PMC4508677_01
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.
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F1
One month prior to admission, the patient was diagnosed with a brainstem infarction (Fig. 1A) and treated with clopidogrel (75 mg) in addition to his regular medications including aspirin (100 mg). At that time, MR images demonstrated an incidental small cyst in the pineal region without ventriculomegaly (Fig. 1B).
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.
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F2
Initial CT scans demonstrated a high density mass lesion in the pineal region and dilatation of the lateral/third ventricles with intraventricular hemorrhage (Fig. 2A). MR imaging suggested acute hemorrhage with iso intensity on T1-weighted (WI), low intensity on T2-WI without enhancement on Gd-enhanced T1-WI sequence (Fig. 2B, C).
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, x400.
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F3
Tokyo). The cyst wall was observed after removal of clot of third ventricle (Fig. 3A). Although minor bleeding from the vascularized parts of the cyst occurred during removal of intracystic hematoma, complete hemostasis was obtained following artificial CSF irrigation (Fig. 3B). There was no evidence of tumor cells in the any of the specimens (Fig. 3C).
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.
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F4
One year after surgery, MR imaging demonstrated membranous tissue obstruction at the entrance of the aqueduct, a post-ETV CSF flow void between the third ventricle and prepontine cistern, and evidence of any cystic lesion in the posterior third ventricle (Fig. 4A, B).