Endoscopic surgery for hemorrhagic pineal cyst following antiplatelet therapy: case report

Abstract

Pineal cysts of the third ventricle presenting with acute obstructive hydrocephalus due to internal cystic hemorrhage are a rare clinical entity. The authors report a case of a 61-year-old man taking antiplatelet medication who suffered from a hemorrhagic pineal cyst and was treated with endoscopic surgery. One month prior to treatment, the patient was diagnosed with a brainstem infarction and received clopidogrel in addition to aspirin. A small incidental pineal cyst was concurrently diagnosed using magnetic resonance (MR) imaging which was intended to be followed conservatively. The patient presented with a sudden onset of headache and diplopia. On admission, the neurological examination revealed clouding of consciousness and Parinaud syndrome. Computerized tomography (CT) scans demonstrated a hemorrhagic mass lesion in the posterior third ventricle. The patient underwent emergency external ventricular drainage with staged endoscopic biopsy and third ventriculostomy using a flexible videoscope. Histological examination revealed pineal tissue with necrotic change and no evidence of tumor cells. One year later MR imaging demonstrated no evidence of cystic lesion and a flow void between third ventricle and prepontine cistern. In patients with asymptomatic pineal cysts who are treated with antiplatelet therapy, it is important to be aware of the risk of pineal apoplexy. Endoscopic management can be effective for treatment of hemorrhagic pineal cyst with obstructive hydrocephalus.

Fig. 1

Magnetic resonance (MR) image 1 month before onset. A: Axial diffusion-weighted MR image showing a high intensity lesion in the brainstem. B: Axial fluid attenuated inversion recovery MR image showing a small high intensity lesion in the pineal region.

Fig. 2

A: Initial computerized tomography (CT) scan showing a high density mass lesion in the posterior third ventricle with evidence of intraventricular hemorrhage. B, C: Sagittal T₁-weighted (B) and Gd-enhanced (C) magnetic resonance (MR) images showing an iso intensity mass lesion without enhancement.

Fig. 3

Intraoperative photogram of the endoscopic surgery for hemorrhagic pineal cyst. A: The cyst wall (asterisk) was exposed by removal of clot around cyst. B: After resection of the cyst wall, intracystic hematoma was removed with grasping forceps. C: Photomicrograph of cyst specimen revealing pineal tissue with necrotic change. H & E, ×400.

Fig. 4

Axial (A) and sagittal (B) T₂-weighted magnetic resonance (MR) images 1 year after surgery. There was no evidence of residual cystic lesion in the posterior third ventricle. The entrance of the aqueduct was obstructed by membrane and a flow void was demonstrated between the third ventricle and the prepotine cistern.