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Azab MA, Atallah O, Hazim A, El-Gohary N, Mostafa H. Pineal cyst apoplexy in a pregnant female: case report and review of literature. BMC Neurol 2025; 25:206. [PMID: 40375163 DOI: 10.1186/s12883-024-03922-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 10/16/2024] [Indexed: 05/18/2025] Open
Abstract
BACKGROUND Pineal cyst is an uncommon condition in pregnancy. It is often encountered as an incidental finding. Most pineal cysts are benign and asymptomatic. Bleeding inside these cysts is rarely encountered in pregnancy. CLINICAL PRESENTATION A 30-year-old female patient with no significant past medical history, presented to the emergency department at 36 weeks gestation with a transient episode of unilateral headache. Headache was associated with dizziness and left arm ascending numbness. She has a history of a known pineal cyst. The neurological examination was normal. INVESTIGATIONS CT head was obtained, reviewed and compared to previous scans 7 years ago. It showed a hemorrhage inside the pineal cyst . MANAGEMENT The patient was admitted to the neurosurgery department for conservative management and a few days later, symptoms gradually improved. FOLLOW-UP Three weeks later, the patient reported spontaneous improvement of the presenting symptoms. The decision was to proceed with continued watchful follow-up and awaiting a caesarian delivery. The patient returned for a follow-up three months later without any symptoms. Following delivery, the patient remained asymptomatic. CONCLUSION Pineal cyst apoplexy is a relatively rare condition and it usually affects young females, however, the exact relation to pregnancy and the effect of apoplexy on the course of pregnancy are not well defined.
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Affiliation(s)
- Mohammed A Azab
- Department of Neurosurgery, Cairo University Hospital, Cairo, Egypt.
| | - Oday Atallah
- Department of Neurosurgery, Hannover Medical School, Hanover, Germany
| | - Ahmed Hazim
- Department of Neurosurgery, Cairo University, Cairo, Egypt
| | | | - Hamed Mostafa
- Faculty of Medicine, Al Azhar University, Damietta, Egypt
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2
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Schmutzer-Sondergeld M, Gencer A, Schmidlechner T, Zimmermann H, Niedermeyer S, Katzendobler S, Stoecklein VM, Liebig T, Schichor C, Thon N. Comparison of surgical approaches and outcome for symptomatic pineal cysts: microscopic/endoscopic fenestration vs. stereotactic catheter implantation. Acta Neurochir (Wien) 2025; 167:27. [PMID: 39888450 PMCID: PMC11785698 DOI: 10.1007/s00701-025-06445-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2024] [Accepted: 01/25/2025] [Indexed: 02/01/2025]
Abstract
PURPOSE Treatment strategies for space-occupying/symptomatic pineal cysts (PC) are still up for debate. In this study we present PC management, outcome data and risk factors for recurrence after surgery, focusing on microscopic/endoscopic procedures vs. stereotactic catheter implantation as alternative treatment concept to permanently drain PC into ventricles/cisterns. METHODS This monocentric retrospective analysis included clinical data from all consecutive PC patients treated surgically between 2000 and 2022. Postoperative neurological and functional outcomes, along with perioperative complications, as well as time to PC recurrence and MR-morphological data were evaluated. RESULTS 39 patients (median age 32.6 years, range: 5.1-71.6 years) were analyzed. Main presenting symptoms were headaches, visual impairment, and epileptic seizures. In 18 patients (46.2%) an enlarged ventricular system was preoperatively found with 7 patients (18.0%) suffering from occlusive hydrocephalus. 14 patients underwent microscopic/endosocopic surgery, in 25 cases stereotaxy was preferred. No complication was seen in the microsurgery/endoscopy group compared to one intracystic postoperative bleeding (2.6%) and two CSF leaks (5.1%) after stereotaxy (p = 0.5). Overall, clinical improvement and significant cyst volume reduction (p < 0.0001) was seen in all patients. Recurrent PC were seen in 23.1%, independent of surgical procedure (p = 0.2). In cases of recurrence, TTR was 25.2 ± 31.2 months. Male gender (p = 0.01), longer surgery time (p = 0.03) and preoperatively increased Evans index (EI) (p = 0.007) were significant risk factors for PC recurrence in multivariate analysis. CONCLUSION In patients suffering from PC, microsurgical and stereotactic approaches can improve clinical symptoms at low procedural risk, with equal extent of volume reduction. However, preoperative ventricular enlargement and EI values should be considered for optimal treatment planning to reduce recurrence.
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Affiliation(s)
- Michael Schmutzer-Sondergeld
- Department of Neurosurgery, LMU University Hospital, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Aylin Gencer
- Department of Neurosurgery, LMU University Hospital, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Tristan Schmidlechner
- Department of Neurosurgery, LMU University Hospital, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Hanna Zimmermann
- Institute of Diagnostic and Interventional Neuroradiology, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Sebastian Niedermeyer
- Department of Neurosurgery, LMU University Hospital, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Sophie Katzendobler
- Department of Neurosurgery, LMU University Hospital, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Veit M Stoecklein
- Department of Neurosurgery, LMU University Hospital, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Thomas Liebig
- Institute of Diagnostic and Interventional Neuroradiology, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Christian Schichor
- Department of Neurosurgery, LMU University Hospital, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Niklas Thon
- Department of Neurosurgery, LMU University Hospital, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, and German Cancer Research Center (DKFZ), Heidelberg, Germany
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Atallah O, Chaurasia B, Badary A, Maria LD, Almealawy YF, Awuah WA, Moustafa W, Ergen A, Fontanella MM. Pineal Apoplexy: Highlighting the Causes, Treatment, and Outcome. J Neurol Surg A Cent Eur Neurosurg 2025; 86:85-98. [PMID: 38788759 DOI: 10.1055/s-0044-1786538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
BACKGROUND Pineal apoplexy, alternatively referred to as pineal hemorrhage or pineal gland hemorrhagic stroke, is an infrequent pathologic condition characterized by bleeding within the pineal gland. In this review, we encompass the primary factors contributing to this uncommon ailment. METHODS The retrieval of pertinent research, including patients with pineal apoplexy, was conducted through PubMed, Google Scholar, and Scopus databases. This study exclusively incorporated comprehensive articles written in the English language. The search encompassed the MeSH terms "pineal apoplexy" and "pineal hemorrhage." RESULTS A total of 41 articles were identified, encompassing a collective sample size of 57 patients. The median age of the patients in the study was 30 years, with a range spanning from 1 to 73 years. There were 27 males, representing 47.4% of the participants. The study identified the most often reported symptoms as headache (49; 86%), nausea/vomiting (19; 33.3%), and Parinaud's syndrome (16; 28.1%). The treatment options encompass several approaches, including open resection, shunting, ventriculostomy, endoscopic aspiration, and conservative care. In the conducted study, a notable number of patients, amounting to 45 cases (78.9%), indicated an amelioration of their symptoms upon their discharge. CONCLUSION Data from a cohort of 57 cases provide insights into symptoms, lesions, treatments, and outcomes. Management approaches range from conservative measures to surgical interventions, with prognosis hinged on timely intervention. This investigation serves as a valuable resource for clinicians and researchers, underscoring the need for early diagnosis before permanent neurologic dysfunction happens and tailored treatments for optimal outcomes in pineal apoplexy cases.
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Affiliation(s)
- Oday Atallah
- Departemnt of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal
| | - Amr Badary
- Departemnt of Neurosurgery, Klinikum Dessau, Dessau-Roßlau, Germany
| | - Lucio De Maria
- Unit of Neurosurgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
- Department of Neurosurgery, University of Brescia, Brescia, Italy
| | | | | | - Wahab Moustafa
- Departemnt of Neurosurgery, Klinikum Dessau, Dessau-Roßlau, Germany
| | - Anil Ergen
- Department of Neurosurgery, Derince Research Hospital, Kocaeli, Turkey
| | - Marco Maria Fontanella
- Unit of Neurosurgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
- Department of Neurosurgery, University of Brescia, Brescia, Italy
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Szathmari A, Vasiljevic A, Di Rocco F, Beuriat PA, Mottolese C. Pineal cysts in children: a paediatric series treated over the last twenty years in Lyon. Childs Nerv Syst 2023; 39:3467-3474. [PMID: 37898987 DOI: 10.1007/s00381-023-06181-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/10/2023] [Indexed: 10/31/2023]
Abstract
BACKGROUND Pineal cysts are a rare lesion of the pineal gland. Pineal cysts are benign lesions, generally asymptomatic, and are usually an incidental discovery on MRI performed for other problems. The management of pineal cysts in children remains a matter for debate. Here, we report our own retrospective paediatric cases that have been surgically treated and review the paediatric literature on this topic. METHODS This is a retrospective monocentric study. All patients operated by the senior author (CM) for a benign pineal cyst from 2000 to 2021 were included. All other pineal region cystic lesions were excluded. Medical and surgical data were extracted from the hospital medical database. RESULTS Twelve patients were included. The clinical symptomatology was characterized by headaches in seven patients, visual troubles in two patients, precocious puberty in one patient, signs of intracranial hypertension in two patients, seizures associated with headache in one patient, and headaches associated with behavioural troubles in another patient. No major post-operative complications were observed in this series. It is to noted that surgery was performed because a suspicion of a true pineal parenchymal tumour has been made. Histopathological study came back with the diagnosis of pineal cyst. CONCLUSIONS Pineal cyst is rare. If the radiological diagnosis is clear, no surgery is advocated except in cases associated with hydrocephalus and rapid growth. In case of a suspicion of a true pineal parenchymal tumour, a surgery may be needed to confirm the diagnosis. Lastly, we stress that only cystic lesions of the pineal gland itself should be considered as pineal cyst.
