Spontaneous pineal apoplexy in a pineal parenchymal tumor of intermediate differentiation

Abstract

Pineal apoplexy is a rare clinical presentation of pineal parenchymal tumors. We report the curative treatment of a case of pineal parenchymal tumor of intermediate differentiation with spontaneous apoplectic hemorrhage. This case is shown through computed tomography and magnetic resonance imaging of the brain, and is confirmed via histopathological studies. Recurrent upward gaze paresis was observed after the stereotactic biopsy. The paresis required an expeditious tumor resection. The mechanism of the pineal apoplectic hemorrhage remains unclear although it has been observed in different pineal region lesions. Clinical and radiological evidence of the cure 5 years post-surgery is available.

Keywords: Apoplexy; Parinaud’s syndrome; obstructive hydrocephalus; pineal gland; pineal parenchymal tumor.

Figure 1

A. The plain CT scan shows a hyperdense pineal mass, which is suggestive of hemorrhage; B. The lesion is enhanced with contrast, and causes an obstructive hydrocephalus with the dilatation of the lateral ventricles. Sagittal T1-weighted gadolinium MRI scans; C. The pre-operative scan reveals a 2.0 cm × 2.5 cm pineal lesion with a well-defined margin, which compresses the cerebral aqueduct; D. The repeated scans at the 5-year follow-up shows no recurrence and complete tumor resection. The closeness of the internal cerebral vein and vein of Galen to the tumor should be noted. These veins remain obvious postoperatively. There is evidence of decompression of the ventricles and cerebral aqueduct.

Figure 2

Pineal parenchymal tumor of intermediate differentiation. A. Area of tumors with uniform round nuclei and nucleus-free pineocytomatous rosettes containing fine fibrillary material. One mitosis is seen (arrow) (H&E staining, 400×); B. More cellular area with mild nuclear atypia and no rosettes (H&E staining, 400×); C. Moderate numbers of neurofilament protein expression among the tumor cells (400×); D. Several Ki-67 labeled nuclei of tumor cells (400×).