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Journal of Neurology, Neurosurgery, and Psychiatry, 1979, 42,
1050-1053
Pineal apoplexyK. HIGASHI, S. KATAYAMA, AND T. ORITAFrom the
Department of Neurosurgery, Yamaguchi University School of
Medicine, Ube, Japan
S U M MARY A case of haematoma in the pineal region is reported
in a patient whose initialsymptom was subarachnoid haemorrhage. The
encapsulated haematoma and surrounding bloodclots were removed
surgically. Haemorrhage into a pineal cyst may have been the cause
of thisparticular intracranial mass.
Although pineal tumours are reported to be notuncommon in Japan
(Katsura et al., 1959; Arakiet al., 1969), haemorrhage into the
pineal tumour,pituitary apoplexy, has been a rare occurrence.Apuzzo
et al. (1976) recently reported a case ofpineal apoplexy caused by
haemorrhage into apineal cyst in a patient on anticoagulant
therapy.We report a case of haematoma in the pinealregion
developing without any anticoagulanttherapy.
Case report
A 51 year old previously healthy woman experi-enced the sudden
onset of severe headache and abrief period of unconsciousness. On
admission tothe local community hospital, spinal tap
revealedgrossly bloody spinal fluid with an opening pressureof 240
mmH2O. The headache, nausea, andvomiting continued for three weeks
and thengradually subsided.On admission on 27 June 1978, the
patient was
alert. Her blood pressure was 140/80 mmHg.There was marked
bilateral papilloedema withretinal haemorrhage. Pupillary light
reflexeswere sluggish bilaterally, without impairment ofthe
accommodation response. There was noParinaud's sign. Left carotid
angiograms demon-strated signs of internal hydrocephalus, and
leftretrograde brachial angiography revealed anelevation of the
medial posterior choroidal arterysuggesting a mass in the pineal
region. lothalamate(Conray) ventriculography confirmed the
presenceof hydrocephalus, including the third ventricle.
Address for reprint requests: Dr K. Higashi, Department of
Neuro-surgery, Yamaguchi University School of Medicine, Ube,
Yamaguchi-ken, Japan.Accepted 7 May 1979
The suprapineal recess was displaced upward andthe aqueduct was
almost completely occluded.The anterior margin of the mass was
clearlydelineated in the posterior part of the thirdventricle (Fig.
1). Ventricular CSF taken duringthe ventriculography was
xanthochromic withprotein 0.38 g/l and 17 cells per mm3
Com-puterised tomography (CAT) scan demonstrated ahigh density mass
in the pineal region, whilecontrast enhancement did not alter the
densityof the mass (Fig. 2 left).The patient underwent a right
occipital crani-
otomy on 10 July. The pineal region was exposedthrough the
transcallosal approach with sectionof the tentorium under the
microscope. On section-ing the splenium of the corpus callosum, a
bluish
Fig. 1 lothalanmate (Conray) ventriculogram withair. The lateral
and third ventricle are dilated. In theposterior third ventricle,
there is an irregular defectwith smooth outline of the pineal mass,
which pushesthe suprapineal recess upward and occludes theaqueduct
almost completely.
1050
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1051Pineal apoplexy
Fig. 2 Pre and postoperative CAT scans. Left: preoperative.
Lateral ventricles aredilated. Periventricular low density is seen
in front of both anterior horns. Highdensity shadow is located in
the posterior third ventricle (without enhancement).Middle: 43rd
postoperative day. High density shadow has completely
disappeared,while ventricular size is unchanged. There is a low
density area in the right occipitallobe. Right: 102nd postoperative
day. Ventricular size is reduced, but low density inthe right
occipital lobe remains.
coloured mass was seen, surrounded by the in-ternal cerebral
vein and by Rosenthal's vein.Several fine vessels appeared to run
on the surfaceof the tumour. Puncture of the tumour yieldeddark red
liquid haematoma, and aspiration of
5 is '
kili'e' s'_89..
about 4 ml of this fluid made the tumour shrink.The mass
consisted of a blood clot which wasremoved piecemeal. The capsule
was 2 mm thickin the posterior part and thinner in the
anteriorportion. There were also blood clots outside the
*.tt^ g #~~~~~~~~~.%..A
W.~~~~~~~~~~~~~A At
b..\ ~~44 %
A ....d_U
Fig. 3 Photomicrographs of the capsule of haematoma. Left:
organised haematomais surrounded by gliosis with haemosiderin-laden
macrophages. Haematoxylin andeosin (H and E), original magn
fication X60. Right: psammoma body is seen withinvascular
granulation tissue. H and E, original magnification X 150.
