Endoscopic treatment of a voluminous benign symptomatic cyst of the pineal region responsible for an obstructive hydrocephalus

Asymptomatic non neoplastic cysts of the pineal region are common incidental findings in adults. On the contrary, voluminous and symptomatic cysts of the pineal region are rare and their management are not well defined. We present the case of a 32-year-old woman suffering who suffered from mild intracranial hypertension, gait disturbance and vertigo for one year. The neuroradiological workup showed a voluminous cyst of the pineal region responsible for an obstructive hydrocephalus. An endoscopic etiological treatment was decided. The operation consisted in a marsupialization of the cyst in the third ventricle with a stereotactic guidance system. A frozen section of the cyst wall failed to show tumoral cells. Immediate postoperative course was uneventful. Intracranial hypertension symptoms resolved in 24 hours. Clinical examination and neuropsychological testing were normal at two years postoperatively. The two years follow-up cerebral MRI demonstrated a remnant cystic cavity without mass effect and the patency of the aqueduct of Sylvius. Endoscopic treatment of symptomatic pineal cysts constitutes an interesting therapeutic alternative in the management of this pathology.     

Surgical management of symptomatic pineal cysts.

The authors present a series of six patients with large symptomatic benign pineal cysts and review the 27 patients previously reported in the literature. Patients with symptomatic pineal cysts most often present with one of three syndromes: 1) paroxysmal headache with gaze paresis; 2) chronic headache, gaze paresis, papilledema, and hydrocephalus; or 3) pineal apoplexy with acute hydrocephalus. Surgical intervention with radical cyst removal is the treatment of choice for all symptomatic pineal cysts. Complete cyst removal is desirable; however, radical subtotal resection is appropriate if the cyst cannot be easily separated from the quadrigeminal plate. Ventricular shunting should be reserved for patients with persistent hydrocephalus after cyst resection.     

Symptomatic Pineal Cysts: Clinical Manifestations and Management

Summary.  Between 1991 and 2000, seven patients presented with symptomatic pineal cysts at our hospital (6 females, 1 male). Average age was 22 years (range 4–33 years). Headache was present in 6 patients, who were subsequently operated on. A scotoma and a transient inferior visual field deficit were minor signs in two patients respectively. A Parinaud syndrome with vertical gaze paralysis was found in none. In one child, paroxysmal pupillary dilatations and contractions (`springing pupils') constituted the only signs and a conservative policy was adopted. Four patients presented with hydrocephalus and were treated by an endoscopic resection of their pineal cysts (one stereotactically, three free-hand). Two other patients presented with a prolonged history of symptoms and signs: headache alone in one, headache with discrete neurological deficits in the other. Ventricles in these two patients were not dilated and therefore an open cyst resection by infratentorial supracerebellar approach was performed. Average follow-up in the six “operated” patients was 29 months (range 12–108 months). All four patients treated by endoscopy, are symptom-free at follow-up, whereas the two who were approached by open surgery, are not. Clinical presentation, radiological evaluation and treatment modalities of pineal cysts are discussed and compared with experiences reported in the literature. It is concluded that pineal cysts in the presence of obstructive hydrocephalus are a clear indication for endoscopy with a rigid endoscope.     

Pineal region lesion masquerading choroid plexus papilloma: case report

BACKGROUND: Choroid plexus papillomas (CPPs) are rare intracranial neoplasms, especially in the third ventricle. We report a patient with a posterior third ventricular CPP extending into the pineal that radiographically and clinically presented as a pineal region lesion. CASE DESCRIPTION: In a 51-year-old female with headache and upward gaze impairment radiological examination showed a mass in the pineal region obstructing the aqueduct of Sylvius and causing hydrocephalus. After ventriculoperitoneal shunting the tumor was approached through the infratentorial-supracerebellar approach and pathological examination revealed a typical CPP. CONCLUSIONS: This case represents an unusual presentation of an intracranial CPP. This entity should be considered an extremely rare cause of a lesion in the pineal region.     

Symptomatic pineal cyst: case report and review of the literature

Asymptomatic cysts of the pineal region are common incidental findings in adults. In contrast, symptomatic pineal cysts are rare and their management is not well defined. We present the case of a 39-year-old woman suffering from intracranial hypertension, with visual disturbance and mild papilledema. The MR images showed a voluminous cyst of the pineal region responsible for an obstructive hydrocephalus. Endoscopic treatment with the aid of computerized neuronavigation consisting in third ventriculostomy and fenestration of the cyst was performed. Intracranial hypertension symptoms resolved in 24 hours. The one year follow-up cerebral MR images demonstrated the normalization of ventricular size with patency of the aqueduct of Sylvius. Reviewing the literature demonstrates that the endoscopic approach represents a minimally invasive and safe procedure in the treatment of symptomatic pineal cysts.     

