The boy who couldn't look up: Curing Parinaud's Syndrome

The first thing I noticed was that he never looked me in the eye. Not out of shyness. Not out of teenage indifference, which is a diagnosis in itself. He simply couldn’t look up. He was 16, bright, funny, and increasingly frustrated by headaches, nausea, and difficulty reading the blackboard at school. His parents had noticed something peculiar: whenever someone called his name, he moved his entire head instead of only his eyes. “Look at the ceiling,” I said. He tried. His eyes barely moved.

Deep within the centre of the brain, a tiny tumour in the pineal region was quietly causing havoc. By blocking the cerebral aqueduct—the narrow channel through which cerebrospinal fluid flows—it had produced hydrocephalus, increasing pressure within the brain. At the same time, it had compressed the centres responsible for vertical gaze, producing a classic condition called Parinaud’s syndrome. In simple terms, the boy who should have been looking up at the future could no longer physically look up at all.

What made the diagnosis even more fascinating was its location. The pineal gland is one of the smallest structures in the brain, scarcely larger than a grain of rice, and yet, it has inspired centuries of speculation. Hidden deep between the two hemispheres, it sits alone, unlike most structures in the brain that come in pairs. Perhaps that is why the philosopher René Descartes famously called it “the seat of the soul”, believing it to be the point where mind and body met. Mystics, theologians, and spiritual traditions have long attached significance to it, often referring to it as the third eye or the centre of higher consciousness.

Modern science is more practical, of course. We now know that the pineal gland regulates melatonin and our sleep-wake cycle. Yet, standing in an operating theatre, preparing to approach one of the deepest regions of the brain, it is difficult not to feel some of the wonder that captivated philosophers centuries ago. As William Blake wrote, “If the doors of perception were cleansed everything would appear to man as it is, infinite.” Few instances in neurosurgery feel closer to that idea than when working in the pineal region.

Reaching the tumour requires one of the most beautiful approaches in brain surgery. There are no direct roads to the pineal region, only narrow anatomical corridors. We approached through the space between the cerebellum and the tentorium—the supracerebellar infratentorial route—allowing gravity to gently assist us as we worked beneath the occipital lobes towards the centre of the brain. The deeper one travels in neurosurgery, the less room there is for bravado. Delicate veins glistened under the microscope like silver threads. The deep venous system, the tectal plate, and the hidden recesses of the brain gradually came into view. Finally, there sat the tumour, quietly occupying a space where it did not belong. Pineal surgery has always felt almost philosophical to me: You spend hours traversing darkness to reach a tiny source of trouble buried at the very centre.

The following morning, I walked into the intensive care unit and found him sitting up in bed. “Good morning,” I said. He looked directly at me. Then, without thinking about it, he looked upward. It was such a simple movement, one that many of us perform thousands of times a day without thinking, without feeling gratitude. Yet, in that moment, it felt miraculous. Eventually, his headaches improved. The hydrocephalus resolved. The pressure within his brain normalised.

Over the following weeks, life slowly returned to being ordinary—which is perhaps the greatest gift medicine can offer. During one follow-up visit, he asked me whether I thought Descartes had been right about the pineal gland being the seat of the soul. I told him honestly that I didn’t know. The deeper I go into the brain, the more I realise how much remains mysterious. We can remove tumours, restore vision, and relieve pressure, but consciousness, hope, love, and wonder continue to evade precise explanation. As Marcel Proust observed, “The real voyage of discovery consists not in seeking new landscapes, but in having new eyes.” Perhaps that is what medicine does at its best—it doesn’t merely change the brain, but it changes the way we see.

As he was leaving, he paused by the door and looked out through the window towards the sky, a sky he had been unable to look at for months. Then he turned back and smiled. “Doctor,” he said, “after all that talk about the soul, my mother only has one question.” I asked him what that was. “She wants to know if the surgery improved my grades.” I laughed. “Unfortunately,” I replied, “that’s a completely different department.” Some mysteries, it seems, remain beyond the reach of even the most sophisticated neurosurgery.

The author is consultant neurosurgeon at Wockhardt Hospital, Mumbai.

mazdaturel@gmail.com @mazdaturel