Department of Pathology, University of Oklahoma Health Sciences Center
January 2009, Case 901-1.
A 49 year-old man with headache and a pineal mass.
The patient was a 49 year-old Caucasian man who presented with a six week history of headaches and complaint of “pressure” in his head. Despite attempted treatment with antibiotics for suspected sinusitis, the patient’s symptoms of pain and pressure worsened significantly during the fifth and sixth weeks. A CT scan performed in an outside hospital was reported to be negative for sinusitis. The patient subsequently presented to the neurosurgical service of this hospital.
His chief complaint was headache. He denied any visual changes, nausea, vomiting, focal weakness or paresthesias. Physical exam was unremarkable with no significant abnormal findings. On neurologic exam, the patient was found to be neurologically intact with no frank papilledema and no focal findings other than bilateral optic disc margin elevation. The patient was married with a past medical history of interstitial cystitis. He denied any use of tobacco or illicit drugs, any excessive alcohol consumption and any recent travel.
An MRI of the brain with and without contrast revealed a 2.6 x 1.3 x 1.6 cm (AP x CC X W) heterogenous lesion within the region of the pineal gland and projecting into the third ventricle. The lesion had both solid and cystic components and demonstrated heterogenous enhancement on T1-weighed images. The enhancement is located medial to the veins of Rosenthal, inferior to the cerebral veins, and posterior to the vein of Galen. The mass is isointense to the cortex on T2-weighed images. No significant midline shift or significant edema was observed. The ventricular system was prominent in size, consistent with mild hydrocephalus. Basilar cisterns were preserved and normal cerebrovascular flow-voids were seen. No abnormalities of the cerebellar or cerebral parenchyma, the brainstem or the cervical spinal cord were observed. Dural venous sinuses and meninges were unremarkable. Regions of the orbit and sella were unremarkable. Paranasal sinuses demonstrated paranasal sinus disease of the bilateral maxillary and left ethmoidal sinuses.
The patient was placed on dexamethasone and a third ventriculostomy with endoscopic biopsy of the pineal mass was performed. As per the neurosurgeon, the tumor appeared pedunculated. The following are representative images.
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Cases of the Month Evaluation Coordinator: KarMing-Fung@ouhsc.edu
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