Endoscopic Surgery for Hemorrhagic Pineal Cyst Following Antiplatelet Therapy: Case Report

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.     

Pineal metastatic tumor from lung cancer initially caused by neurological abnormalities of pineal body tumor

A rare case is reported of pineal metastasis from lung cancer initially caused by neurological abnormalities of pineal tumor. A 70-year-old female suffering from headache and deterioration of consciousness for 1 week was admitted. She also had a tumor on both sides of her neck. On admission, neurological examination revealed disturbance of upward gaze, and CT scans showed hydrocephalus and pineal tumor. The tumor was seen as a slightly high density mass on non-contrast CT, and was homogeneously enhanced after administration of contrast material. Right V-P shunt and excision of the left neck tumor were performed at the same time. Pathological diagnosis of neck tumor was undifferentiated carcinoma metastasized to cervical lymph nodes. Extensive study was made, by bronchial fiberscope and biopsy, in order to find the origin of the malignancy and disclosed a small cell lung cancer of left lower lobe. The patient took radiation therapy for both the whole brain (60 Gy) and for the bilateral cervical regions (45 Gy). Two courses of chemotherapy using CDDP, ADR, VCR and CY were administered. Both the neck and the pineal tumors were markedly reduced in size at the termination of radiation therapy. However, she was readmitted 3 months later because of dyspnea. Chest X-P revealed enlargement of the left-lung tumor. She died on April 22, 1987. General autopsy disclosed invasive enlargement of left lung cancer, however, no remote metastasis was found. Examination of pineal region showed only necrotic pineal tissue, and no tumor cell was seen in either macroscopic or microscopic study.(ABSTRACT TRUNCATED AT 250 WORDS)     

Renal cell carcinoma- diagnosis by computed tomography

In approximately 10% of cases, renal cell carcinoma (RCC) could present as a fluid- filled cystic mass. There are three mechanisms by which RCC may become cystic: extensive cystic necrosis, intrinsic cystic growth and origin from the epithelium lining a simple renal cyst. Simple renal cysts are very common. Uncommonly these cysts are complicated by hemorrhage, infection and possibly ischemia. The goal of the radiologist in evaluating these cystic lesions is to distinguish malignant neoplastic cystic masses from non-neoplastic complicated cysts so that appropriate management can be undertaken: RCC is best treated by surgical excision while non-neoplastic complicated cysts do not require surgery. The radiologic findings in these cystic masses which must be carefully evaluated include calcification, abnormal density, septations, nodularity, wall thickening and enhancement.     

Symptomatic pineal cyst: case report

Pineal cysts are being described with increasing frequency since the advent of magnetic resonance imaging. Although pineal cysts are incidental findings in as many as 4% of magnetic resonance imaging studies, symptomatic pineal cysts are quite rare. We present a case of pineal cyst causing aqueductal obstruction with symptomatic hydrocephalus and resultant headache and syncope, which was treated by surgical resection. A review of the relevant literature and discussion follow.     

Multiple epidermoid cysts located in the pineal and extracranial regions treated by neuroendoscopy

A 22-year-old woman presented with a rare case of multiple epidermoid cysts located in the pineal and extracranial regions. Magnetic resonance (MR) imaging showed a lesion in the pineal region as hypointense on the T(1)-weighted image and hyperintense on the T(2)-weighted image, without enhancement. Neuroendoscopic treatment was performed under a diagnosis of pineal cyst. However, the cyst wall was too thick to perforate, although third ventriculostomy was performed. Diffusion-weighted MR imaging demonstrated the lesions in the pineal and extracranial regions as marked hyperintensity. The diagnosis was epidermoid cyst. Subsequently, neuroendoscopic treatment of the pineal epidermoid cyst was performed. Careful preoperative diagnosis of epidermoid cysts based on diffusion-weighted MR imaging is required.     

Intratumoral hemorrhage of cholesterol granuloma in the frontal bone showing rapid progressive symptoms: a case report

A 30-year-old man developed an exopthalmus in his right eye and diplopia at upward gaze those were progressive in two days. On admission, his upper eye lid in the right eye swelled and upward gaze was limited in the right eye. CT scan showed an osteolytic lesion in the right frontorbital bone. MR imaging showed a high signal tumor in both T1- and T2-weighted imaging with sharp margin and no enhancement. Right frontal craniotomy was performed and the cystic tumor consisting of old hematoma, and soft tissue surrounding the cyst was totally removed. The orbital roof had a large defect and tumor compressed periorbita. Neither communication with the frontal sinus nor mucosa with inflammation were seen. The postoperative course was uneventfull and pathological diagnosis was cholesterol granuloma with hematoma. Orbitofrontal bone is a rare site to have cholesterol granuloma. Most of them are asymptomatic. In our case, intratumoral hemorrhage caused compression on the perioribital, leading to a progressive mass sign. Preoperative differential diagnosis from other orbital tumors, such as epidermoid and lipoma was difficult.     

