Symptomatic pineal apoplexy unlike pituitary apoplexy is uncommon. A patient with an apoplectic pineal cyst, identified preoperatively using MRI and confirmed histologically presented with episodic syncope, and features of raised intracranial pressure, but no localizing neuro-ophthalmological signs. This case prompted a review of the clinicopathological features of pineal apoplexy. There are no diagnostic clinical features and the neuropathological associations of pineal region haemorrhage are diverse. There is no consistent clinicopathological syndrome of pineal apoplexy.