;3C.VW
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1052
capsule anteriorly, between the capsule andependyma of the third
ventricle. Opening of thethird ventricle revealed that the inside
of theependyma was intact. The capsule was totallyremoved.
Histological study of the capsule of the haema-toma demonstrated
very vascular granulationtissue with abundant haemosiderin-laden
macro-phages and hyalinized connective tissue surround-ing the
organised haematoma. Proliferation ofastroglia was seen in some
areas. Although therewere a few psammoma bodies, distinct
pinealtissue was not observed (Fig. 3).Because of persistence of
internal hydro-
cephalus, a ventriculoperitoneal shunt was placedon the tenth
postoperative day, but abdominalpain with high fever began two
weeks later.Suspicion of shunt infection compelled theremoval of
the shunt system and symptoms dis-appeared promptly thereafter.
Hydrocephalus re-lated symptoms no longer appeared after removalof
the shunt, and papilloedema cleared completely.A CAT scan performed
on the forty-third post-operative day revealed disappearance of the
highdensity shadow in the pineal region, though thesize of the
ventricles was unchanged. There was alow density area in the right
occipital lobe whereit had been retracted during surgery (Fig.
2middle). The postoperative course was uneventfulexcept for the
above-mentioned events and upwardgaze palsy which developed
postoperatively. Thepatient was discharged on the fifty-seventh
post-operative day without any neurological deficitexcept for
upward gaze palsy and sluggish lightreflexes. Re-examination by CAT
scan on 16October demonstrated reduction of ventricularsize, while
the low density area in the rightoccipital lobe still remained
(Fig. 2 right).Discussion
This patient, whose initial symptom was subarach-noid
haemorrhage, had an encapsulated haema-toma located in the pineal
region, which occludedthe Sylvian aqueduct and caused internal
hydro-cephalus. In spite of ventriculographic demon-stration of a
mass in the posterior third ventricleresembling pineal tumour, a
high density shadowin the CAT scan led to the suspicion of
haema-toma. As causes of intracranial haematoma inthis region,
either haemorrhage into a pinealtumour (pineal apoplexy) or a
vascular anomalylocated in this region should be
considered.Haemorrhage into brain tumour is common
when the patient's symptoms increase suddenly.
K. Higashi, S. Katayama, and T. OritaMoreover, cerebral tumours
have occasionallybeen found in patients with massive
haemorrhagepresenting clinically like haemorrhagic
strokes.Richardson and Einhorn (1963) reported sevensuch cases in
their 108 necropsy cases of primaryintracerebral haemorrhage.
Although more than180 cases of pituitary apoplexy have been
re-ported (Rovit and Fein, 1972) little reference hasbeen made to
pineal apoplexy.The case of Apuzzo et al. (1976) may be the
only case reported so far. On reviewing the litera-ture, they
were unable to find any other cases ofhaemorrhage from a pineal
tumour. Histologicalexamination of their case indicated that
thehaemorrhage occurred into the pineal cyst withoutevidence of
neoplasm. Among pineal tumours, thenon-neoplastic cyst is a rare
entity. It is usuallyseen in adults as a residue of a pineal
diverticulumor related to a degenerative process in the centralcore
of the pineal gland (Russell and Rubinstein,1971).Subarachnoid
haemorrhage associated with
brain tumour is uncommon. Locksley et al. (1966)found only 28
cases among 5836 patients withsubarachnoid haemorrhage.
Subarachnoid haemor-rhage from pineal tumour is
particularlyexceptional. Steinbock et al. (1977) recently re-ported
two cases of pineocytoma presenting assubarachnoid haemorrhage, and
they believed thatthese were the first examples of
pineocytomaspresenting in such fashion. Our present case alsohad
subarachnoid haemorrhage as an initialsymptom. In view of the
operative findings, bloodclots outside the capsule may reasonably
explaina subarachnoid haemorrhage secondary to ruptureof the
haematoma capsule.Haemorrhage from a vascular anomaly or
vascular tumour in the pineal region is also rare.Miller (1961)
reported a case with haematoma inthe posterior third ventricle
caused by haemor-rhage from a cavernous haemangioma involvingthe
cistern of the great cerebral vein and associ-ated recurrent
subarachnoid haemorrhage.Although such an aetiology must be
considered inour case, we were unable to find either an ab-normal
vascular shadow in the angiograms or anyvascular anomaly on
histology. On the basis ofthe operative findings and the histology
of thehaematoma capsule, we concluded that this is acase of
haemorrhage into a pineal cyst similar tothe case of Apuzzo et al.
(1976). The haematomacapsule was totally removed by
microsurgery.Nevertheless, upward gaze palsy developed
post-operatively, probably because of damage topretectal tissue
during surgery.
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Pineal apoplexy
References
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1053
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