Hemorrhagic pineal cyst (pineal apoplexy)
2 month history of worsening headache with associated drowsiness, nausea and vomiting, and one episode of blurred vision.
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Well defined cystic lesion within the pineal gland suggestive of a pineal cyst. Fluid-sensitive sequences confirm a fluid-fluid level within the cyst, consistent with a recent/subacute hemorrhage within the cyst (pineal apoplexy).
The walls of the cyst appear considerably dark on fluid-sensitive images, confirming the findings of blood products within the pineal cyst. The location of the cyst causes narrowing of the aqueduct and compression from the posterior aspect, with partially obstructed CSF flow through the aqueduct, though no hydrocephalus or transependymal seepage of CSF is observed.
Pineal apoplexy is a rare sequela of a pineal cyst, characterized by an acute neurological decline secondary to rapid expansion of the pineal lesion, often due to hemorrhage within a pre-existing cyst. The most common presenting complaint is an acute-onset severe headache, which may mimic other types of intracranial hemorrhage.
Expansion of the underlying cyst may progress to cause hydrocephalus and patients may present with symptoms related to this. The precise pathophysiology of pineal apoplexy is not fully understood. Case studies suggest a predisposition towards female patients but due to the rarity of the condition there is a lack of strong demographic data.
MRI is essential to diagnosis, allowing visualization of the cyst, hematocrit effect within the cyst, intracranial blood at different ages, and fluid-fluid levels. MRI also allows visualization of sequelae such as hydrocephalus.
Treatment involves surgical resection or stereotactic aspiration; the former is preferred as it minimizes the risk of recurrence and complications. The most common post-operative complication is diplopia, which may resolve without further intervention.