Nearoradiologv
Neuroradiology 17, 215-217 (1979)
© by Springer-Verlag 1979
Spontaneous Rupture of a Pineal Teratoma K. Ghoshhajra 1, P. Baghai-Naiini2, H. S. Hahn 1, C. E. Pena 3 and S. Hayat 2 Departments of Radiologya, Neurosurgery2 and Pathology3 MercyHospital,Pittsburgh, Pennsylvania,USA
S u m m a r y . A case of a spontaneously ruptured pineal
teratoma is presented. This was diagnosed by computed tomography (CT) and was confirmed later at operation. K e y words: Pineal gland - T e r a t o m a - Computed
tomography - Calcification
Introduction
Prior to the introduction of CT, the diagnosis of tumors of the pineal region was made by angiography, ventriculography and pneumoencephalography. The histology often remained obscure. With the advent of CT, which can distinguish various tissue densities, the specific diagnosis of a lesion can be made [2, 4]. The demonstration of fat densities from ruptured intracranial epidermoids and dermoids in the ventricular system and subarachnoid spaces by CT has been reported [1, 5, 6]. This communication reports the spontaneous rupture of a pineal teratoma with the demonstration of fat globules throughout the ventricular system and subarachnoid spaces.
Case R e p o r t
A 19-year-old male was admitted with headache and nausea for 3 weeks. There was no loss of consciousness. He noted some difficulty in walking with a tendency to fall to the right. On neurological examination his pupils were unequal (left: 4mm; right:
3 mm) and nonreactive to light and accommodation. Both eyes were deviated downwards. Upward gaze was abolished. Both fundi were normal. He had slight rigidity of the neck. There was no sensory deficit. Mild right hemiparesis and right central facial paresis were present. Deep tendon reflexes were increased on the right with a positive Babinski. No evidence of cerebellar dysfunction was demonstrated. The X-ray film of the skull revealed a linear band-like calcification in the pineal region which was displaced posteriorly, and a circular mass with flecks of calcification at the periphery was seen in the pineal region on the plain CT scan (Fig. 1). The mass measured 2.8 cm in diameter and encroached upon the posterior portion of the third ventricle which appeared dilated. The left thalamic region contained some ill-defined decreased density with a speck of calcification. There were multiple isolated low density (-30 EMI units) structures in both frontal horns, third ventricle, quadrigeminal cistern, interhemispheric fissure and sylvian fissures (Fig. 2). Following contrast infusion, ring-like enhancement of the pineal mass was seen (Fig. 3) with nonhomogenous enhancement extending into the left thalamus. Angiography demonstrated elevation of the internal cerebral vein with AP compression of the vein of Galen. The thalamoperforate and choroidal arteries were hypertrophied and the choroidal arteries were displaced upwards and posteriorly. At operation the tumor was seen to be partially encapsulated and multiple fat globules were present in the CSF. After removal of the cystic part of the mass, a solid gray tumor with cheese-like material and hair, was found infiltrating the left thalamus and posterior limb of the internal capsule. The patient remained comatose after operation and expired 7 weeks later. Postmortem examination was refused. 0028-3940/79/0017/0215/$01.00
216
K. Ghoshhajra et al.: Spontaneous Rupture of a Pineal Teratoma
Fig. 1. Plain CT scan demonstrates large rounded pineal mass encroaching into 3rd ventricle and quadrigeminal cistern Fig. 2. Same CT scan seen at low window level and window width, demonstrates fat densities in ventricular system and subarachnoid spaces
(arrows) Fig. 3. Contrast enhanced CT scan with ring-like enhancement of pineal tumor and involvement of left basal ganglia
dysgerminoma-like tissue that had cells with relatively large nuclei intermingled with lymphocytes. This represented the typical appearance of a pineal teratoma with some dysgerminoma-like material.
Discussion
Fig. 4. Section of cyst with sebaceous gland and keratin material (H.E. X 100)
Pathology Approximately 50g of tissue was available for examination. Grossly the tumor was composed of cystic as well as solid areas. The former contained a mucinous fluid whereas the latter appeared pearly and had occasional hairs. Microscopically (Fig. 4), the tumor consisted of well-differentiated mucinous and ciliated epithelium, smooth muscle, bone, and skin with sebaceous glands. There were, in addition, occasional foci of slightly immature cartilage and of
CT enables us to demonstrate detailed density changes occurring within the tumor and its surrounding structures. Specific diagnosis of intracranial dermoid and epidermoid tumors can easily be made by CT because of their fat content [1, 2, 4, 5, 6]. Four cases of ruptured intracranial dermoid and epidermoid tumors, diagnosed preoperatively by demonstrating fat globules in ventricles and subarachnoid spaces, have been reported [1, 5, 6]. We present a spontaneously ruptured, large, partially calcified pineal teratoma involving the left thalamus with fat globules in the ventricular system and subarachnoid spaces. The tumor ruptured 3 weeks prior to the patient's admission to hospital with the sudden onset of headache. His clinical condition did not deteriorate until after operation. Though spread of cyst material in the subarachnoid space can cause chemical meningitis, it is not necessarily a fatal complication [1, 5, 6].
