Presentation
Severe headache, vertigo since <24 hours.
Patient Data
- an about 15 mm partially calcific, cystic lesion is visible in the pineal gland, which seems to compress the cerebral aqueduct, as the lumen is barely discernible in the sagittal plane
- supratentorial ventricles somewhat enlarged considering the age group and the absent prior morbidity
- large mucosal retention cyst in the right maxillary sinus
The possibility of aqueductal stenosis due to the cystic lesion was raised, and further assessment with MRI, and in particular dynamic liquor flow imaging was recommended.
The MRI demonstrates the septated internal structure of the cystic pineal lesion, with coarse SWI signal dropout also indicating calcifications. No increased internal constrast enhancement is observed in the lesion. On the dynamic liquor imaging sequence the aqueduct is narrowed, but the CSF flow signal is maintained.
Case Discussion
Larger (>10 mm) and symptomatic pineal cystic lesions mandate contrast enhanced MRI to differentiate them from pineocytomas. Larger pineal cysts such as this one may show atypical features such as a multilocular, worrisome structure, coarse calcifications, and may exert a mass effect on the tectal plate or the aqueduct.