Large cysts of the pineal gland: report of two cases

Two cases of large, nontumorous cysts of the pineal gland are reported, the histopathology of which was confirmed using surgically resected specimens. Both patients were middle-aged, and the pineal cysts were found incidentally. The histopathological findings in the two cases were strikingly similar to each other and were characterized by the following points: 1) the cyst wall typically consisted of three layers, namely, collagenous fibers, glia-like cells, and normal pineal cells; 2) the cyst wall was relatively thin, approximately 100 to 300 microns in thickness; and 3) deposits of calcification almost always existed on the side of the layer of collagenous fiber. Because these findings are clearly different from those previously reported, large benign cysts of the pineal gland, or at least some of them, may constitute a new pathological entity. It is important to consider this possible pathological diagnosis when dealing with pineal cysts.     

Intraneural ganglion cyst of the ulnar nerve in an unusual location: A case report

IntroductionIntraneural ganglion cysts are benign, mucinous, non-neoplastic lesions of the peripheral nerves. While the most common location of intraneural ganglion cysts is the ulnar nerve and its branches, intraneural ganglion cyst involving the superficial branch of the ulnar nerve has not yet been reported.Presentation of caseA-25-year-old woman presented with pain and a palpable mass in the hypothenar region of the volar side of her right hand. Her neuromuscular examination was normal. The pain was unresponsive to nonsurgical treatments. After confirming with imaging modalities, the initial diagnosis was considered as an intraneural ganglion cyst arising from superficial ulnar nerve. Excision of the ganglion and exploration of the articular branch (if seen in operation) decision was undertaken by the senior author. Whether MRI or intraoperative exploration, not identified an articular branch.DiscussionIntraneural ganglion cysts of peripheral nerves may be seen in miscellaneous locations in the body. However, to our knowledge, an intraneural ganglion cyst involving the superficial branch of the ulnar nerve is unique. While a variety of theories have been proposed to enlighten the etiopathogenesis of intraneural ganglia, the latest and most affirmed is the unifying articular (synovial) theory.ConclusionIntraneural ganglion cysts may be seen on the hypothenar side of the palm. The etiology and treatment of choice are closely associated with each other in this rare disorder. It is important to realize a related articular branch, otherwise the origin of cyst formation remains, and this may cause other para-articular cysts.     

A case of Rathke's cleft cyst in association with a ruptured aneurysm of the anterior cerebral artery mimicking pituitary apoplexy

We present a rare case of a Rathke's cleft cyst in association with a ruptured aneurysm of the anterior cerebral artery (ACA). A 44-year-old man suffered from sudden onset of headache. Initial computed tomographic (CT) scan revealed a high-density mass lesion in the suprasellar region and a diffuse high-density area in the basal cistern. Using emergent magnetic resonance imaging (MRI), we found a cyst showed homogeneously high and iso-intensity on T1 and T2-weighted image, respectively. The cyst showed no enhancement of the cyst wall, but on Gd-DTPA, it was shown to compress the normal pituitary gland. Angiography showed an aneurysm at the A1 portion of the left ACA. Based on/these findings, we were able to diagnose Rathke's cleft cyst and a ruptured aneurysm. An operation was performed through the interhemispheric approach. The suprasellar cystic mass compressed the optic nerves and chiasm upward. Neck clipping of the aneurysm and opening of the cyst were performed. We confirmed the cause of the subarachnoid hemorrhage as being a ruptured aneurysm at the A1 portion of the left ACA. Histological diagnosis was Rathke's cleft cyst. Postoperative course was uneventful. There has been only one reported case of Rathke's cleft cyst in association with a ruptured aneurysm. When we encounter a case presenting subarachnoid hemorrhage with suprasellar mass and intracerebral aneurysm, we must discriminate between ruptured aneurysm and pituitary apoplexy in the acute stage as the cause of the subarachnoid hemorrhage. If the mass is Rathke's cleft cyst, we speculate that the cause of the subarachnoid hemorrhage is a ruptured aneurysm, because there are no reports of Rathke's cleft cyst with subarachnoid hemorrhage.     