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Affiliation(s)
- Alexandru Szathmari
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 32 Avenue du Doyen Jean Lépine, 69500, Bron, France
| | - Alexandre Vasiljevic
- Department of Pathology and Neuropathology, GHE, Hospices Civils de Lyon, 69500, Bron, France
| | - Federico Di Rocco
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 32 Avenue du Doyen Jean Lépine, 69500, Bron, France
- Université Claude Bernard, Lyon 1, 69100, Villeurbanne, France
| | - Pierre-Aurélien Beuriat
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 32 Avenue du Doyen Jean Lépine, 69500, Bron, France
- Université Claude Bernard, Lyon 1, 69100, Villeurbanne, France
| | - Carmine Mottolese
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 32 Avenue du Doyen Jean Lépine, 69500, Bron, France.
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5
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Hasegawa H, Inoue A, Helal A, Kashiwabara K, Meyer FB. Pineal cyst: results of long-term MRI surveillance and analysis of growth and shrinkage rates. J Neurosurg 2023; 138:113-119. [PMID: 35623363 DOI: 10.3171/2022.4.jns22276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/12/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Pineal cyst (PC) is a relatively common true cyst in the pineal gland. Its long-term natural course remains ill defined. This study aims to evaluate the long-term natural history of PC and examine MRI risk factors for cyst growth and shrinkage to help better define which patients might benefit from surgical intervention. METHODS The records and MRI of 409 consecutive patients with PC were retrospectively examined (nonsurgical cohort). Cyst growth and shrinkage were defined as a ≥ 2-mm increase and decrease in cyst diameter in any direction, respectively. In addition to size, MRI signal intensity ratios were analyzed. RESULTS The median radiological follow-up period was 10.7 years (interquartile range [IQR] 6.4-14.3 years). The median change in maximal diameter was -0.6 mm (IQR -1.5 to 1.3 mm). During the observation period, cyst growth was confirmed in 21 patients (5.1%). Multivariate logistic regression analysis revealed that only age (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93-0.99, p < 0.01) was significantly associated with cyst growth. No patient required resection during the observation period. Cyst shrinkage was confirmed in 57 patients (13.9%). Multivariate analysis revealed that maximal diameter (OR 1.22, 95% CI 1.12-1.35, p < 0.01) and cyst CSF T2 signal intensity ratio (OR 9.06, 95% CI 1.38-6.62 × 101, p = 0.02) were significantly associated with cyst shrinkage. CONCLUSIONS Only 5% of PCs, mainly in patients younger than 50 years of age, have the potential to grow, while cyst shrinkage is more likely to occur across all age groups. Younger age is associated with cyst growth, while larger diameter and higher signal intensity on T2-weighted imaging are associated with shrinkage. Surgery is rarely needed for PCs, despite the possibility of a certain degree of growth.
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Affiliation(s)
- Hirotaka Hasegawa
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,2Department of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan
| | - Akitoshi Inoue
- 3Department of Radiology, Mayo Clinic, Rochester, Minnesota; and
| | - Ahmed Helal
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kosuke Kashiwabara
- 4Department of Biostatistics, School of Public Health, Graduate School of Medicine, University of Tokyo, Japan
| | - Fredric B Meyer
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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6
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Shafqat A, AlGethami HJ, Shafqat S, Islam SSU. Pineal cyst apoplexy and memory loss: a novel complication. Radiol Case Rep 2022; 17:3739-3744. [PMID: 35965931 PMCID: PMC9363962 DOI: 10.1016/j.radcr.2022.07.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 11/16/2022] Open
Abstract
An 8-year-old boy presented to our hospital complaining of a bilateral headache associated with episodes of anterograde amnesia. He had a road traffic accident 3 years ago when a computed tomography (CT) scan revealed traumatic brain injury. In addition, a small pineal cyst (PC) was noted with minor intramural calcifications. A follow-up CT a day later demonstrated increased density in the pineal gland of 60 Hounsfield Units, suggestive of apoplectic changes in the PC. However, the patient was lost to follow-up and presented with memory loss a year and a half later, upon which CT and magnetic resonance imaging revealed enlargement of the PC. PC apoplexy is a very rare occurrence usually affecting young adult women; cases in children are rarely reported. Furthermore, PC apoplexy secondary to severe craniofacial trauma manifesting as memory loss has not yet been reported in the literature to the best of our knowledge.
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Affiliation(s)
- Areez Shafqat
- College of Medicine, Alfaisal University, Riyadh, Kingdom of Saudi Arabia
- Corresponding author.
| | - Hanin Jaber AlGethami
- Division of Neurology, Department of Pediatrics, King Salman Hospital, Riyadh, Kingdom of Saudi Arabia
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Konovalov A, Pitskhelauri D, Serova N, Shishkina L, Abramov I. Pineal cyst management: A single-institution experience spanning two decades. Surg Neurol Int 2022; 13:350. [PMID: 36128100 PMCID: PMC9479525 DOI: 10.25259/sni_130_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 07/20/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Pineal cysts (PCs) are benign lesions commonly found on intracranial imaging. Despite their high prevalence, there is no clear consensus on the most appropriate management of patients with PCs, especially those with symptomatic nonhydrocephalic cysts. Methods: A retrospective analysis was performed on 142 patients with PCs (103 surgical cases and 39 conservatively managed cases). Data were examined, including clinical presentation, imaging findings, ophthalmological status, natural course, postoperative outcomes, and complications. Results: Surgical group: the most common symptom was headache (92%), followed by signs of intracranial hypertension due to hydrocephalus (22%). New radiological feature of PCs was found in 11 patients. From 71 patients with long-term follow-up, headache completely resolved in 44 (62%) patients; marked improvement was observed in 20 (29%); in 7 (9%) – headache remained unchanged. The most common postoperative complication was neuro-ophthalmological disorders (23%), with a tendency for resolution in the long-term follow-up period. Neuro-ophthalmological symptoms at last follow-up included upward gaze palsy (6%) and skew deviation (5%), followed by convergence disorders (3%) and eyelid-retraction (2%). Natural course group: PC size remained stable in 34 (87%) patients during the follow-up period. The patient’s gender or age was not a significant predictor of cyst growth (P = 0.4, P = 0.56). Conclusion: The majority of patients with a newly diagnosed PC remain clinically and radiologically stable. Patients with nonhydrocephalic PCs and intractable headaches experience significant relief in headache symptoms, but are at risk of mild to moderate neuro-ophthalmological disorders. The natural course of PCs and factors promoting their growth still remains poorly defined.
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Affiliation(s)
- Alexander Konovalov
- Department of Neurosurgery, Burdenko Neurosurgery Center, Moscow, Russian Federation
| | - David Pitskhelauri
- Department of Neurosurgery, Burdenko Neurosurgery Center, Moscow, Russian Federation
| | - Natalia Serova
- Department of Neuro-Ophthalmology, Burdenko Neurosurgery Center, Moscow, Russian Federation
| | - Lyudmila Shishkina
- Department of Neuropathology, Burdenko Neurosurgery Center, Moscow, Russian Federation
| | - Irakliy Abramov
- Department of Neurosurgery, Burdenko Neurosurgery Center, Moscow, Russian Federation
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8
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Hanna B, Robinson MW, Skoch J. Exclusively endoscopic management of complicated pineal cysts in young children: Definitive treatment through single burr-hole technique. Surg Neurol Int 2022; 13:281. [PMID: 35855169 PMCID: PMC9282818 DOI: 10.25259/sni_302_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/14/2022] [Indexed: 11/26/2022] Open
Abstract
Background: The management of complicated symptomatic pineal cysts in the pediatric population is challenging and variable. Surgical management may include treatment of hydrocephalus alone, or direct treatment of the cyst with or without direct hydrocephalus management. This is typically done through craniotomy-based microsurgical approaches to the pineal region or an endoscopic transventricular approach. Methods: We present a stepwise minimally invasive technique to treat complicated pineal cysts in young children associated with an obstructive hydrocephalus in a single procedure through third ventriculostomy combined with an intraventricular marsupialization of the pineal cyst through a single burr-hole using stereotactic navigation. Results: Two young patients with over 2 years of follow-up have done well without complication using this technique. Other literature reports for complex pineal cysts in pediatric patients are reviewed and this technique is not previously described for this population. Conclusion: Endoscopic third ventriculostomy and cyst marsupialization using a single burr-hole and stereotactic navigation for symptomatic or enlarging pineal cysts in children allow for minimally invasive management, a rapid recovery, short hospital stay, and durable outcome owed to redundant CSF flow pathways.
