PMC2810602_01
Brain CT and MR imaging showing the acute hemorrhage in the pineal region extending to the third ventricle.
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F1
The brain CT and MR imaging showed acute hemorrhage in the pineal region extending to the third ventricle (Fig. 1).
Conventional 4-angiography revealed no vascular anomaly.
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F2
To rule out the vascular malformations, we performed a 4-vessel angiography procedure, but we could not locate any vascular anomaly (Fig 2).
Follow-up brain CT demonstrating the repeat hemorrhages in the pineal region and the obstructive hydrocephalus. A follow-up brain CT demonstrates the presence of a newly developed hemorrhage and the enlarged ventricles (A and B). We treated the acute hydrocephalus by shunting (C). Two days after shunting, the patient's condition further deteriorated and he became stuporous. Repeat brain CT reveals the presence of a new, huge hemorrhage of different ages in the pineal region and the aggravated hydrocephalus (D).
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F3
A follow-up brain CT demonstrated the presence of a newly developed hemorrhage and enlarged ventricles (Fig. 3A and B). Heyer-Schulte highpressure shunt system (Fig. 3C). However, the patient's condition continued to deteriorate and he became stuporous 2 weeks after the shunting. We repeated the brain CT and it revealed the presence of a new, huge hemorrhage in the pineal region that was of a different age than the previous lesion, and the patient's hydrocephalus had worsened (Fig. 3D).
Follow-up brain MRI revealed no residual mass, and the postop changes.
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F4
The patient was subsequently cured with some residual limitation of the upward gaze remaining (Fig. 4).
PMC2810602_02
Brain CT showing the acute hemorrhages in the pineal region extending into the third ventricle and spots of calcification (A). This hemorrhage shows mixed signals with different ages on T1- and T2 weighted MR imaging (B and C). There was no vascular abnormality on the MR angiography (D).
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F6
The brain CT showed acute hemorrhage in the third ventricle and there were also spots of calcification (Fig. 6A). T2-weighted MR (Fig. 6B and C). The clinical differential diagnosis was primarily split between intratumoral hemorrhages originating from a pineal germ cell tumor, specifically choriocarcinoma vs. hemorrhage from a pineal cyst. The presence of a cavernous malformation was considered to be a less likely diagnostic possibility. We were easily able to rule out the possibility of vascular malformations because MR angiography revealed no such abnormalities (Fig. 6D).
Follow-up Brain CT in case 2. Brain CTs, performed weekly after the first attack of symptoms, reveal the resolving hemorrhage and progressively enlarged ventricles (A, B, and C). Rebleeding from the previous lesion is found on the brain CT 2 days after shunting (D).
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F7
Brain CTs, performed weekly after the first attack of symptoms, revealed a resolving hemorrhage and the progressively enlarging ventricles (Fig. 7A, B, and C). The follow-up brain CT revealed rebleeding from the previous lesion (Fig. 7D).
Follow-up brain MRI revealed no residual mass, but there is hemosiderin deposition from old hemorrhagic residue at the posteromedial aspect of the right thalamus and roof of the third ventricle.
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F8
After surgery, his conjugation problem was not completely resolved right away, but he was otherwise in good health (Fig. 8).
Histologic examination showed the presence of a cavernous malformation composed of hematoma, variable sized vascular channels (A, x40) and hyalinized vascular channels without intervening glial tissue (B, x100).
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F9
The pathology of this case was confirmed as being a cavernous malformation (Fig. 9).