Presentation
Patient presenting with headache and failure of up-gaze.
Patient Data
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A large well circumscribed mass is located in the pineal region. It is slightly hyperdense on precontrast imaging and demonstrates vivid contrast enhancement. It severely distorts the midbrain, compressing the aqueduct with marked obstructive hydrocephalus. A focus of increased density, probably calcium is seen immediately below the mass, possibly representing displaced pineal calcifications.
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A large well circumscribed mass is located in the pineal region. It is isointense to grey matter on both T1 and T2 weighted imaging with a central region of lower T2 signal (possibly due to a vascular core). It demonstrates vivid contrast enhancement. Restricted diffusion is seen throughout most of the mass, sparing the central region.
It severely distorts the midbrain, compressing the aqueduct with marked obstructive hydrocephalus. Best seen on sagittal post contrast T1 images, a small nodule to tissue is seen immediately below the mass which represents the tectal plate, and given the calcification on CT possibly possibly also a displaced pineal gland.
The internal cerebral veins are located above and the basal veins of Rosenthal below and lateral to the mass.
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A well circumscribed mass (yellow dotted line) is isodense to grey matter and demonstrates vivid enhancement. Posterosuperiorly (blue arrow) it appear continuous with the falx (red dotted line) and appears to displace the tectum and probably pineal gland inferiorly (green dotted line).
The patient went on to have a posterior fossa (sub-tentorial) craniotomy and resection of this tumor.
Histology
The sections show multiple fragments of tumor, some associated with a densely fibrous membrane consistent with dura mater. The tumor shows a variety of growth patterns, including fascicular areas, areas with abundant collagenous fibrous tissue between cells and foci of whorl formation. A very occasional psammoma body is noted. Individual tumor cells are elongate, with fairly abundant eosinophilic cytoplasm, often with poorly circumscribed cytoplasmic outlines. Nuclei are generally rounded or oval, with finely granular nucleoplasm, sometimes with cytoplasmic inclusions.
There are areas of the tumor where cellularity is high, with large crowded nuclei and cells with raised nuclear to cytoplasmic ratio. In such areas, the mitotic count is up to 10 per 10HPF. The features are those of a meningioma, WHO grade 2. No cerebral tissue is recognized and no comment can be made about cerebral invasion.
FINAL DIAGNOSIS: Pineal region tumor - meningioma, WHO grade 2.
Case Discussion
A meningioma, is an uncommon cause of pineal mass. As always it is important to remember that some conditions can occur in unusual places, and one should not limit a differential only to lesions which are characteristic of a particular region.