Tag: pineal cyst

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Pineal cyst surgery beyond morphology: a critical evaluation of a consecutive surgical series

Acta Neurochirurgica (2026) 168:85

This study evaluates surgical management of symptomatic pineal cysts in a consecutive single-center cohort, comparing microsurgical, endoscopic, and stereotactic techniques. Radiological measures — notably aqueduct diameter and predominant cyst expansion — were analyzed alongside clinical outcomes using the Chicago Chiari Outcome Scale, showing durable benefit when surgery is guided by clinicoradiological criteria.

Findings indicate aqueduct narrowing and anterior expansion better predict positive postoperative outcomes than cyst size alone. Each surgical approach demonstrated specific indications: microsurgery for suspicious lesions, endoscopy for hydrocephalus/anterior compression, and stereotactic drainage for deep or high-risk cases, with overall high rates of sustained improvement.

Clinical problem: Surgical management of pineal cysts is especially controversial in non-hydrocephalic symptomatic patients because clinical–radiological correlations are inconsistent and many studies rely mainly on size/morphology for decisions.

Study design: Retrospective single-center cohort of 46 symptomatic pineal cyst patients (2008–2024), comparing surgical (n=18) vs non-surgical (n=28) groups and analyzing radiological markers (e.g., cyst dimensions, aqueduct diameter, predominant expansion) alongside outcomes measured by CCOS over time.

Key differentiators for surgery: Compared with non-surgical patients, surgical patients had larger cysts, narrower aqueducts (0.9 vs 1.6 mm, p<0.001), and much more frequent predominant anterior expansion (67% vs 7%, p<0.001).

Overall outcomes: After surgery, 94% achieved good/excellent CCOS (≥12) at 12 months, and 93% maintained good/excellent outcomes at long-term follow-up (mean 62 months).

Predictors: Aqueduct diameter was more closely associated with outcome than pineal cyst size; neither cyst volume nor hydrocephalus consistently predicted postoperative outcome.

Technique comparison: Microsurgical resection (n=12) had favorable long-term outcomes (mean CCOS 14.9) but the highest complication rate (3 patients) and the highest recurrence of headache despite total excision.

Endoscopic approach: Endoscopic fenestration + ventriculostomy (n=3) produced the best long-term outcomes (mean CCOS 15.7) with no recurrences reported.

Stereotactic option: Stereotactic drainage + Rickham reservoir (n=3) achieved stable decompression but lower long-term CCOS (mean 13.0) than other approaches.

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Microsurgical pineal cyst fenestration: A safe and effective treatment strategy in patients with symptomatic pineal cyst syndrome

Acta Neurochirurgica (2025) 167:179

Microsurgical fenestration of pineal cysts significantly improved symptoms in 94% of non-hydrocephalic patients with nonspecific symptoms, with no mortality or severe adverse events. Cyst size and radiological features did not predict outcomes. The study supports fenestration as a safe, effective treatment, but optimal indications remain unclear.

• Microsurgical fenestration of pineal cysts (PC) was studied as a treatment for symptomatic patients without hydrocephalus.

• Most patients had nonspecific symptoms like headache, dizziness, and sleep disturbances; nearly all saw surgery as a last resort.

• 47 patients were analyzed, with an average follow-up of about 7 years post-surgery.

• Significant symptom improvement was observed: mean pain score (VAS) dropped from 7 to 1, with 96% reporting relief.

• No mortality or severe complications occurred; minor complications included CSF leaks (10%) and one surgical site infection.

• No clinical or radiological factors predicted better outcomes; even small cysts could benefit from surgery.

• Fenestration of both anterior and posterior cyst walls was seen as key to success, potentially safer than full resection.

• Further research is needed to define indications, optimal technique, and pathophysiology of symptomatic pineal cysts.

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Pineal cyst: results of long-term MRI surveillance and analysis of growth and shrinkage rates

J Neurosurg 138:113–119, 2023

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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Surgical treatment of symptomatic pineal cysts without hydrocephalus—meta‑analysis of the published literature

Acta Neurochirurgica (2022) 164:61–77

To examine published data and assess evidence relating to safety and efficacy of surgical management of symptomatic pineal cysts without hydrocephalus (nhSPC), we performed a systematic review of the literature and meta-analysis.

Methods Following the PRISMA guidelines, we searched Pubmed and SCOPUS for all reports with the query ‘Pineal Cyst’ AND ‘Surgery’ as of March 2021, without constraints on study design, publication year or status (PROSPERO_ CRD:42,021,242,517). Assessment of 1537 hits identified 26 reports that met inclusion and exclusion criteria.

Results All 26 input studies were either case reports or single-centre retrospective cohorts. The majority of outcome data were derived from routine physician-recorded notes. A total of 294 patients with surgically managed nhSPC were identified. Demographics: Mean age was 29 (range: 4–63) with 77% females. Mean cyst size was 15 mm (5–35). Supracerebellar infratentorial approach was adopted in 90% of cases, occipital-transtentorial in 9%, and was not reported in 1%. Most patients were managed by cyst resection (96%), and the remainder by fenestration. Mean post-operative follow-up was 35 months (0–228). Presentation: Headache was the commonest symptom (87%), followed by visual (54%), nausea/vomit (34%) and vertigo/dizziness (31%). Other symptoms included focal neurology (25%), sleep disturbance (17%), cognitive impairment (16%), loss of consciousness (11%), gait disturbance (11%), fatigue (10%), ‘psychiatric’ (2%) and seizures (1%). Mean number of symptoms reported at presentation was 3 (0–9). Outcomes: Improvement rate was 93% (to minimise reporting bias only consecutive cases from cohort studies were considered, N = 280) and was independent of presentation. Predictors of better outcomes were large cyst size (OR = 5.76; 95% CI: 1.74–19.02) and resection over fenestration (OR = 12.64; 3.07–52.01). Age predicted worse outcomes (OR = 0.95; 0.91–0.99). Overall complication rate was 17% and this was independent of any patient characteristics. Complications with long-term consequences occurred in 10 cases (3.6%): visual disturbance (3), chronic incisional pain (2), sensory disturbance (1), fatigue (1), cervicalgia (1), cerebellar stroke (1) and mortality due to myocardial infarction (1).

Conclusions Although the results support the role of surgery in the management of nhSPCs, they have to be interpreted with a great deal of caution as the current evidence is limited, consisting only of case reports and retrospective surgical series. Inherent to such studies are inhomogeneity and incompleteness of data, selection bias and bias related to assessment of outcome carried out by the treating surgeon in the majority of cases. Prospective studies with patient-reported and objective outcome assessment are needed to provide higher level of evidence.

 

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Pineal cyst resection in the absence of ventriculomegaly or Parinaud’s syndrome

Pineal cyst resection in the absence of ventriculomegaly or Parinaud’s syndrome

J Neurosurg 123:352–356, 2015

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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