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Affiliation(s)
- Baher Hanna
- Department of Pediatric Neurosurgery, Cincinnati Children’s Medical Center, Cincinnati, Ohio, United States
| | - Michael W. Robinson
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Jesse Skoch
- Department of Pediatric Neurosurgery, Cincinnati Children’s Medical Center, Cincinnati, Ohio, United States
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9
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Pineal cysts without hydrocephalus: microsurgical resection via an infratentorial-supracerebellar approach-surgical strategies, complications, and their avoidance. Neurosurg Rev 2022; 45:3327-3337. [PMID: 35829978 PMCID: PMC9492705 DOI: 10.1007/s10143-022-01831-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 02/03/2023]
Abstract
Indications for surgery of pineal cysts without ventriculomegaly are still under debate. In view of the limited data for pineal cyst resection in the absence of hydrocephalus, and the potential risk of this approach, we have analyzed our patient cohort focusing on strategies to avoid complications according to our experience in a series of 73 pineal cyst patients. From 2003 to 2015, we reviewed our database retrospectively for all patients operated on a pineal cyst. Furthermore, we prospectively collected patients from 2016 to 2020. In summary, 73 patients with a pineal cyst were treated surgically between 2003 and 2020. All patients were operated on via a microscopic supracerebellar-infratentorial (SCIT) approach. The mean follow-up period was 26.6 months (range: 6-139 months). Seventy-three patients underwent surgery for a pineal cyst. An absence of enlarged ventricles was documented in 62 patients (51 female, 11 male, mean age 28.1 (range 4-59) years). Main presenting symptoms included headache, visual disturbances, dizziness/vertigo, nausea/emesis, and sleep disturbances. Complete cyst resection was achieved in 59/62 patients. Fifty-five of 62 (89%) patients improved after surgery with good or even excellent results according to the Chicago Chiari Outcome Scale, with complete or partial resolution of the leading symptoms. Pineal cysts resection might be an indication in certain patients for surgery even in the absence of ventriculomegaly. The high percentage of postoperative resolution of quality-of-life impairing symptoms in our series seems to justify surgery. Preoperatively, other causes of the leading symptoms have to be excluded.
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10
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Celtikci E, Nunez M, Liu JK, Gardner PA, Cohen-Gadol AA, Fernandez-Miranda JC. Interhemispheric Precuneus Retrosplenial Transfalcine Approach for Falcotentorial Meningiomas: Anatomic Study and Clinical Series. Oper Neurosurg (Hagerstown) 2021; 21:48-56. [PMID: 33930163 DOI: 10.1093/ons/opab095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 01/31/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Falcotentorial meningiomas are surgically challenging. Currently accepted approaches include occipital interhemispheric and supracerebellar infratentorial approaches, which have documented drawbacks. OBJECTIVE To propose an alternative approach to the posterior tentorial incisural space, the interhemispheric precuneus retrosplenial transfalcine approach (IPRTA). METHODS A total of 6 colored-silicone-injected adult cadaveric heads were dissected. We measured the interval between bridging veins and studied computed tomography venography scans of 20 subjects to confirm the feasibility of the IPRTA. Bony landmarks, the region's bridging veins, and the anterior and posterior borders of the approach were identified. The surgical corridor widths (veins' interval) and lengths were compared between alternative midline approaches. We also reviewed 4 consecutive clinical cases using this approach. RESULTS The IPRTA provides the shortest distance to the anterior and posterior limits of the posterior tentorial incisura. Moreover, it is the only approach that provides direct visualization of the anterior and posterior limits of falcotentorial junction meningiomas. In all specimens and patients, a minimum 30-mm interval between the anterior and posterior parietal veins was found in at least one of the hemispheres. Tumor removal was successful in all 4 patients but resulted in mild paresthesia in the lower extremities of 2 patients and temporary foot drop in 1 patient. CONCLUSION The IPRTA offers the shortest and most direct corridor for falcotentorial meningiomas and provides excellent visualization of most of the critical structures in the region. Detailed preoperative evaluation of the deep and superficial venous structures is recommended.
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Affiliation(s)
- Emrah Celtikci
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Maximiliano Nunez
- Department of Neurological Surgery, Stanford University, Stanford, California, USA
| | - James K Liu
- Department of Neurological Surgery, Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Aaron A Cohen-Gadol
- Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA.,The Neurosurgical Atlas, Carmel, Indiana, USA
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11
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Choque-Velasquez J, Colasanti R, Baluszek S, Resendiz-Nieves J, Muhammad S, Ludtka C, Hernesniemi J. Systematic review of pineal cysts surgery in pediatric patients. Childs Nerv Syst 2020; 36:2927-2938. [PMID: 32691194 PMCID: PMC7649165 DOI: 10.1007/s00381-020-04792-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/03/2020] [Indexed: 01/26/2023]
Abstract
INTRODUCTION We present a consecutive case series and a systematic review of surgically treated pediatric PCs. We hypothesized that the symptomatic PC is a progressive disease with hydrocephalus at its last stage. We also propose that PC microsurgery is associated with better postoperative outcomes compared to other treatments. METHODS The systematic review was conducted in PubMed and Scopus. No clinical study on pediatric PC patients was available. We performed a comprehensive evaluation of the available individual patient data of 43 (22 case reports and 21 observational series) articles. RESULTS The review included 109 patients (72% females). Ten-year-old or younger patients harbored smaller PC sizes compared to older patients (p < 0.01). The pediatric PCs operated on appeared to represent a progressive disease, which started with unspecific symptoms with a mean cyst diameter of 14.5 mm, and progressed to visual impairment with a mean cyst diameter of 17.8 mm, and hydrocephalus with a mean cyst diameter of 23.5 mm in the final stages of disease (p < 0.001). Additionally, 96% of patients saw an improvement in their symptoms or became asymptomatic after surgery. PC microsurgery linked with superior gross total resection compared to endoscopic and stereotactic procedures (p < 0.001). CONCLUSIONS Surgically treated pediatric PCs appear to behave as a progressive disease, which starts with cyst diameters of approximately 15 mm and develops with acute or progressive hydrocephalus at the final stage. PC microneurosurgery appears to be associated with a more complete surgical resection compared to other procedures.
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Affiliation(s)
- Joham Choque-Velasquez
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital Helsinki, Helsinki, Finland.
- Juha Hernesniemi International Center for Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China.
| | - Roberto Colasanti
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
- Department of Neurosurgery, Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Szymon Baluszek
- Laboratory of Molecular Neurobiology, Nencki Institute of Experimental Biology, Warsaw, Poland
- Clinical Department of Neurosurgery, Central Clinical Hospital Ministry of Interior, Warsaw, Poland
| | - Julio Resendiz-Nieves
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital Helsinki, Helsinki, Finland
| | - Sajjad Muhammad
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital Helsinki, Helsinki, Finland
- Department of Neurosurgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Christopher Ludtka
- Department of Biomedical Engineering, University of Florida, Florida, USA
| | - Juha Hernesniemi
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital Helsinki, Helsinki, Finland
- Juha Hernesniemi International Center for Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
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Milton CK, Pelargos PE, Dunn IF. Headache outcomes after surgery for pineal cyst without hydrocephalus: A systematic review. Surg Neurol Int 2020; 11:384. [PMID: 33408918 PMCID: PMC7771429 DOI: 10.25259/sni_541_2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 10/16/2020] [Indexed: 11/15/2022] Open
Abstract
Background: Pineal cysts are common entities, with a reported prevalence between 10 and 54%. Management of pineal cysts has historically been expectant, with surgical treatment of these lesions usually reserved for patients with a symptomatic presentation secondary to mass effect. The appropriate management of pineal cysts in patients presenting with headache in the absence of hydrocephalus – often the most common clinical scenario – has been more ambiguous. Here, we report the results of a comprehensive systematic review of headache outcomes for surgically treated, non-hydrocephalic pineal cyst patients without signs of increased intracranial pressure (ICP). Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to construct a systematic review. A comprehensive search of the PubMed, Embase, Scopus, and Web of Science databases was conducted from through June 2020. Relevant English-language articles were identified using the search terms “pineal cyst” and “headache.” The following eligibility criteria were applied: the inclusion of at least one surgically-treated, non-hydrocephalic pineal cyst patient presenting with headache in the absence of hemorrhage or signs and symptoms of increased ICP. Patient demographics and post-operative headache outcomes for the included studies were extracted and summarized. Results: A total of 24 pineal cyst cases meeting our selection criteria were identified across 11 included studies. Postoperative improvement or resolution of headaches was reported for 23/24 patients. Our systematic review of the literature demonstrates that non-hydrocephalic patients with pineal cysts have a high rate of headache improvement following surgical intervention. Conclusion: The results indicate a need for further investigation of the link between headache and pineal cysts in the non-hydrocephalic patient.
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Affiliation(s)
- Camille K Milton
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, United States
| | - Panayiotis E Pelargos
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, United States
| | - Ian F Dunn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, United States
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13
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Woodward K, Sitaram A, Peters S. Isolated convergence-retraction nystagmus secondary to intralesional haemorrhage of a pineal cyst: an easily missed neurological finding with potentially life-threatening consequences. BMJ Case Rep 2020; 13:13/9/e233469. [PMID: 32928827 DOI: 10.1136/bcr-2019-233469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
This case report describes a patient who presented to the emergency department with intermittent visual disturbance and was found to have convergence-retraction nystagmus. This occurred in the setting of supratherapeutic anticoagulation on warfarin for an aortic dissection graft repair. Urgent imaging demonstrated haemorrhagic transformation of a previously identified incidental pineal cyst. After close monitoring given the risk of secondary hydrocephalus, the patient was discharged in stable condition with symptom resolution and without any further significant complications. This case report highlights the importance of identifying subtle clinical findings and the risk of secondary haemorrhage of pineal cysts when on anticoagulation. While the risk of secondary hydrocephalus is a significant concern, clinically stable patients can be followed without need for neurosurgical intervention.
