% patients were seizure free. There was no difference in PGC volume, nor in described compression of the PGC on surrounding brain structures between epilepsy and control group. Based on our findings, pathomechanism of epileptic seizures in patients with PGC cannot be attributable solely to PGC volume or described compression on surrounding brain structures based on MRI findings.

[Pineal cyst]

A pineal cyst (PC) is a benign neoplasm in the pineal region, or more precisely in the pineal body. Most cysts are incidental findings and are not associated with symptoms typical of patients seeking medical advice. Symptomatic cysts are discovered less often and, depending on the clinical picture, require different treatment approaches.

MATERIAL AND METHODS

We analyzed the literature data about the clinical picture, diagnosis, and treatment of PCs for more than a century (1914-2016).

CONCLUSION

To date, there is no single approach for managing PC patients. The indications for surgical treatment of symptomatic PCs are still not fully defined. It remains unclear which PC cases should be followed-up, and how often control examinations should be performed. More research of PCs is needed to develop new approaches to treatment of PC patients.

Endoscopic surgery for hemorrhagic pineal cyst following antiplatelet therapy: case report

Pineal cysts of the third ventricle presenting with acute obstructive hydrocephalus due to internal cystic hemorrhage are a rare clinical entity. The authors report a case of a 61-year-old man taking antiplatelet medication who suffered from a hemorrhagic pineal cyst and was treated with endoscopic surgery. One month prior to treatment, the patient was diagnosed with a brainstem infarction and received clopidogrel in addition to aspirin. A small incidental pineal cyst was concurrently diagnosed using magnetic resonance (MR) imaging which was intended to be followed conservatively. The patient presented with a sudden onset of headache and diplopia. On admission, the neurological examination revealed clouding of consciousness and Parinaud syndrome. Computerized tomography (CT) scans demonstrated a hemorrhagic mass lesion in the posterior third ventricle. The patient underwent emergency external ventricular drainage with staged endoscopic biopsy and third ventriculostomy using a flexible videoscope. Histological examination revealed pineal tissue with necrotic change and no evidence of tumor cells. One year later MR imaging demonstrated no evidence of cystic lesion and a flow void between third ventricle and prepontine cistern. In patients with asymptomatic pineal cysts who are treated with antiplatelet therapy, it is important to be aware of the risk of pineal apoplexy. Endoscopic management can be effective for treatment of hemorrhagic pineal cyst with obstructive hydrocephalus.

Pineal cysts in children: case-based update

PURPOSE

Pineal cysts (PC) are found in children as often asymptomatic and without change in their size over the time. However, there are some debatable issues about their evolution and management in the pediatric population. The aim of the present paper is to update the information regarding pathogenesis, clinical presentation, and management of these lesions.

METHODS

All the pertinent literature was reviewed, and a meta-analysis of operated on cases was carried out. An illustrative case regarding the clinical evolution of a 13-year-old girl is also presented.

RESULTS AND CONCLUSIONS

PC are often asymptomatic and do not evolve over the time. However, since there is a certain risk of clinical and/or radiological progression, or even sudden and severe clinical onset (apoplexy), both a clinical and radiological follow-up is recommended in the pediatric age. The surgical excision is usually limited to symptomatic patients or to cases with clear radiological evolution.

Pineal cyst apoplexy: report of an unusual case managed conservatively

Pineal cyst apoplexy is a very rare entity with previously reported symptoms of severe frontal or occipital headache, gaze paresis and visual field defects, nausea or vomiting, syncope, ataxia, hearing loss and sudden death. The treatment options for symptomatic pineal cysts are observation, shunting, aspiration via stereotactic guidance or endoscopy, third ventriculostomy, ventriculocysternostomy, and/or surgical resection by craniotomy and microsurgery. Here, the authors report an unusual case of a 28-year-old male patient with pineal cyst apoplexy, presenting with headache, insomnia, and sexual dysfunction symptoms who is being managed conservatively and observed for two years by an academic tertiary care unit.