Cervico-Mediastinal Bronchogenic Cyst Occurring in the Prenatal Period: Report of a Case

We experienced a case of cervico-mediastinal bronchogenic cyst in which a cervical cystic mass was detected by prenatal ultrasonography. On prenatal ultrasound, a unilocular, well-defined and hypoechoic mass was detected in the fetal neck. The baby was born by a normal vaginal delivery at 40 weeks of gestation, and had no respiratory distress. Radiological investigations demonstrated a cyst in the cervico-mediastinal region, which displaced the trachea to the left. At the age of 32 days, an elective resection was easily performed through a right inferior collar incision after first aspirating the contents of the cyst. Prenatal sonography showing abnormal findings is effective for identifying cysts in the perinatal period and allows for the timely resection of such cysts before respiratory distress occurs. Received: October 22, 1999 / Accepted: May 30, 2000     

A case report of a paraesophageal bronchogenic cyst and an esophageal cyst]

There are relatively few paraesophageal bronchogenic and esophageal cysts in mediastinal tumors. It is often difficult to distinguish between these cysts. Case 1: 11 year old, male with no symptoms. An abnormal tumor shadow was revealed by chest roentgenogram. Before operating, CT, MRI and other laboratory tests were suggested that the tumor was neurogenic. A cyst with a pedicle connected to the esophageal muscle layer was found during the operation. Pathological examination confirmed a bronchogenic cyst lined with cartilage. Case 2: 38 year old female with epigastralgia. Upper gastrointestinal series revealed that the thoracic esophagus was smoothly compressed from the outside. CT and MRI showed a well-defined cystic mass in the posterior mediastinum. The cyst bordered the esophagus, but there was no direct communication between them. The pathological findings showed the presence of a double layer of smooth muscle without cartilage which was diagnosed as an esophageal cyst.     

Benign parathyroid cyst causing vocal fold paralysis: a case report and review of the literature

BACKGROUND: Parathyroid cysts are uncommon, frequently asymptomatic lesions of the neck and superior mediastinum. Symptomatic parathyroid cysts are very rare, with roughly only 200 cases reported in the literature. Of these, only nine cases have been reported with recurrent laryngeal nerve (RLN) paralysis METHODS: We report a case of a 49-year-old man initially seen with a 6-month history of worsening hoarseness. Physical examination revealed a palpable 3-cm, firm, smooth, nontender mass of the right thyroid lobe. Fiberoscopic laryngoscopy showed right vocal cord immobility consistent with RLN paralysis. After CT and fine-needle aspiration of the mass, the patient underwent a right thyroid lobectomy. During surgery, the recurrent laryngeal nerve was found to be stretched and adherent to a right inferior lobe mass. RESULTS: Histologic analysis of the surgical specimen revealed a benign parathyroid adenomatous cyst. Postoperatively, the patient's voice improved markedly. This case represents an extremely rare return of function of the RLN after cyst removal. CONCLUSION: Parathyroid cysts should be included in the differential diagnosis for vocal fold paralysis.     

The endoscopic intraventricular management of pineal cysts: a minimally invasive modus operandi

Background

The management of pineal cysts is still debatable, especially for asymptomatic incidental ones. For symptomatic cysts associated with hydrocephalus, the surgical management is mandatory and may include either classical microsurgical approaches to the pineal region or endoscopic trans-ventricular approaches in a minimally invasive philosophy.

Method

The authors expose a stepwise technique to treat a pineal cyst associated with an obstructive hydrocephalus in one procedure gathering a third ventriculostomy followed by an intraventricular marsupialisation of the pineal cyst.

Conclusion

This endoscopic approach allows the treatment of the hydrocephalus and the pineal cyst in one short minimally invasive procedure.     

Pineal region metastasis appearing as hypointensity on T2-weighted magnetic resonance imaging--case report

A 48-year-old female presented with headache and limitation of upward gaze. She had a history of total gastrectomy for gastric adenocarcinoma 2 years previously. Computed tomography with contrast medium and T1-weighted magnetic resonance (MR) imaging with gadolinium showed ring-like enhancement of a solitary mass in the pineal region with obstructive hydrocephalus. T2-weighted MR imaging showed the tumor as hypointense. This MR imaging finding complicated the preoperative diagnosis, but malignancy was suspected from the medical history. The tumor was subtotally resected via the occipital transtentorial approach with a rigid endoscope. Histological examination of the surgical specimen revealed adenocarcinoma cells with extensive coagulation necrosis, which might have contributed to the hypointensity on T2-weighted MR imaging. Correct diagnosis of metastatic adenocarcinoma based only on MR imaging may be difficult in such cases, but metastatic adenocarcinoma of the pineal region must be considered in the differential diagnosis of pineal tumors.     

Tectal plate cyst in adults

Summary Tectal plate cysts are very rare. We report two adult patients with benign tectal plate cyst and secondary hydrocephalus. The first patient had an unusual eye movement disorder with bilateral upper eyelid retraction (Collier’s sign), limited upgaze, severe upgaze evoked nystagmus and retraction nystagmus. The second patient presented with ataxia and failure of upward gaze. Endoscopic fenestration of the tectal plate cyst and endoscopic third ventriculostomy in both cases result in neurological improvement. To the best of our knowledge, similar lesions at this site have not been reported in adults. The differential diagnosis with arachnoid cysts of the quadrigeminal CSF cistern is discussed.