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Affiliation(s)
- Kristine Woodward
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Steven Peters
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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14
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Kim E, Kwon SM. Pineal Cyst Apoplexy: A Rare Complication of Common Entity. Brain Tumor Res Treat 2020; 8:66-70. [PMID: 32390357 PMCID: PMC7221466 DOI: 10.14791/btrt.2020.8.e4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 02/26/2020] [Accepted: 03/25/2020] [Indexed: 11/24/2022] Open
Abstract
Pineal cysts (PCs) are often encountered as incidental findings in intracranial images. The vast majority of cysts are normally asymptomatic and clinically benign. Bleeding into the cysts, which leads to neurological symptoms and signs, is considered to be quite rare. The authors illustrate a newly identified complication of PC in a 56-year-old woman who characterized by headache of sudden onset and vomiting. MRI disclosed a small hemorrhagic PC without narrowing of the cerebral aqueduct. The patient was managed conservatively without any surgical interventions, and she remained symptom-free over a period of 15-year follow-up. The description of this case adds to the limited literature on the series in which nonsurgical treatments had a role in the care for patients with PC complicated by intracystic hemorrhage.
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Affiliation(s)
- El Kim
- Department of Neurosurgery, Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea.
| | - Sae Min Kwon
- Department of Neurosurgery, Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
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15
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Koziarski A, Podgórski A, Zieliński GM. Surgical treatment of pineal cysts in non-hydrocephalic and neurologically intact patients: selection of surgical candidates and clinical outcome. Br J Neurosurg 2018; 33:37-42. [DOI: 10.1080/02688697.2018.1530731] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Andrzej Koziarski
- Department of Neurosurgery, Military Institute of Medicine, Warsaw, Poland
| | - Andrzej Podgórski
- Department of Neurosurgery, Military Institute of Medicine, Warsaw, Poland
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16
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Gokce E, Beyhan M. Evaluation of pineal cysts with magnetic resonance imaging. World J Radiol 2018; 10:65-77. [PMID: 30079153 PMCID: PMC6068724 DOI: 10.4329/wjr.v10.i7.65] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/29/2018] [Accepted: 05/23/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate radiological imaging findings of patients who had been found to have pineal cyst (PC) in brain magnetic resonance imaging (MRI).
METHODS A total of 9546 patients who had brain MRI examination in March 2010-January 2018 period were studied. Fifty-six patients (44 female and 12 male) found to have PC were evaluated. Eighteen of the patients had had follow-up examinations of 2-94 mo (mean 30.50 ± 28.83). PC dimensions and volume, radiological imaging features (signal intensities, contours, internal septation-loculation and contrast-enhancement features) and natural history in cases who had been followed-up were evaluated by two radiologists.
RESULTS Of 9546 patients, 5555 were female (58.2%) and 3991 male (41.8%). Age range was 1-99 (mean 43.18 ± 20.94). PC frequency was calculated to be 0.58%. Forty-four of the 56 patients (78.57%) with PC were female and 12 male (21.43%), and their age range was 5-61 (mean 31.26 ± 12.73). Thirty-five of the PCs were typical (62.50%) and 21 (37.50%) were atypical. No significant difference was found between initial and final imaging sizes of PCs which were monitored by follow-up examinations (P > 0.05).
CONCLUSION PCs are cysts which do not show clear size and natural changes and are more frequently observed in females and in adult ages. Most of them are isointense with cerebrospinal fluid on T1 and T2A weighted images, hyperintense compared to cerebrospinal fluid on fluid-attenuated inversion recovery; sequence and smoothly contoured. Their typical forms have peripheral rim and multilocular ones may have septal contrast-enhancement.
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Affiliation(s)
- Erkan Gokce
- Department of Radiology, Gaziosmanpaşa University, School of Medicine, Tokat 60100, Turkey
| | - Murat Beyhan
- Department of Radiology, Tokat State Hospital, Tokat 60100, Turkey
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17
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Sudden and Unexpected Death During Sexual Activity, Due to a Glial Cyst of the Pineal Gland. Am J Forensic Med Pathol 2018; 39:157-160. [PMID: 29570483 DOI: 10.1097/paf.0000000000000396] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cysts of the pineal gland are benign lesions. Often asymptomatic, in the majority of cases they are discovered incidentally during brain magnetic resonance imaging or autopsy. Sporadically, however, they may cause such symptoms as chronic headache, loss of consciousness, corticospinal and sensory impairment, and, in some cases, even sudden death. A 45-year-old woman, in apparently good health, collapsed and died suddenly, after reaching orgasm while engaged in sexual intercourse. According to the circumstantial account of her relatives, the woman suffered from severe headaches, which were exacerbated by certain types of physical strain, such as sexual activity. Postmortem examination revealed no external injuries or internal diseases except for a cystic lesion of the pineal gland. Microscopically, the wall of the cyst consisted of a layer of glial tissue surrounded by an area of pineal elements. A complete forensic approach concluded that the cause of death was fatal cardiorespiratory failure resulting from midbrain compression due to a nonneoplastic pineal gland cyst, exacerbated by sexual activity. In this case, the intracranial pressure increase, secondary to Valsalva maneuver during climax, may further aggravate compression on the brainstem, thus concurring to determine the death.
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18
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Arenas RM, Shoemaker JM, Phillips J. High prevalence of pineal cysts in adults who stutter. BRAIN AND LANGUAGE 2018; 177-178:18-22. [PMID: 29421268 DOI: 10.1016/j.bandl.2018.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 01/03/2018] [Accepted: 01/18/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Richard M Arenas
- Department of Speech and Hearing Sciences, University of New Mexico, Albuquerque, NM, United States.
| | | | - John Phillips
- Mind Research Network, Albuquerque, NM, United States; Department of Neurology, University of New Mexico Health Sciences, United States
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19
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Abramov IT, Pitskhelauri DI, Serova NK. [Pineal cyst]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2017; 81:113-120. [PMID: 28914878 DOI: 10.17116/neiro2017814113-120] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
UNLABELLED A pineal cyst (PC) is a benign neoplasm in the pineal region, or more precisely in the pineal body. Most cysts are incidental findings and are not associated with symptoms typical of patients seeking medical advice. Symptomatic cysts are discovered less often and, depending on the clinical picture, require different treatment approaches. MATERIAL AND METHODS We analyzed the literature data about the clinical picture, diagnosis, and treatment of PCs for more than a century (1914-2016). CONCLUSION To date, there is no single approach for managing PC patients. The indications for surgical treatment of symptomatic PCs are still not fully defined. It remains unclear which PC cases should be followed-up, and how often control examinations should be performed. More research of PCs is needed to develop new approaches to treatment of PC patients.
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Affiliation(s)
- I T Abramov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - N K Serova
- Burdenko Neurosurgical Institute, Moscow, Russia
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20
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Starke RM, Cappuzzo JM, Erickson NJ, Sherman JH. Pineal cysts and other pineal region malignancies: determining factors predictive of hydrocephalus and malignancy. J Neurosurg 2016; 127:249-254. [PMID: 27767399 DOI: 10.3171/2016.8.jns16220] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Cystic lesions of the pineal gland are most often uncomplicated benign lesions with typical MRI characteristics. The authors aimed to study pineal lesion characteristics on MRI to better distinguish benign pineal cysts from other pineal region malignancies as well as to determine which characteristics were predictive of the latter malignancies. They also aimed to study risk factors predictive of hydrocephalus or malignancy in patients harboring these lesions. METHODS The authors performed a retrospective review of a prospectively compiled database documenting the outcomes of patients with suspected pineal cysts on MRI who had presented in the period from 1998 to 2004. Inherent patient and lesion characteristics were assessed in a univariate logistic regression analysis to predict the following dependent variables: development of hydrocephalus, biopsy-confirmed malignancy, and intervention. Possible inherent patient and lesion characteristics included age, sex, T1 and T2 MRI signal pattern, contrast enhancement pattern, presence of cyst, presence of blood, complexity of lesion, presence of calcification, and duration of follow-up. Inherent patient and lesion characteristics that were predictive in the univariate analysis (p < 0.15) were included in the multivariable logistic regression analysis. RESULTS Of the 79 patients with benign-appearing pineal cysts, 26 (33%) were male and 53 (67%) were female, with a median age of 38 years (range 9-86 years). The median cyst radius was 5 mm (range 1-20 mm). Two patients (2.5%) had evidence of calcifications, 7 (9%) had multicystic lesions, and 25 (32%) had some evidence of contrast enhancement. The median follow-up interval was 3 years (range 0.5-13 years). Seven patients (9%) had an increase in the size of their lesion over time. Eight patients (10%) had a hemorrhage, and 11 patients (14%) developed hydrocephalus. Nine (11%) received ventriculoperitoneal shunts for the development of hydrocephalus, and 12 patients (16%) were found to have malignancies following biopsy or resection. In the multivariate analysis, contrast enhancement on MRI (OR 1.6, 95% CI 2.86-74.74, p = 0.013) and hemorrhage (OR 26.9, 95% CI 3.4-212.7, p = 0.022) were predictive of hydrocephalus. Increasing lesion size and hydrocephalus were near perfect predictors of malignancy and thus were removed from multivariate analysis. In addition, contrast enhancement on MRI (OR 8.8, 95% CI 2.0-38.6, p = 0.004) and hemorrhage (OR 6.8, 95% CI 1.1-40.5, p = 0.036) were predictive of malignancy. CONCLUSIONS Although cystic abnormalities of the pineal gland are often benign lesions, they are frequently monitored over time, as other pineal region pathologies may appear similarly on MRI. Patients with growing lesions, contrast enhancement, and hemorrhage on MRI are more likely to develop hydrocephalus and have malignant pathology on histological examination and should therefore be followed up with serial MRI with a lower threshold for neurosurgical intervention.
