Pineal apoplexy

Pineal apoplexy is rare and refers to the sudden neurological deterioration following haemorrhage in the pineal region, most commonly into a pineal cyst. 

Epidemiology

The condition is rare and since it results from bleeding from or into an underlying pineal region mass, no single demographic can be identified.

Clinical presentation

As is the case with the far more common pituitary apoplexy, the term pineal apoplexy refers to a sudden neurological event similar to, and sometimes due to, subarachnoid haemorrhage. Patients develop a sudden severe headache, with associated features including drop in conscious level and meningism. 

Pathology

Aetiology

Underlying lesions include:

• pineal cyst (most common)
• pineal tumour
• vascular malformation
  • cavernoma ²

Radiographic features

CT

• visualisation of blood
  • acute haemorrhage may be seen as a hyperattenuating lesion in the pineal region
  • haematocrit effect may be visible (gradual shading or fluid fluid level)
• effects of enlargement
  • normal pineal calcification may be displaced
  • obstruction of aqueduct leading to hydrocephalus

MRI

MR findings in the pineal apoplexy follow the typical findings of intracranial haematoma at different ages (see ageing of blood on MRI).

A pineal cyst accident is the most common cause of pineal apoplexy, haemorrhage may frequently appear as haematocrit level in a pineal cyst.

Treatment and prognosis

Surgical excision is believed to be the most effective treatment that reduces the risk of recurrence and complications, but stereotactic aspiration has been also practiced in some studies ⁴.