Histopathology of tumors of the pineal region

Pineal region tumors are heterogeneous lesions and include mainly pineal parenchymal tumors (PPTs), papillary tumors of the pineal region (PTPRs) and germ cell tumors (GCTs). This article describes the cystic pineal gland compared with normal tissue and histopathological features of the most frequent pineal region tumors. PPTs are subdivided into pineocytoma (grade I), pineoblastoma (grade IV) and tumors with intermediate differentiation (PPTIDs; grades II-III). A grading system based on the number of mitoses and neurofilament protein expression distinguishes low- from high-grade PPTID. PTPR is a new tumoral entity thought to originate from the subcommissural organ. GCTs include germinoma, embryonal carcinoma, teratoma, yolk sac tumor and choriocarcinoma and are often of mixed histologic composition. New histogenetic data for GCTs are presented.

Pseudoneoplasms of the Nervous System

Context.—Pseudoneoplasms of the nervous system vary greatly in nature. Ranging from inflammatory to autoimmune, infectious, malformative, reactive, degenerative, and radiation induced, they all mimic true tumors. Thus, they have the potential to mislead clinicians, radiologists, and pathologists alike. Their clinical and/or neuroimaging and histologic features are readily misinterpreted as tumor. Knowledge of the pitfalls is essential to avoid mismanagement, specifically overtreatment. In such instances, pathologists must take the entire clinical picture into consideration, acquainting themselves with presenting symptoms, physical findings, and neuroimaging.

Objective.—To present 10 examples of pseudoneoplasms of the nervous system, analyze the basis for their mimicry, and discuss their differential diagnosis.

Data Sources.—Review of the pertinent literature related to pseudoneoplasms of the nervous system and review of the consultation files of one of the authors (B.W.S.).

Conclusions.—The identification of tumor mimics may be difficult under the best of circumstances, and maintaining a broad differential diagnosis as well as application of a variety of immunocytochemical and occasionally ultrastructural and/or molecular genetic methods is essential to arrive at a correct diagnosis.

Symptomatic intracystic hemorrhage in pineal cysts. Report of 3 cases

Pineal cysts are benign and often asymptomatic intracranial entities. Occasionally they can lead to neurological symptoms through growth or due to intracystic hemorrhage. The purpose of the current report is to describe their clinical characteristics and treatment options. In the current study, the authors illustrate the course of disease in 3 patients who developed neurological symptoms due to hemorrhage into a pineal cyst. Two of their patients had additional cerebral disease, and regular MR imaging examinations were conducted. This circumstance allowed documentation of growth and intracystic hemorrhage. After the occurrence of new neurological symptoms with severe headache, MR images showed a fluid-fluid interface due to intracystic hemorrhage. The third patient presented with acute triventricular hydrocephalus and papilledema due to aqueductal stenosis caused by intracystic hemorrhage. In all 3 cases, excision of the pineal cysts via an infratentorial/supracerebellar approach was performed. Histological examination revealed the characteristic structure of pineal cyst in all cases, with hemorrhagic residues in the form of hemosiderin deposits. All patients recovered fully after surgical removal of the cysts. Furthermore, resolution of occlusive hydrocephalus could be demonstrated in those cases with ventricular enlargement. Pineal cysts without neurological symptoms are often discovered as incidental findings on cranial MR images. In contrast, neurological symptoms such as severe headache, diplopia, or Parinaud syndrome, may occur as a result of pineal apoplexy due to intracystic hemorrhage. The authors' cases confirm that MR imaging can identify intracystic hemorrhage by a characteristic fluid-fluid interface. Their experience suggests that microsurgical resection of cysts may be an effective and curative treatment option.

Endoscopic supracerebellar infratentorial approach for pineal cyst resection: technical case report

OBJECTIVE

Accepted surgical strategies to address symptomatic pineal cysts include transventricular flexible or rigid endoscopy and supracerebellar infratentorial or occipital transtentorial microsurgical approaches. We report the first application of the endoscopic supracerebellar infratentorial approach for the complete resection of a pineal cyst. Unlike transventricular endoscopy, this technique poses no risk to the fornices and can be applied independent of ventricular size.

CLINICAL PRESENTATION

A 37-year-old woman sought treatment for intractable headaches. A thorough evaluation revealed only a pineal cyst exerting mass effect on the tectum but causing no hydrocephalus. A period of nonoperative management was unsuccessful, and the patient was referred for surgery.

TECHNIQUE

The patient was positioned in the semi-sitting position. The supracerebellar infratentorial corridor was accessed through a burr-hole. The pineal cyst was resected completely via the endoscope. Postoperatively, the patient's headaches resolved completely.