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Affiliation(s)
- Robert M Starke
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | | | - Jonathan H Sherman
- Department of Neurological Surgery, The George Washington University, Washington, DC
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21
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Májovský M, Netuka D, Beneš V. Clinical management of pineal cysts: a worldwide online survey. Acta Neurochir (Wien) 2016; 158:663-669. [PMID: 26897024 DOI: 10.1007/s00701-016-2726-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 01/27/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND A pineal cyst is a benign affection of a pineal gland on the borderline between a pathological lesion and a variant of normality. Clinical management of patients with a pineal cyst remains controversial, especially when patients present with non-specific symptoms. METHODS An online questionnaire consisting of 13 questions was completed by 110 neurosurgeons worldwide. Responses were entered into a database and subsequently analysed. RESULTS Based on data from the questionnaire, the main indication criteria for pineal cyst resection are hydrocephalus (90 % of the respondents), Parinaud's syndrome (80 %) and growth of the cyst (68 %). Only 15 % of the respondents occasionally operate on patients with non-specific symptoms. If surgery is indicated, improvement is expected in 88 % of the patients. The vast majority of the respondents favour a supracerebellar infratentorial approach to the pineal region. Most (78 %) of the respondents regarded the patient registry as a potentially useful instrument. CONCLUSIONS This survey sheds light on the current practice of pineal cyst management across the world. Most of the respondents perform surgery on pineal cysts only if patients are presenting with symptoms attributable to a mass effect. Surgery for patients with non-specific complaints (headache, vertigo) is not widely accepted, although it may prove effective. A prospective patient registry might be useful in the decision-making process in the clinical management of pineal cysts.
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22
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Nevins EJ, Das K, Bhojak M, Pinto RS, Hoque MN, Jenkinson MD, Chavredakis E. Incidental Pineal Cysts: Is Surveillance Necessary? World Neurosurg 2016; 90:96-102. [PMID: 26944882 DOI: 10.1016/j.wneu.2016.02.092] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 02/21/2016] [Accepted: 02/22/2016] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The natural history of incidental pineal cysts is poorly understood. Neurosurgeons and neuroradiologists are more frequently faced with this disease in the advent of higher-resolution magnetic resonance imaging (MRI) scanning. We aim to suggest a suitable surveillance strategy for these patients. METHODS All patients who had MRI of the brain between June 2007 and January 2014 (n = 42,099) at The Walton Centre for Neurology and Neurosurgery were included. Radiologic reports containing the terms "pineal" and "cyst" were reviewed to identify patients. RESULTS A total of 281 patients were identified with pineal cysts. The principal indication for head MRI was headache (50.2%), although no symptoms were deemed attributable to pineal disease. A total of 178 patients (63.3%) were female, and the age at diagnosis ranged from 16 to 84 years. The median size of pineal cyst at diagnosis was 10 mm. A total of 181 patients had subsequent follow-up at a median time of 6 months (range, 1-68). Eleven pineal cysts (6%) changed size during the follow-up period. Four patients had a reduction in cyst size; the median change was 2.5 mm. A further 7 pineal cysts increased in cyst size; the median change was 2 mm. No patients developed complications. CONCLUSIONS Incidental pineal cysts typically show a benign course. In the adult population, they do not require long-term neurosurgical follow-up, because pineal cysts tend to remain a stable size. In asymptomatic patients, we recommend a single follow-up MRI scan at 12 months to confirm diagnosis. The patient should then be discharged if the cyst remains stable.
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Affiliation(s)
- Edward J Nevins
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom.
| | - Kumar Das
- Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Maneesh Bhojak
- Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Rohan S Pinto
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Mohammed N Hoque
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Michael D Jenkinson
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom; Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Emmanuel Chavredakis
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
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23
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Magnetic resonance imaging biomarkers indicate a central venous hypertension syndrome in patients with symptomatic pineal cysts. J Neurol Sci 2016; 363:207-16. [PMID: 27000252 DOI: 10.1016/j.jns.2016.02.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 02/15/2016] [Accepted: 02/16/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND While most pineal cysts (PCs) are asymptomatic, some PCs are accompanied with symptoms of variable severity. We suggested that symptom severity in symptomatic patients with non-hydrocephalic PCs relates to venous compression causing central venous hypertension. This study explored whether possible magnetic resonance imaging (MRI) biomarkers of central venous hypertension could differentiate the severity of symptoms in individuals with non-hydrocephalic PCs. METHODS The study included all individuals with PCs and MRI available for analysis followed conservatively within the department from 2003 to 2014. Severity of symptoms at follow-up were assessed from a questionnaire. Suggested MRI biomarkers indicative of central venous hypertension were explored, in addition to MRI measures of cyst size, aqueduct stenosis, and tectal compression. RESULTS The study included 66 patients. As compared to the 27/66 patients (41%) with "None-Moderate" symptoms at follow-up, the 39/66 patients (59%) with "Much-Severe" symptoms presented with significantly altered indices of central venous hypertension (tectum-splenium-cyst ratio and indices of thalamic and periventricular edema). PC grading based on MRI biomarkers of central venous hypertension differentiated the severity of symptoms. CONCLUSION The results indicate an association between severity of symptoms and MRI biomarkers of central venous hypertension in symptomatic individuals with non-hydrocephalic PCs.
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24
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Bot GM, Constantini S, Roth J. Conservative treatment of cysts of the cavum septum pellucidum presenting in childhood: report of 3 cases. J Neurosurg Pediatr 2015; 16:283-6. [PMID: 26090550 DOI: 10.3171/2015.3.peds14714] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cavum septum pellucidum (CSP) cysts are relatively rare. The most common presenting symptom is headache, which is thought to be secondary to elevated intracranial pressure. Many CSP cysts are treated surgically; conservative treatment is seldom recommended. The authors describe 3 cases of pediatric CSP cysts that were managed without surgery. The patients ranged in age from 5 months to 8 years old. Two presented with headaches, which were associated with mild ventricular enlargement in 1 case. Over the course of 5-15 months, 2 cysts became markedly reduced in size, and in one of these 2 cases a substantial reduction in ventricle size was also observed. At last follow-up, all 3 children were asymptomatic. The authors note that CSP cysts are often associated with headaches. In the absence of hydrocephalus, they recommend conservative management with clinical and radiological follow-up.
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Affiliation(s)
- Gyang Markus Bot
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Shlomi Constantini
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Jonathan Roth
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
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25
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Kalani MYS, Wilson DA, Koechlin NO, Abuhusain HJ, Dlouhy BJ, Gunawardena MP, Nozue-Okada K, Teo C. Pineal cyst resection in the absence of ventriculomegaly or Parinaud's syndrome: clinical outcomes and implications for patient selection. J Neurosurg 2015; 123:352-6. [DOI: 10.3171/2014.9.jns141081] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Surgical indications for patients with pineal cysts are controversial. While the majority of patients harboring a pineal cyst require no treatment, surgery is a well-accepted option for a subset of those patients with secondary hydrocephalus or Parinaud's syndrome. The majority of pineal cysts are identified incidentally during workup for other potential conditions, which may or may not be related to the presence of the cyst. In the absence of clear obstruction of CSF pathways, the treatment of presumed symptomatic pineal cysts is debatable. To clarify the role of surgery in these borderline cases, the authors reviewed their experience with resection of pineal cysts in the absence of ventriculomegaly or Parinaud's syndrome.
METHODS
The authors retrospectively reviewed medical records and imaging of all patients surgically treated between 2001 and 2014 with a pineal cyst in the absence of ventriculomegaly and Parinaud's syndrome. The presenting symptoms, preoperative cyst size, preoperative radiographic aqueductal compression, extent of resection, and radiographic and clinical follow-up were documented.
RESULTS
Eighteen patients (14 female and 4 male; mean age 24 years, range 4–47 years) underwent cyst resection in the absence of ventriculomegaly or Parinaud's syndrome. Presenting symptoms included headache (17 patients), visual disturbances (10 patients), gait instability (5 patients), dizziness (5 patients), episodic loss of consciousness (2 patients), and hypersomnolence (1 patient). The mean preoperative cyst diameter was 1.5 cm (range 0.9–2.2 cm). All patients had a complete resection. At a mean clinical follow-up of 19.1 months (range postoperative to 71 months), 17 (94%) patients had resolution or improvement of their presenting symptoms.
CONCLUSIONS
The authors' results suggest that ventriculomegaly and Parinaud's syndrome are not absolute requisites for a pineal cyst to be symptomatic. Analogous to colloid cysts of the third ventricle, intermittent occlusion of cerebrospinal fluid pathways may cause small pineal cysts to become intermittently symptomatic. A select cohort of patients with pineal cysts may benefit from surgery despite a lack of hydrocephalus or other obvious compressive pathology.