Acknowledgements. We
are indebted to Dr. L. Scotti, of St. Francis General Hospital for his critical review, to L. D'Amico for secretarial assistance, to V. Froetschel and K. Gesuale for technical assistance and to G. Hangard for photographic reproduction.
K. Ghoshhajra et al.: Spontaneous Rupture of a Pineal Teratoma
References 1. Amendola, M. A., Garfinkle, W. B., Ostrum, B. J., Katz, M. R., Katz, R.I.: Preoperative diagnosis of a ruptured intracranial dermoid cyst by computed tomography. J. Neurosurg. 48, 1035-1037 (1978) 2. Fawcitt, R.A., Isherwood, I.: Radic,diagnosis of intracranial pearly tumors with particular reference to the value of computed tomography. Neuroradiology 11, 235-242 (1976) 3. Hahn, F. J. Y., Rim, K., Schapiro, R. L.: The normal range and position of the pineal gland on computed tomography. Radiology 119, 599-600 (1976) 4. Kleefield, J., Solis, O. J., Davis, K. R., Kleinman, G., Roberson, G.H., Ellis, G.T., Merino, G.: Cx~mputed tomography of tumors of the pineal region. Computed Tomography 1, 257-265 (1977)
217 5. Laster, D.W., Moody, D. M., Ball, M. R.: Epidermoid tumors with intraventricular and subarachnoid fat: Report of two cases. Am. J. Roentgenol. 128, 504-507 (1977) 6. Maravilla, K. R.: Intraventricular fat - fluid level secondary to rupture of an intracranial dermoid cyst. Am. J. Roentgenol. 128, 500-501 (1977) Received: 7 July 1978
Dr. K. Ghoshhajra Department of Radiology Mercy Hospital Pride and Locust Streets Pittsburgh, PA 15219 USA
Neuroradiology 17, 215-217 (1979)
© by Springer-Verlag 1979
Spontaneous Rupture of a Pineal Teratoma K. Ghoshhajra 1, P. Baghai-Naiini2, H. S. Hahn 1, C. E. Pena 3 and S. Hayat 2 Departments of Radiologya, Neurosurgery2 and Pathology3 MercyHospital,Pittsburgh, Pennsylvania,USA
S u m m a r y . A case of a spontaneously ruptured pineal
teratoma is presented. This was diagnosed by computed tomography (CT) and was confirmed later at operation. K e y words: Pineal gland - T e r a t o m a - Computed
tomography - Calcification
Introduction
Prior to the introduction of CT, the diagnosis of tumors of the pineal region was made by angiography, ventriculography and pneumoencephalography. The histology often remained obscure. With the advent of CT, which can distinguish various tissue densities, the specific diagnosis of a lesion can be made [2, 4]. The demonstration of fat densities from ruptured intracranial epidermoids and dermoids in the ventricular system and subarachnoid spaces by CT has been reported [1, 5, 6]. This communication reports the spontaneous rupture of a pineal teratoma with the demonstration of fat globules throughout the ventricular system and subarachnoid spaces.
