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Pineal region cavernoma

Case contributed by: Dr Frank Gaillard

Presentation:

Increasing headache and confusion. Diplopia.

Patient Data:

Age: Adult

CT brain

Modality: CT

In the region of the pineal gland or mesencephalic tectum is a large well circumscribed hyperdense mass. The ventricles are enlarged and sulci effaced consisted with hydrocephalus. 

MRI brain

Modality: MRI

The ventricles have significantly reduced in size and the mass in the dorsal midbrain is still visible, again with peripheral hemosiderin and internal heterogeneous signal. There is no restricted diffusion. No surrounding oedema. 

A prominent flow void is seen through the floor of the third ventricle in keeping with a third ventriculostomy. This is best seen on axial T2 images. 

The patient remained well for 6 months, until the presented acutely with right sided weakness. 

MRI brain - 6 months later

Modality: MRI

The previously described cavernous haemangioma is again visible. On the left side of the lesion is a region of very high T1 signal with surrounding oedema involving the thalamus and cerebral peduncle. 

The patient went on to have a craniotomy and resection of the cavernoma. Histological examination confirmed the diagnosis. 

MRI brain - post op

Modality: MRI

The previously described cavernous malformation has been excised. Hemosiderin staining of the resection margins remains. Flow void through the floor of the third ventricle is still easily visible. 

Case Discussion:

Cavernous malformations (also known as cavernomas or cavernous haemangiomas) can occur anywhere in the brain or spinal cord but have fairly consistent imaging findings. When larger or in unexpected locations they can lead to confusion. 

In themselves they are non-aggressive, but they do have a predilection to repeatedly leak / haemorrhage. Complete resection is curative. 

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