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Affiliation(s)
- M. Yashar S. Kalani
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
- 2Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and
| | - David A. Wilson
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Nicolas Olmo Koechlin
- 2Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and
| | - Hazem J. Abuhusain
- 2Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and
| | - Brian J. Dlouhy
- 2Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and
- 3Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | | | - Kyoko Nozue-Okada
- 2Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and
| | - Charles Teo
- 2Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and
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Abstract
In recent years, the utilization of diagnostic imaging of the brain and spine in children has increased dramatically, leading to a corresponding increase in the detection of incidental findings of the central nervous system. Patients with unexpected findings on imaging are often referred for subspecialty evaluation. Even with rational use of diagnostic imaging and subspecialty consultation, the diagnostic process will always generate unexpected findings that must be explained and managed. Familiarity with the most common findings that are discovered incidentally on diagnostic imaging of the brain and spine will assist the pediatrician in providing counseling to families and in making recommendations in conjunction with a neurosurgeon, when needed, regarding additional treatments and prognosis.
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Tamura Y, Yamada Y, Tucker A, Ukita T, Tsuji M, Miyake H, Kuroiwa T. Endoscopic surgery for hemorrhagic pineal cyst following antiplatelet therapy: case report. Neurol Med Chir (Tokyo) 2014; 53:625-9. [PMID: 24067776 PMCID: PMC4508677 DOI: 10.2176/nmc.cr2012-0396] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Pineal cysts of the third ventricle presenting with acute obstructive hydrocephalus due to internal cystic hemorrhage are a rare clinical entity. The authors report a case of a 61-year-old man taking antiplatelet medication who suffered from a hemorrhagic pineal cyst and was treated with endoscopic surgery. One month prior to treatment, the patient was diagnosed with a brainstem infarction and received clopidogrel in addition to aspirin. A small incidental pineal cyst was concurrently diagnosed using magnetic resonance (MR) imaging which was intended to be followed conservatively. The patient presented with a sudden onset of headache and diplopia. On admission, the neurological examination revealed clouding of consciousness and Parinaud syndrome. Computerized tomography (CT) scans demonstrated a hemorrhagic mass lesion in the posterior third ventricle. The patient underwent emergency external ventricular drainage with staged endoscopic biopsy and third ventriculostomy using a flexible videoscope. Histological examination revealed pineal tissue with necrotic change and no evidence of tumor cells. One year later MR imaging demonstrated no evidence of cystic lesion and a flow void between third ventricle and prepontine cistern. In patients with asymptomatic pineal cysts who are treated with antiplatelet therapy, it is important to be aware of the risk of pineal apoplexy. Endoscopic management can be effective for treatment of hemorrhagic pineal cyst with obstructive hydrocephalus.
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Affiliation(s)
- Yoji Tamura
- Department of Neurosurgery, Osaka Medical College
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Mehrzad R, Mishra S, Feinstein A, Ho MG. A new identified complication of intracystic hemorrhage in a large pineal gland cyst. Clin Imaging 2014; 38:515-517. [DOI: 10.1016/j.clinimag.2014.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 03/09/2014] [Accepted: 03/13/2014] [Indexed: 11/28/2022]
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Update on the management of pineal cysts: Case series and a review of the literature. Neurochirurgie 2014; 61:201-7. [PMID: 24907165 DOI: 10.1016/j.neuchi.2013.08.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 08/13/2013] [Accepted: 08/30/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The natural history of pineal cysts still remains unclear. Incidental pineal cysts have become more common which raises the question of their management. Symptomatic pineal cysts may require a surgical solution but therapeutic indications have not yet been clearly established. METHOD From 1986 to 2012, 26 patients with pineal cysts were identified. Their medical records were retrospectively assessed focusing on the initial symptoms, imaging characteristics of the cyst, management strategy, operative technique and their complications, as well as the latest follow-up. A systematic review of the literature is also presented. RESULTS Twenty-six patients with pineal cysts were identified. The mean age was 23.5 years ranging from 7 to 49 years. Symptoms included intracranial hypertension with obstructive hydrocephalus in 18 cases and oculomotor anomalies in 12 cases. Two adult cases presented with non-specific headaches and did not require surgery. Twenty patients were operated via a suboccipital transtentorial approach with total removal of the cyst in 70% of the cases, while the remaining 4 cases were treated with an intraventricular endoscopic marsupialization associating a third ventriculostomy. Four patients required a preoperative ventriculo-peritoneal shunt due to life-threatening obstructive hydrocephalus. Overall, peri-operative mortality was nil. In the two non-operated patients, the cyst remained stable and no recurrences were observed in all operated patients with a mean follow-up of 144 months. CONCLUSION In the majority of incidental pineal cysts, a clinical and imaging follow-up is sufficient but occasionally not required especially in adults as very rare cases of increase in size have been reported.
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Whitehead MT, Oh CC, Choudhri AF. Incidental pineal cysts in children who undergo 3-T MRI. Pediatr Radiol 2013; 43:1577-83. [PMID: 23852563 DOI: 10.1007/s00247-013-2742-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 05/14/2013] [Accepted: 06/12/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pineal cysts, both simple and complex, are commonly encountered in children. More cysts are being detected with MR technology; however, nearly all pineal cysts are benign and require no follow-up. OBJECTIVE To discover the prevalence of pineal cysts in children at our institution who have undergone high-resolution 3-T MRI. MATERIALS AND METHODS We retrospectively reviewed 100 consecutive 3-T brain MRIs in children ages 1 month to 17 years (mean 6.8 ± 5.1 years). We evaluated 3-D volumetric T1-W imaging, axial T2-W imaging, axial T2-W FLAIR (fluid attenuated inversion recovery) and coronal STIR (short tau inversion recovery) sequences. Pineal parenchymal and cyst volumes were measured in three planes. Cysts were analyzed for the presence and degree of complexity. RESULTS Pineal cysts were present in 57% of children, with a mean maximum linear dimension of 4.2 mm (range 1.5-16 mm). Of these cysts, 24.6% showed thin septations or fluid levels reflecting complexity. None of the cysts demonstrated complete T2/FLAIR signal suppression. No cyst wall thickening or nodularity was present. There was no significant difference between the ages of children with and without cysts. Cysts were more commonly encountered in girls than boys (67% vs. 52%; P = 0.043). There was a slight trend toward increasing pineal gland volume with age. CONCLUSION Pineal cysts are often present in children and can be incidentally detected by 3-T MRI. Characteristic-appearing pineal cysts in children are benign, incidental findings, for which follow-up is not required if there are no referable symptoms or excessive size.
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Affiliation(s)
- Matthew T Whitehead
- Department of Radiology, University of Tennessee Health Science Center, Memphis, TN, USA,
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Kahilogullari G, Massimi L, Di Rocco C. Pineal cysts in children: case-based update. Childs Nerv Syst 2013; 29:753-60. [PMID: 23283557 DOI: 10.1007/s00381-012-2011-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 12/17/2012] [Indexed: 02/08/2023]
Abstract
PURPOSE Pineal cysts (PC) are found in children as often asymptomatic and without change in their size over the time. However, there are some debatable issues about their evolution and management in the pediatric population. The aim of the present paper is to update the information regarding pathogenesis, clinical presentation, and management of these lesions. METHODS All the pertinent literature was reviewed, and a meta-analysis of operated on cases was carried out. An illustrative case regarding the clinical evolution of a 13-year-old girl is also presented. RESULTS AND CONCLUSIONS PC are often asymptomatic and do not evolve over the time. However, since there is a certain risk of clinical and/or radiological progression, or even sudden and severe clinical onset (apoplexy), both a clinical and radiological follow-up is recommended in the pediatric age. The surgical excision is usually limited to symptomatic patients or to cases with clear radiological evolution.
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Abstract
Pineal cysts (PCs) are benign and often asymptomatic lesions of the pineal region that are typically small and do not change in size over time. PCs appear as small, well circumscribed, unilocular masses that either reside within or completely replace the pineal gland. This article reviews and discusses the characteristic features of PCs-clinical, histological, and identifiable by various imaging modalities-which assist clinicians in narrowing the differential diagnosis for pineal lesions.
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Ayhan S, Bal E, Palaoglu S, Cila A. Pineal cyst apoplexy: report of an unusual case managed conservatively. Neurol Neurochir Pol 2012; 45:604-607. [PMID: 22212992 DOI: 10.1016/s0028-3843(14)60129-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Pineal cyst apoplexy is a very rare entity with previously reported symptoms of severe frontal or occipital headache, gaze paresis and visual field defects, nausea or vomiting, syncope, ataxia, hearing loss and sudden death. The treatment options for symptomatic pineal cysts are observation, shunting, aspiration via stereotactic guidance or endoscopy, third ventriculostomy, ventriculocysternostomy, and/or surgical resection by craniotomy and microsurgery. Here, the authors report an unusual case of a 28-year-old male patient with pineal cyst apoplexy, presenting with headache, insomnia, and sexual dysfunction symptoms who is being managed conservatively and observed for two years by an academic tertiary care unit.