Case R e p o r t
A 19-year-old male was admitted with headache and nausea for 3 weeks. There was no loss of consciousness. He noted some difficulty in walking with a tendency to fall to the right. On neurological examination his pupils were unequal (left: 4mm; right:
3 mm) and nonreactive to light and accommodation. Both eyes were deviated downwards. Upward gaze was abolished. Both fundi were normal. He had slight rigidity of the neck. There was no sensory deficit. Mild right hemiparesis and right central facial paresis were present. Deep tendon reflexes were increased on the right with a positive Babinski. No evidence of cerebellar dysfunction was demonstrated. The X-ray film of the skull revealed a linear band-like calcification in the pineal region which was displaced posteriorly, and a circular mass with flecks of calcification at the periphery was seen in the pineal region on the plain CT scan (Fig. 1). The mass measured 2.8 cm in diameter and encroached upon the posterior portion of the third ventricle which appeared dilated. The left thalamic region contained some ill-defined decreased density with a speck of calcification. There were multiple isolated low density (-30 EMI units) structures in both frontal horns, third ventricle, quadrigeminal cistern, interhemispheric fissure and sylvian fissures (Fig. 2). Following contrast infusion, ring-like enhancement of the pineal mass was seen (Fig. 3) with nonhomogenous enhancement extending into the left thalamus. Angiography demonstrated elevation of the internal cerebral vein with AP compression of the vein of Galen. The thalamoperforate and choroidal arteries were hypertrophied and the choroidal arteries were displaced upwards and posteriorly. At operation the tumor was seen to be partially encapsulated and multiple fat globules were present in the CSF. After removal of the cystic part of the mass, a solid gray tumor with cheese-like material and hair, was found infiltrating the left thalamus and posterior limb of the internal capsule. The patient remained comatose after operation and expired 7 weeks later. Postmortem examination was refused. 0028-3940/79/0017/0215/$01.00
216
K. Ghoshhajra et al.: Spontaneous Rupture of a Pineal Teratoma
Fig. 1. Plain CT scan demonstrates large rounded pineal mass encroaching into 3rd ventricle and quadrigeminal cistern Fig. 2. Same CT scan seen at low window level and window width, demonstrates fat densities in ventricular system and subarachnoid spaces
(arrows) Fig. 3. Contrast enhanced CT scan with ring-like enhancement of pineal tumor and involvement of left basal ganglia
dysgerminoma-like tissue that had cells with relatively large nuclei intermingled with lymphocytes. This represented the typical appearance of a pineal teratoma with some dysgerminoma-like material.
Discussion
Fig. 4. Section of cyst with sebaceous gland and keratin material (H.E. X 100)
Pathology Approximately 50g of tissue was available for examination. Grossly the tumor was composed of cystic as well as solid areas. The former contained a mucinous fluid whereas the latter appeared pearly and had occasional hairs. Microscopically (Fig. 4), the tumor consisted of well-differentiated mucinous and ciliated epithelium, smooth muscle, bone, and skin with sebaceous glands. There were, in addition, occasional foci of slightly immature cartilage and of
CT enables us to demonstrate detailed density changes occurring within the tumor and its surrounding structures. Specific diagnosis of intracranial dermoid and epidermoid tumors can easily be made by CT because of their fat content [1, 2, 4, 5, 6]. Four cases of ruptured intracranial dermoid and epidermoid tumors, diagnosed preoperatively by demonstrating fat globules in ventricles and subarachnoid spaces, have been reported [1, 5, 6]. We present a spontaneously ruptured, large, partially calcified pineal teratoma involving the left thalamus with fat globules in the ventricular system and subarachnoid spaces. The tumor ruptured 3 weeks prior to the patient's admission to hospital with the sudden onset of headache. His clinical condition did not deteriorate until after operation. Though spread of cyst material in the subarachnoid space can cause chemical meningitis, it is not necessarily a fatal complication [1, 5, 6].
Acknowledgements. We
are indebted to Dr. L. Scotti, of St. Francis General Hospital for his critical review, to L. D'Amico for secretarial assistance, to V. Froetschel and K. Gesuale for technical assistance and to G. Hangard for photographic reproduction.
K. Ghoshhajra et al.: Spontaneous Rupture of a Pineal Teratoma
References 1. Amendola, M. A., Garfinkle, W. B., Ostrum, B. J., Katz, M. R., Katz, R.I.: Preoperative diagnosis of a ruptured intracranial dermoid cyst by computed tomography. J. Neurosurg. 48, 1035-1037 (1978) 2. Fawcitt, R.A., Isherwood, I.: Radic,diagnosis of intracranial pearly tumors with particular reference to the value of computed tomography. Neuroradiology 11, 235-242 (1976) 3. Hahn, F. J. Y., Rim, K., Schapiro, R. L.: The normal range and position of the pineal gland on computed tomography. Radiology 119, 599-600 (1976) 4. Kleefield, J., Solis, O. J., Davis, K. R., Kleinman, G., Roberson, G.H., Ellis, G.T., Merino, G.: Cx~mputed tomography of tumors of the pineal region. Computed Tomography 1, 257-265 (1977)
217 5. Laster, D.W., Moody, D. M., Ball, M. R.: Epidermoid tumors with intraventricular and subarachnoid fat: Report of two cases. Am. J. Roentgenol. 128, 504-507 (1977) 6. Maravilla, K. R.: Intraventricular fat - fluid level secondary to rupture of an intracranial dermoid cyst. Am. J. Roentgenol. 128, 500-501 (1977) Received: 7 July 1978
Dr. K. Ghoshhajra Department of Radiology Mercy Hospital Pride and Locust Streets Pittsburgh, PA 15219 USA
