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Published on: June 28, 2024
Endoscopic surgery for hemorrhagic pineal cyst following antiplatelet therapy: case report
Yoji Tamura1, Yoshitaka Yamada, Adam Tucker
1Department of Neurosurgery, Osaka Medical College.
Insights
Hemorrhagic pineal cysts causing obstructive hydrocephalus are rare. Endoscopic surgery effectively treated a patient on antiplatelet therapy, highlighting the risk of pineal apoplexy in such cases.
Area of Science:
- Neurosurgery
- Neurology
- Radiology
Background:
- Pineal cysts in the third ventricle can rarely cause acute obstructive hydrocephalus due to internal hemorrhage.
- Patients on antiplatelet therapy may have an increased risk of pineal apoplexy.
Observation:
- A 61-year-old male on antiplatelet medication developed sudden headache and diplopia.
- Neurological examination revealed clouded consciousness and Parinaud syndrome.
- CT scans confirmed a hemorrhagic mass in the posterior third ventricle.
Findings:
- The patient underwent emergency external ventricular drainage followed by endoscopic biopsy and third ventriculostomy.
- Histological examination showed pineal tissue with necrosis, excluding tumor cells.
- One-year follow-up MRI showed resolution of the cyst and no recurrence.
Implications:
- Asymptomatic pineal cysts in patients on antiplatelet therapy warrant careful consideration due to the risk of 'pineal apoplexy'.
- Endoscopic management offers an effective treatment strategy for hemorrhagic pineal cysts causing obstructive hydrocephalus.
- This case underscores the importance of recognizing rare complications of common conditions and the utility of minimally invasive neurosurgical techniques.
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.