CONCLUSION

The endoscopic supracerebellar infratentorial approach involves minimal brain retraction, poses no risk to the fornices, allows visualization and avoidance of the Galenic veins, and can be performed regardless of the size of the ventricle. Consequently, it is an excellent minimally invasive surgical option for resection or fenestration of symptomatic pineal cysts.

Pineal cyst apoplexy: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Although most pineal cysts are clinically benign and asymptomatic, some can become symptomatic. Of the various symptomatic presentations, apoplexy is the rarest and most ill-defined. A comprehensive search of publications in the English language yielded 18 cases of pineal cyst apoplexy. We reviewed the literature to compare symptomatology and management strategies and their outcomes.

CLINICAL PRESENTATION

A 29-year-old woman with a 1-month history of headaches presented with an acute worsening of her symptoms with a severe occipital headache and trouble focusing when reading. Her neurological examination was otherwise normal. Magnetic resonance imaging showed pineal cyst apoplexy and accompanying hydrocephalus.

INTERVENTION

A left paramedian craniotomy with a transcallosal, transchoroidal approach using an intraoperative neuronavigation system was used to resect a pineal cyst. Postoperative imaging showed complete removal of the cyst and resolution of the hydrocephalus. Follow-up imaging at 12 months demonstrated no evidence of recurrence or any hydrocephalus. The patient has remained asymptomatic for 18 months.

CONCLUSION

Pineal cyst apoplexy should always be considered when following a patient with a pineal cyst that becomes symptomatic. The most common symptom was severe headache of sudden onset or acute worsening. Other signs of hydrocephalus may or may not be present. Magnetic resonance imaging is essential to making a diagnosis. Although we believe that surgical resection is the most effective approach because it minimizes the risk for recurrence and complication, stereotactic aspiration has been used successfully to treat this condition.

Spontaneous involution of a large pineal region hemorrhagic cyst in an infant. Case report

The authors report the case of a newborn presenting at birth with macrocephaly and a large pineal region hemorrhagic cyst without neurological deficit. No neurosurgical intervention was performed, and subsequent imaging studies demonstrated complete involution of the cyst.

Pineal cavernous malformations: report of two cases

Pineal hemorrhage only occurs in rare cases, and this known to have several different causes such as germ cell tumors, pineal cysts and vascular malformations, including the cavernous malformations. Pineal cavernous malformations are extremely rare: to date only fifteen cases have been reported worldwide. Although the diagnosis of pineal cavernous malformation is not easy because of the extreme rareness of this condition, the presence of this lesion can be suspected based on its typical radiological findings. Case 1. A 42-year- old man presented with a limitation in his upward gazing. Radiologic examinations showed acute hemorrhage in the pineal region. He underwent ventriculo-peritoneal (VP) shunting but the patient's condition deteriorated after the shunting surgery. We operated and totally removed the tumor and the hemorrhages via an occipital-transtentorial approach. Case 2. A 37-year-old man presented with diplopia. Radiologic examinations showed acute hemorrhage in the third ventricle. He underwent VP shunting, and after this procedure the diplopia was aggravated. We operated and totally removed the tumor and the hemorrhages via an occipital-transtentorial approach. If there is no doubt about the pineal cavernous malformation on MR imaging, we strongly recommend early surgical intervention without performing a risky biopsy. In this study, we describe our experiences for the diagnosis of cavernous malformations in the pineal region with special emphasis on the radiological aspects and the clinical course of this disease.

Successful conservative operative management of pineal apoplexy

A 71-year-old woman presented with obstructive hydrocephalus caused by a haemorrhagic pineal mass. A right ventriculo-peritoneal shunt was inserted with successful treatment of the hydrocephalus and resolution of symptoms and signs. Post-operative MRI both as an inpatient and at 5 and 18 months showed no contrast enhancement of the lesion and there was resolution of the radiographic abnormality. She remains symptom-free at 18 months. Previous reports have advocated resection of the pineal lesion, but this patient has done well with CSF shunting and MRI surveillance.

Pineal cysts in childhood

INTRODUCTION

Little is known about the incidence and symptomatology of pineal cysts in children. Until now, the proper management of this group of patients has not been established.

PURPOSE

The purpose of this study was to evaluate the epidemiological and clinical features of pineal cysts in children and adolescents and to try to find guidelines for their management.