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Affiliation(s)
- Selim Ayhan
- Department of Neurosurgery, Hacettepe University School of Medicine, Ankara, Turkey.
| | - Ercan Bal
- Department of Neurosurgery, Hacettepe University School of Medicine, Ankara, Turkey
| | - Selcuk Palaoglu
- Department of Neurosurgery, Hacettepe University School of Medicine, Ankara, Turkey
| | - Aysenur Cila
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
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Uschold T, Abla AA, Fusco D, Bristol RE, Nakaji P. Supracerebellar infratentorial endoscopically controlled resection of pineal lesions: case series and operative technique. J Neurosurg Pediatr 2011; 8:554-64. [PMID: 22132912 DOI: 10.3171/2011.8.peds1157] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECT The heterogeneous clinical manifestations and operative characteristics of pathological entities in the pineal region represent a significant challenge in terms of patient selection and surgical approach. Traditional surgical options have included endoscopic transventricular resection; open supratentorial microsurgical approaches through the midline, choroidal fissure, lateral ventricle, and tentorium; and supracerebellar infratentorial (SCIT) approaches through the posterior fossa. The object of the current study was to review the preoperative characteristics and outcomes for a cohort of patients treated purely via the novel endoscopically controlled SCIT approach. METHODS A single-institution series of 9 consecutive patients (4 male and 5 female patients [10 total cases]; mean age 21 years, range 6-37 years) treated via the endoscopically controlled SCIT approach for a pathological entity in the pineal region was retrospectively reviewed. The mean follow-up time was 13.2 months. RESULTS The endoscopically controlled SCIT approach was successfully used to approach a variety of pineal lesions, including pineal cysts (6 patients), epidermoid tumor, WHO Grade II astrocytoma (initial biopsy and recurrence), and malignant mixed germ cell tumor (1 patient each). Gross-total resection and/or adequate cyst fenestration was achieved in 8 cases. Biopsy with conservative debulking was performed for the single case of low-grade astrocytoma and again at the time of recurrence. The mean preoperative tumor and cyst volumes were 9.9 ± 4.4 and 3.7 ± 3.2 cm(3), respectively. The mean operating times were 212 ± 71 minutes for tumor cases and 177 ± 72 minutes for cysts. Estimated blood loss was less than 150 ml for all cases. A single case (pineal cyst) was converted to an open microsurgical approach to enhance visualization. There were no operative complications, as well as no documented CSF leaks, additional CSF diversion procedures, or air emboli. Seven patients underwent concomitant third ventriculostomy into the quadrigeminal cistern. At the time of the last follow-up evaluation, all patients had a stable or improved modified Rankin Scale score. CONCLUSIONS The endoscopically controlled SCIT approach may be used for the biopsy and resection of appropriately selected solid tumors of the pineal region, in addition to the fenestration and/or resection of pineal cysts. Preoperative considerations include patient presentation, anticipated disease and vascularity, degree of local venous anatomical distortion, and selection of optimal paramedian trajectory.
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Affiliation(s)
- Timothy Uschold
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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Tseng KY, Ma HI, Liu WH, Tang CT. Endoscopic supracerebellar infratentorial retropineal approach for tumor resection. World Neurosurg 2011; 77:399.E1-4. [PMID: 22120379 DOI: 10.1016/j.wneu.2011.05.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 04/16/2011] [Accepted: 05/13/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Lesions located in the pineal region represent a surgical challenge. Multiple approaches to this region have been described, each with its advantages and disadvantages. We report the first application of the endoscopic supracerebellar infratentorial approach for complete resection of a pineal tumor. Unlike transventricular endoscopy, this technique poses no risk to the fornices and can be applied independent of ventricular size. CASE DESCRIPTION A 21-year-old man sought treatment for diplopia. Magnetic resonance images of brain revealed a heterogeneous, contrast-enhancing mass that originated from the pineal gland. This tumor exerted the mass effect on the tectum and invaded to the bilateral dorso-medial thalamus and hypothalamus but caused no obstructive hydrocephalus. The results of a cytological study of the cerebrospinal fluid, alpha-fetoprotein, and beta-human chorionic gonadotropin were negative. The patient was referred for the surgical work-up. TECHNIQUE The patient was positioned in the semi-sitting position. The supracerebellar infratentoria corridor was accessed through two paramedian burr holes, which provided natural by-gravity cerebellar traction. The excellent illumination and magnification without sacrificing the inferior occipital sinus could be achieved with the aid of the endoscope. The pineal tumor was resected completely via the full-endoscopic approach. Postoperatively, the patient's diplopia resolved completely, and his hospital course was uneventful. CONCLUSIONS Taking the advantages of the endoscope and peculiar supracerebellar infratentoria corridor, we could successfully remove the gross-total tumor without violating the critical neurovascular structures. Moreover, this approach can be performed regardless of the size of the ventricle. Consequently, it is an excellent minimally invasive surgical option for resection of symptomatic pineal tumor.
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Affiliation(s)
- Kuan-Yin Tseng
- Department of Neurological Surgery, Tri-service General Hospital, Taipei, Taiwan
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Neurosurgical venous considerations for tumors of the pineal region resected using the infratentorial supracerebellar approach. J Clin Neurosci 2011; 18:1481-5. [PMID: 21917460 DOI: 10.1016/j.jocn.2011.02.035] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 02/14/2011] [Accepted: 02/16/2011] [Indexed: 11/22/2022]
Abstract
The authors present a microsurgical technique for the resection of a heterogeneous group of pineal-region tumors and discuss the key points for successfully performing this surgery. Twenty-six consecutive patients with pineal-region tumors were resected by the senior author (H.B.) and analyzed retrospectively. For all 26 patients, the operation was conducted using the infratentorial supracerebellar (ITSC) approach in the sitting (23 patients) or Concorde (three patients) positions. Twenty-five patients had symptomatic obstructive hydrocephalus and were treated with ventricular drainage, a previously inserted ventriculoperitoneal shunt, or an endoscopic third ventriculostomy before undergoing resection of the pineal-region tumor. The gross total removal of the tumor was achieved in 23 patients and subtotal removal was achieved in three patients. The tumors were pathologically diagnosed mainly as pineocytomas (10), pilocytic astrocytomas (6), or pineal cysts (4). Twenty-five of the patients clinically improved after surgery, and there was no mortality. Two patients experienced transient postoperative neurological deterioration: one patient developed Parinaud syndrome, and one patient developed intermittent diplopia. Successful surgery and patient outcome when treating tumors of the pineal region using the ITSC approach requires: (i) preservation of the venous flow of the Galenic draining system; (ii) preservation of the thick bridging veins of the tentorial surface of the cerebellum, especially the hemispheric bridging veins; and (iii) minimizing retraction of the cerebellum during surgery to avoid adverse effects caused by both direct cerebellar compression and disturbance of the venous circulation.
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Al-Holou WN, Terman SW, Kilburg C, Garton HJL, Muraszko KM, Chandler WF, Ibrahim M, Maher CO. Prevalence and natural history of pineal cysts in adults. J Neurosurg 2011; 115:1106-14. [PMID: 21780858 DOI: 10.3171/2011.6.jns11506] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECT We reviewed our experience with pineal cysts to define the natural history and clinical relevance of this common intracranial finding. METHODS The study population consisted of 48,417 consecutive patients who underwent brain MR imaging at a single institution over a 12-year interval and who were over 18 years of age at the time of imaging. Patient characteristics, including demographic data and other intracranial diagnoses, were collected from cases involving patients with a pineal cyst. We then identified all patients with pineal cysts who had been clinically evaluated at our institution and who had at least 6 months of clinical and imaging follow-up. All inclusion criteria for the natural history analysis were met in 151 patients. RESULTS Pineal cysts measuring 5 mm or larger in greatest dimension were found in 478 patients (1.0%). Of these, 162 patients were male and 316 were female. On follow-up MR imaging of 151 patients with pineal cyst at a mean interval of 3.4 years from the initial study, 124 pineal cysts remained stable, 4 increased in size, and 23 decreased in size. Cysts that were larger at the time of initial diagnosis were more likely to decrease in size over the follow-up interval (p = 0.004). Patient sex, patient age at diagnosis, and the presence of septations within the cyst were not significantly associated with cyst change on follow-up. CONCLUSIONS Follow-up imaging and neurosurgical evaluation are not mandatory for adults with asymptomatic pineal cysts.
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Affiliation(s)
- Wajd N Al-Holou
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-5338, USA
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García Amorín Z, Rodríguez Delhi C, Soriano Guillén L, Suárez Tomás J, Riaño Galán I. Implicación de los quistes de la glándula pineal en la patogenia de la pubertad precoz central. An Pediatr (Barc) 2010; 72:420-3. [DOI: 10.1016/j.anpedi.2010.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2009] [Revised: 11/22/2009] [Accepted: 01/10/2010] [Indexed: 10/19/2022] Open
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Al-Holou WN, Maher CO, Muraszko KM, Garton HJL. The natural history of pineal cysts in children and young adults. J Neurosurg Pediatr 2010; 5:162-6. [PMID: 20121364 DOI: 10.3171/2009.9.peds09297] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors reviewed their experience with pediatric pineal cysts to define the natural history and clinical relevance of this common intracranial finding. METHODS The authors identified all patients with pineal cysts who had been clinically evaluated at their institution over an 11.5-year interval and were < 25 years of age at the time of diagnosis. All inclusion criteria were met in 106 patients, and included repeated MR imaging as well as repeated clinical evaluation over at least a 6-month interval. RESULTS The mean age at diagnosis was 11.7 +/- 7.2 years. Forty-two patients were male and 64 were female. On follow-up MR imaging evaluation at a mean interval of 3.0 years from the initial study, 98 pineal cysts had no increase in size and no change in imaging appearance. Six pineal cysts increased in size and 2 others had a change in imaging characteristics without associated growth. Younger age was associated with cyst change or growth on follow-up imaging (p = 0.02). The mean age of patients with cysts that changed or grew was 5.5 years, and the mean age of patients with stable pineal cysts was 12.2 years. Initial cyst size and appearance on MR imaging were not significant predictors of growth or change in imaging appearance at follow-up. Similarly, the patient's sex was not a significant predictor of growth or change in imaging characteristics. CONCLUSIONS Follow-up imaging and neurosurgical evaluation may be considered optional in older children with pineal cysts.
