Presentation
Headache and diplopia for past 2-3 days. No significant background medical history.
Patient Data
Solid dense pineal region mass with no discernible enhancement. Two small foci of calcification lie to the left of the lesion posterosuperiorly. This likely represents normal pineal calcification.
There is impression on the midbrain, posterior aspect of the third ventricle and aqueduct, with early obstructive hydrocephalus and dilatation of the supratentorial ventricles and temporal horns.
Management: Initial MRI showed acute blood in the pineal region. The patient developed obstructive hydrocephalus and frontal EVDs were inserted. An endoscopic third ventriculostomy was performed. She remained well and discharged with planned surveillance of the lesion with MRI.
The rounded lesion arises to the right of midline from the superior colliculi of the tectal plate. It demonstrates mixed T2 hyperintensity with a low T2 signal rim and is isointense on T1 with minimal areas of internal enhancement. There is peripheral hemosiderin staining.
The lesion is partially effacing the cerebral aqueduct of sylvius. This appears to remain patent. No hydrocephalus.
The lesion had remained unchanged in size across the prior MRIs.
Case Discussion
Brainstem cavernous malformations may cause significant neurological impairment due to hemorrhage.
Rate of re-hemorrhage is estimated at 30-60% per person/year. Hemorrhage may be fatal in ~20% of cases 1.
MRI is the investigation of choice. They are typically described as having a 'popcorn' appearance due to a rim of surrounding signal loss is due to hemosiderin which demonstrates prominent blooming on susceptibility-weighted sequences.
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