METHODS AND RESULTS

We analyzed 24 patients (17 girls, mean age 9, and 7 boys, mean age 14) with pineal cysts found as the only pathology on MRI. Six patients were treated surgically (excision of the cysts via a supracerebellar-infratentorial approach) because of the progression of neurological symptoms or the enlargement of the cyst at follow-up. In this group of patients, no surgery-related complications were noted, nor was residual cyst observed on postoperative MRI. In 4 cases, histological examination revealed simple cysts, but in 2 cases pineocytomas were diagnosed. Preoperative symptoms disappeared except light headache in 2 cases and in 1 case no improvement was obtained. The remaining 18 patients had a mean follow-up of 38 months (range 24-60 months). None of the cysts diminished or collapsed. We also measured the circadian pattern of melatonin secretion as well as beta-HCG and AFP levels in serum before surgery. We found very high night levels of melatonin in both of the patients with pineocytomas, while the patients with pineal cysts showed normal or depressed melatonin secretion profile.

CONCLUSION

We concluded that though most pineal cysts were clinically benign they should be followed up for many years. If the cyst grows larger in follow-up MRI study and neurological symptoms are progressive, surgical treatment should be performed. In the authors' opinion, one of the markers discriminating benign and neoplastic lesions may be melatonin.

Intraventricular congenital lesions and colloid cysts

Intraventricular congenital lesions and colloid cysts comprise a rather large spectrum of different pathologic conditions. In most cases, treatment in not warranted unless there is progressive ventricular obstruction with hydrocephalus or growth of the lesion itself, making tissue biopsy and histopathologic diagnosis necessary. Accordingly, a precise neuroradiologic evaluation is of the utmost importance, because most lesions, if not symptomatic, only require clinical and radiologic follow-up.

Pineal apoplexy: is it a facilitator for the development of pineal cysts?

BACKGROUND

The radiographic identification of pineal cysts has increased dramatically within the last two decades due to the advent of magnetic resonance imaging. Pineal cysts are often found incidentally with only a minority of these lesions ever becoming symptomatic and requiring treatment. Many theories attempting to explain the pathogenesis of these cysts exist.

METHODS

We describe a case of a 12-year-old girl who presents with a pineal hemorrhage of unknown etiology with associated hydrocephalus.

RESULTS

Her hydrocephalus was initially treated with an external ventricular drain followed by a third ventriculostomy. She had no evidence of elevated beta human chorionic gonadotropin or alpha-fetoprotein within the serum or cerebrospinal fluid. Follow-up imaging at seven weeks revealed resolution of her hemorrhage, however, there was development of a progressive cystic lesion within the pineal region. In order to make a definitive tissue diagnosis, a supracerebellar infratentorial surgical approach with complete resection was performed. During the resection, brownish fluid was aspirated from the cyst and the cyst wall was removed. The pathological diagnosis was a pineal cyst.

CONCLUSIONS

Although cases have been described of pineal apoplexy with an underlying cyst, this case describes the development of a progressive pineal cyst secondary to a hemorrhage. This case demonstrates that pineal hemorrhage may be a promotor for the development or progression of pineal cysts.

Pineal apoplexy due to massive hemorrhage associated with cavernous angioma: case report

BACKGROUND

Pineal apoplexy is a rare apoplectic event in the pineal region with various possible causes. We report a case of massive hemorrhage in the pineal region associated with a cavernous angioma, and discuss the pathogenesis of pineal apoplexy.

CASE DESCRIPTION

An 11-year-old girl presented with nausea and vomiting persisting for 1 week. Neuroimaging revealed enlarged ventricles and a 4 cm round mass in the pineal region consistent with hematoma. Two weeks after cerebrospinal fluid drainage, the mass was totally removed via the occipital transtentorial approach. The postoperative course of the patient was uneventful. Magnetic resonance imaging after the operation confirmed two paraventricular lesions with surrounding hemosiderin rings, characteristic of cavernous angioma. Histologic examination showed large hematomas and numerous vascular spaces lined by a single layer of endothelium. The diagnosis was pineal apoplexy associated with cavernous angioma, based on the histologic and radiological findings.

CONCLUSIONS

Pineal cavernous angiomas are extremely rare, with only fourteen cases reported previously. We recommend total removal of the causative lesion in cases of pineal apoplexy to prevent repeated bleeding or life-threatening massive hemorrhage.