8. Goel A, Dange N. Immediate postoperative regression of retroodontoid pannusafter lateral mass reconstruction in a patient with rheumatoid disease of thecraniovertebral junction: case report. J Neurosurg Spine 2008;9:273–6.

9. Jun BY. Complete reduction of retro-odontoid soft tissue mass in osodontoideumfollowing the posterior C1–C2 transarticular screw fixation. Spine1999;24:1961–4.

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11. Ito K, Sakai K, Yako T, et al. Atlantoaxial dislocation associated with a mass inthe extradural craniovertebral junction unrelated to rheumatoid arthritis: casereport. Neurol Med Chir (Tokyo) 2007;47:182–5.

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doi:10.1016/j.jocn.2009.08.009

652 Case Reports / Journal of Clinical Neuroscience 17 652–653

Cavernoma in the pineal region

Antonio Figueiredo a, Shradha Maheshwari a, Atul Goel b,*

a Lilavati Hospital and Research Centre, Bandra West, Mumbai, Indiab Department of Neurosurgery, Seth G.S. Medical College and King Edward Memorial Hospital, Acharya Donde Marg, Parel, Mumbai 400012, India

a r t i c l e i n f o

Article history:Received 2 August 2009Accepted 4 August 2009

Keywords:CavernomaMidbrainPineal region

a b s t r a c t

A 19-year-old girl presented with symptoms of severe headache and diplopia. Investigations revealed alarge and partly calcified lesion in the pineal region. At surgery a large cavernoma was identified and wasradically resected. Following surgery, the patient recovered from all her symptoms. Giant cavernomas inthe pineal region are rare. The literature on the subject is reviewed.

� 2009 Elsevier Ltd. All rights reserved.

1. Introduction

Although brain cavernomas have been found in up to 0.5% of thepopulation in a large autopsy and MRI series,1,2 these lesions arenot common in clinical practice and the true prevalence of caver-nomas is largely unknown. Location of cavernomas in the pinealregion is particularly uncommon.3 We report a patient with acavernoma in the pineal region, review the literature and discussits management.

2. Case report

A 19-year-old girl had moderate headaches for 8 months. Theheadaches worsened acutely over 15 days and she developed dip-lopia. She had bilateral papilloedema. There was no clear gazerestriction or extraocular muscle weakness. There was no otherneurological deficit.

Investigations revealed a large, partly calcified, enhancing le-sion in the region of the pineal gland accompanied by moderatehydrocephalus. She underwent surgery by a supracerebellar infra-tentorial approach (Fig. 1). During the operation a large lesion wasidentified with multiple blood vessels over its surface and withinit. There were areas suggesting old hemorrhage, and of xantho-chromia within and around the lesion. The entire lesion was dis-sected progressively from the adjoining neural structures and

* Corresponding author. Tel.: +91 22 24129884; fax: +91 22 24143435.E-mail address: atulgoel62@hotmail.com (A. Goel).

resected. There was a relatively well-defined plane of dissection.Histopathology of the lesion showed multiple large vascular chan-nels in various stages of hemorrhage along with thrombosis andcalcification in some vessels, confirming the operative impressionof a cavernoma (Supplementary Fig. 1). The patient recovered rap-idly from her symptoms, and at 2-year follow-up, she was asymp-tomatic. Repeat investigation at this time confirmed resection ofthe lesion (Supplementary Fig. 2).

3. Discussion

Cavernomas in the region of the pineal gland are rare. Ourliterature search revealed 16 reported cases of cavernomas in thislocation,4 the youngest patient being 4 weeks old.5 Our patient wasyoung and the lesion was large with areas of calcification. Theseclinical and tumor morphological characteristics could easilybe mistaken for those of other pineal region tumors such aspineocytoma, pineoblastoma and germinoma, all of which may ex-hibit calcifications. The large lesion, presence of large blood vesselsand the location close to the midbrain and other critical structuresmade surgery a formidable task. Surgical resection was made eas-ier by a relatively well-defined plane of dissection in this patient.The histology confirmed the lesion to be cavernous hemangiomain the majority of reported patients,4 but mixed hemangioma hasalso been reported.5,6 Total resection of the lesion was achievedin nine reported patients.4,7 Partial resection of the tumor was re-ported to have led to repeated episodes of subarachnoid hemor-

Fig. 1. (a) Sagittal T1-weighted MRI showing an isointense pineal region tumor; (b) axial T2-weighted MRI showing the lesion and the multiple flow-voids/calcifications; (c)sagittal contrast-enhanced T1-weighted MRI showing the lesion to heterogeneously enhance; and (d) axial contrast-enhanced CT scan showing the lesion and the calcifiedareas within the tumor.

Case Reports / Journal of Clinical Neuroscience 17 652–653 653

rhage and subsequent death.8 In our patient, radical resection ledto recovery from all symptoms.

Cavernomas in the pineal region are likely to be either missed ormisdiagnosed because they are rare, and as a result the patientmay receive inappropriate treatment such as stereotactic biopsyor radiation.9 Cerebrospinal fluid diversionary shunt surgery cansafely be avoided in patients with cavernomas. Successful resec-tion of an entirely benign cavernoma is curative, compared to mostother tumors in this region, most of which will need prolongedtreatment and care.

We conclude that cavernomas in the region of the pineal glandare rare but are benign, eminently resectable and curable com-pared to other lesions in the region.

Appendix A. Supplementary material

Supplementary data associated with this article can be found, inthe online version, at doi:10.1016/j.jocn.2009.08.009.

doi:10.1016/j.jocn.2009.08.009

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3. Slavin KV, Dujovny M, McDonald LW, et al. Pineal region: rare location ofcavernous haemangioma. Neurol Res 1994;16:133–6.

4. Muzumdar DP, Mishra BK, Bhaduri AS. Pineal region cavernoma. Neurol Med Chir(Tokyo) 2000;40:372–9.

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