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Do my head in

Updated: Oct 16, 2023

41M was brought in by ambulance with reduced GCS 8 (E2,V2,M4) to A&E. According to the mom who rang for help, he was complaining of headache, vomiting, difficulty looking up and double vision.

On assessment:

He is not alert and snoring away. On head-tilt chin lift, his snoring improves. Oxygen saturation is 91% on room air but improves to 93% with 15L non-rebreathe mask, respiratory rate is 13 per minute. Chest is clear on auscultation and resonant on percussion with good equal expansion bilaterally. Heart sounds are 1+2+0 regular with a heart rate of 59 beats per minute. Blood pressure is 194/102 mmHg. GCS is E2,V2,M4. Pupils are 3mm bilaterally and sluggish on light reflex. No formal cranial nerve exams and peripheral limb assessment carried out due to low GCS. Abdomen is soft non tender and calves are soft non tender. Blood sugar is 7mmol/L.

What would your next step be? Pick one answer from the following.

  • Bloods - FBC, U&Es, LFTs, Coagulation profile

  • CT brain

  • Lumbar puncture

  • Electrocardiogram (ECG)



The patient is safely intubated and sedated by the anaesthetic team prior to the CT brain.

Investigation Results

What can you interpret from the CT scan?

What can you interpret from the CT brain? Pick one or more answer.

  • Cerebral Abscess

  • Normal Pressure Hydrocephalus

  • Acute Hydrocephalus

  • Glioblastoma

You can vote for more than one answer.


He was then reviewed by the neurosurgical team with plan for surgical management of the acute hydrocephalus. Following discussion with the consultant, the team opted for an external ventricular drain (EVD) insertion on the right side.


Pineal Gland Tumour

QOV: Function and anatomy of pineal gland

Located in the epithalamus, pineal gland projects inferoposteriorly into the quadrigeminal cistern. The structure sits in a depression between the two superior colliculi. Superiorly bounded by splenium of corpus callosum, laterally by thalamus, and anteriorly by the third ventricle. Histologically, consisted of 95% pinealocytes with dendritic process and 5% neuroglial cells.

Pineal gland is a neuroendocrine secretory circumventricular organ which produces melatonin to modulate sleep patterns.


More common in children compared to adults

3-11% in paediatrics

< 1% in adults

Primary pineal tumours subtypes include 2 main groups:

1. Pineal parenchymal tumours

a. Pineocytoma

b. Papillary tumour

c. Pineal parenchymal tumour of intermediate differentiation

d. Pineoblastoma

2. Germ cell tumours

a. Germinoma

b. Choriocarcinoma

c. Teratoma

d. Embryonal carcinoma

e. Yolk sac tumour

f. Mixed germ cell tumour

Pineal germ cell tumours derived from primordial germ cells accounting for 50% of all paediatric germ cell tumour with germinomas being the most common subtype.

Primary CNS pineal region tumours can be categorised into 4 grades:

Grade 1: Pineocytoma

Grade 2/3: Pineal parenchymal or papillary tumours

Grade 4: Pineoblastoma


Further imaging including MRI brain with contrast will provide confirmation of the pineal gland tumour in case of uncertainty. This is due to differentials from other structures such as midbrain glioma, and brainstem gliomas.

CSF tumour marker can be used together with histological sample to aid diagnosis. Germinomas are associated with raised CSF beta HCG, placental alkaline phosphatase (PLAP) and alpha fetoprotein (AFP).


Treatment is dependent on the subtypes of pineal gland tumour which includes surgical resection, stereotactic radiosurgery and chemoradiotherapy. But in most cases, pineal gland tumour tends to present with acute hydrocephalus (up to 70%) which will need acute surgical management.

Three different forms of surgery can be provided to relief the raised intracranial pressure:

  1. External ventricular drain (EVD) insertion

  2. Endoscopic third ventriculostomy (ETV) +/- biopsy of the lesion

  3. Shunting such as ventriculoperitoneal shunt (VPS)*

Management of acute hydrocephalus for midbrain mass remained controversial due to preferences from different surgical team. EVD is only a temporising management to relief the high intracranial pressure. This is due to the increased risk of cerebral infection associated with prolonged EVD use. ETV on the other hand is a well recognised minimially invasive procedure to relief acute obstructive hydrocephalus from midbrain tumour which has the added benefit of lesion biopsy. This will provide further knowledge on the type of lesion and how it can be further managed. Germ cell tumours are typically radiosensitive which can be managed conservatively whilst pineal parenchymal tumours may benefit from surgical removal.

*The placement of VPS has lost its favour due to increased risk of shunt malfunction as well as peritoneal seeding.

Food for thoughts

  • What is the breakdown of Glasgow coma scale (GCS)?

  • What kind of clinical syndrome does the signs and symptoms above point towards?

  • Can you explain why this gentleman's blood pressure is high and heart rate is low?

  • Why would the surgical team opt for EVD insertion on the right rather than the left?

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