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Affiliation(s)
- Wajd N Al-Holou
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-5338, USA
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Al-Holou WN, Garton HJL, Muraszko KM, Ibrahim M, Maher CO. Prevalence of pineal cysts in children and young adults. Clinical article. J Neurosurg Pediatr 2009; 4:230-6. [PMID: 19772406 DOI: 10.3171/2009.4.peds0951] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECT Pineal cysts are a frequent incidental finding on intracranial imaging. In adults, the prevalence of pineal cysts is estimated to be 1.1-4.3%. However, the prevalence is not well established in younger patients. METHODS The authors retrospectively reviewed a consecutive series of 14,516 patients 25 years of age and younger, who underwent brain MR imaging at a single institution over an 11-year period. In patients identified with pineal cysts, the authors analyzed the images according to cyst size, signal characteristics, enhancement pattern, and evidence of local mass effect. Patient characteristics including demographics and other intracranial diagnoses were collected in the pineal cyst population and compared with a randomly selected age- and sex-matched control patient population. The data were evaluated using univariate and multivariate logistic regression, linear regression, and ANOVA. RESULTS The authors identified 288 pineal region cysts (2.0%). The prevalence of pineal cysts was higher in female (2.4%) than in male patients (1.5%; p < 0.001). Pineal cysts were identified in patients of all ages, with an increased prevalence found in older patients (p < 0.001). Pineal cyst size was similar for all age and sex groups. CONCLUSIONS Pineal cysts are common in the pediatric population, with an increased prevalence in girls and in older patients.
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Affiliation(s)
- Wajd N Al-Holou
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan, 48109-5335, USA
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Sarikaya-Seiwert S, Turowski B, Hänggi D, Janssen G, Steiger HJ, Stummer W. Symptomatic intracystic hemorrhage in pineal cysts. Report of 3 cases. J Neurosurg Pediatr 2009; 4:130-6. [PMID: 19645546 DOI: 10.3171/2009.4.peds08309] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Pineal cysts are benign and often asymptomatic intracranial entities. Occasionally they can lead to neurological symptoms through growth or due to intracystic hemorrhage. The purpose of the current report is to describe their clinical characteristics and treatment options. In the current study, the authors illustrate the course of disease in 3 patients who developed neurological symptoms due to hemorrhage into a pineal cyst. Two of their patients had additional cerebral disease, and regular MR imaging examinations were conducted. This circumstance allowed documentation of growth and intracystic hemorrhage. After the occurrence of new neurological symptoms with severe headache, MR images showed a fluid-fluid interface due to intracystic hemorrhage. The third patient presented with acute triventricular hydrocephalus and papilledema due to aqueductal stenosis caused by intracystic hemorrhage. In all 3 cases, excision of the pineal cysts via an infratentorial/supracerebellar approach was performed. Histological examination revealed the characteristic structure of pineal cyst in all cases, with hemorrhagic residues in the form of hemosiderin deposits. All patients recovered fully after surgical removal of the cysts. Furthermore, resolution of occlusive hydrocephalus could be demonstrated in those cases with ventricular enlargement. Pineal cysts without neurological symptoms are often discovered as incidental findings on cranial MR images. In contrast, neurological symptoms such as severe headache, diplopia, or Parinaud syndrome, may occur as a result of pineal apoplexy due to intracystic hemorrhage. The authors' cases confirm that MR imaging can identify intracystic hemorrhage by a characteristic fluid-fluid interface. Their experience suggests that microsurgical resection of cysts may be an effective and curative treatment option.
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Borruat FX, Kawasaki A. Isolated Accommodation Palsy Associated with a Pineal Cyst. Report of a Case and Review of the Literature. Neuroophthalmology 2009. [DOI: 10.1080/01658100701501141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Gore PA, Gonzalez LF, Rekate HL, Nakaji P. Endoscopic supracerebellar infratentorial approach for pineal cyst resection: technical case report. Neurosurgery 2008; 62:108-9; discussion 109. [PMID: 18424974 DOI: 10.1227/01.neu.0000317380.60938.79] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Accepted surgical strategies to address symptomatic pineal cysts include transventricular flexible or rigid endoscopy and supracerebellar infratentorial or occipital transtentorial microsurgical approaches. We report the first application of the endoscopic supracerebellar infratentorial approach for the complete resection of a pineal cyst. Unlike transventricular endoscopy, this technique poses no risk to the fornices and can be applied independent of ventricular size. CLINICAL PRESENTATION A 37-year-old woman sought treatment for intractable headaches. A thorough evaluation revealed only a pineal cyst exerting mass effect on the tectum but causing no hydrocephalus. A period of nonoperative management was unsuccessful, and the patient was referred for surgery. TECHNIQUE The patient was positioned in the semi-sitting position. The supracerebellar infratentorial corridor was accessed through a burr-hole. The pineal cyst was resected completely via the endoscope. Postoperatively, the patient's headaches resolved completely. CONCLUSION The endoscopic supracerebellar infratentorial approach involves minimal brain retraction, poses no risk to the fornices, allows visualization and avoidance of the Galenic veins, and can be performed regardless of the size of the ventricle. Consequently, it is an excellent minimally invasive surgical option for resection or fenestration of symptomatic pineal cysts.
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Affiliation(s)
- Pankaj A Gore
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Leveque S, Derrey S, Martinaud O, Freger P, Proust F. [Pineal cyst: usefulness of endoscopic treatment]. Neurochirurgie 2007; 53:95-9. [PMID: 17507051 DOI: 10.1016/j.neuchi.2007.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2005] [Accepted: 03/01/2007] [Indexed: 11/30/2022]
Abstract
Glial cysts of the pineal gland are usually benign and asymptomatic. They develop from the pineal parenchyma and contain liquid. The diagnosis is made by magnetic resonance imaging. In contrast large cysts can be symptomatic due to compression of the aqueduct of Sylvius, compression of the midbrain tectum or mass effect in the posterior fossa. We report the case of a symptomatic cyst treated by an endoscopic procedure.
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Affiliation(s)
- S Leveque
- Service de neurochirurgie, CHU de Rouen, boulevard Gambetta, 76031 Rouen cedex, France
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Patel AJ, Fuller GN, Wildrick DM, Sawaya R. Pineal cyst apoplexy: case report and review of the literature. Neurosurgery 2006; 57:E1066; discussion E1066. [PMID: 16284546 DOI: 10.1227/01.neu.0000179990.46401.66] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE AND IMPORTANCE Although most pineal cysts are clinically benign and asymptomatic, some can become symptomatic. Of the various symptomatic presentations, apoplexy is the rarest and most ill-defined. A comprehensive search of publications in the English language yielded 18 cases of pineal cyst apoplexy. We reviewed the literature to compare symptomatology and management strategies and their outcomes. CLINICAL PRESENTATION A 29-year-old woman with a 1-month history of headaches presented with an acute worsening of her symptoms with a severe occipital headache and trouble focusing when reading. Her neurological examination was otherwise normal. Magnetic resonance imaging showed pineal cyst apoplexy and accompanying hydrocephalus. INTERVENTION A left paramedian craniotomy with a transcallosal, transchoroidal approach using an intraoperative neuronavigation system was used to resect a pineal cyst. Postoperative imaging showed complete removal of the cyst and resolution of the hydrocephalus. Follow-up imaging at 12 months demonstrated no evidence of recurrence or any hydrocephalus. The patient has remained asymptomatic for 18 months. CONCLUSION Pineal cyst apoplexy should always be considered when following a patient with a pineal cyst that becomes symptomatic. The most common symptom was severe headache of sudden onset or acute worsening. Other signs of hydrocephalus may or may not be present. Magnetic resonance imaging is essential to making a diagnosis. Although we believe that surgical resection is the most effective approach because it minimizes the risk for recurrence and complication, stereotactic aspiration has been used successfully to treat this condition.
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Affiliation(s)
- Akash J Patel
- Department of Neurosurgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030-4950, USA
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Nimmagadda A, Sandberg DI, Ragheb J. Spontaneous involution of a large pineal region hemorrhagic cyst in an infant. Case report. J Neurosurg 2006; 104:275-8. [PMID: 16619640 DOI: 10.3171/ped.2006.104.4.275] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report the case of a newborn presenting at birth with macrocephaly and a large pineal region hemorrhagic cyst without neurological deficit. No neurosurgical intervention was performed, and subsequent imaging studies demonstrated complete involution of the cyst.
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Affiliation(s)
- Anitha Nimmagadda
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Florida, USA
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Harrer JU, Klötzsch C, Oertel MF, Möller-Hartmann W. Sonographic detection and follow up of an atypical pineal cyst: a comparison with magnetic resonance imaging Case report. J Neurosurg 2005; 103:564-6. [PMID: 16235692 DOI: 10.3171/jns.2005.103.3.0564] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The incidental ultrasonographic detection of an asymptomatic cystic pineal lesion in a young woman is described and compared with findings on magnetic resonance (MR) images. Follow-up studies obtained using both imaging modalities are presented. The results indicate that transcranial ultrasonography may represent an easy and cost-effective imaging technique for follow up of cystic lesions of the pineal gland, especially in patients unable to undergo MR imaging.
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Affiliation(s)
- Judith U Harrer
- Department of Neurology, RWTH Aachen University Hospital, Aachen, Germany.
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