Symptomatic intracystic hemorrhage in pineal cysts

Abstract

<jats:p>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.</jats:p> <jats:p>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.</jats:p> <jats:p>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.</jats:p> <jats:p>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.</jats:p>

Prevalence and natural history of pineal cysts in adults

“…It may be associated with an increased likelihood of symptomatic presentation, 5,19,20,49,58,63 and sudden death from pineal hemorrhage with acute hydrocephalus has been reported. 41,55 Fleege et al 20 found fluid-fluid levels consistent with previous hemorrhage in 3 of 19 patients who presented with symptomatic pineal cysts.…”

A Hemorrhagic Pineal Cyst with a Bacterial Meningitis-like Manifestation and Benign Outcome

“…Although the vast majority of pineal cysts, even large ones, can be expected to be found incidentally and remain asymptomatic (1), some patients may present with signs and symptoms of increased intracranial pressure or focal signs and symptoms due to compression and edema in neighboring structures (2, 3). Pineal apoplexy is generally considered to be rare (1,(4)(5)(6). Most patients with pineal apoplexy have been reported to have relatively severe symptoms that often accompany acute occlusive hydrocephalus (4-6) and may occasionally result in sudden death (11) or the need for surgical treatment.…”

“…Although the majority of these cysts are benign and are usually asymptomatic, some are occasionally associated with headaches, hydrocephalus, extraocular movement abnormalities and Parinaud's syndrome (2,3). The hemorrhage of a pineal cyst, which is sometimes referred to as pineal apoplexy, is considered to be rare and is often associated with severe symptoms (4)(5)(6). We herein describe an adult case of chemical meningitis induced by an intracystic hemorrhage of the pineal region in which the patient presented with clinical manifestations resembling bacterial meningitis and was able to achieve a benign outcome without any surgical treatment.…”

Pineal Apoplexy: Imaging Diagnosis and Follow-up of Three New Cases

“…In addition, pineal cysts often show a thin (no greater than 2mm) rim of enhancement upon contrast due to surrounding pineal parenchyma, which lacks a blood-brain barrier 5 . Pineal tumors on the other hand, have been reported to typically appear similar to grey matter on MRIs 5,6 . In all our cases, appearances in CT and MRI were indicative of blood derivate content within the lesion, which obscured its appearance, hindering identification of the pathological process underlying the lesion.…”

“…Pineal cysts appear strongly hyperintense to brain parenchyma and often CSF on T2-weighted images 1,5,6 . In addition, pineal cysts often show a thin (no greater than 2mm) rim of enhancement upon contrast due to surrounding pineal parenchyma, which lacks a blood-brain barrier 5 .…”