Incidental pineal cysts in children who undergo 3-T MRI

Structural brain abnormalities in Pallister-Killian syndrome: a neuroimaging study of 31 children

BACKGROUND

Pallister-Killian syndrome (PKS) is a rare genetic disorder caused by mosaic tetrasomy of 12p with wide neurological involvement. Intellectual disability, developmental delay, behavioral problems, epilepsy, sleep disturbances, and brain malformations have been described in most individuals, with a broad phenotypic spectrum. This observational study, conducted through brain MRI scan analysis on a cohort of patients with genetically confirmed PKS, aims to systematically investigate the neuroradiological features of this syndrome and identify the possible existence of a typical pattern. Moreover, a literature review differentiating the different types of neuroimaging data was conducted for comparison with our population.

RESULTS

Thirty-one individuals were enrolled (17 females/14 males; age range 0.1-17.5 years old at first MRI). An experienced pediatric neuroradiologist reviewed brain MRIs, blindly to clinical data. Brain abnormalities were observed in all but one individual (compared to the 34% frequency found in the literature review). Corpus callosum abnormalities were found in 20/30 (67%) patients: 6 had callosal hypoplasia; 8 had global hypoplasia with hypoplastic splenium; 4 had only hypoplastic splenium; and 2 had a thin corpus callosum. Cerebral hypoplasia/atrophy was found in 23/31 (74%) and ventriculomegaly in 20/31 (65%). Other frequent features were the enlargement of the cisterna magna in 15/30 (50%) and polymicrogyria in 14/29 (48%). Conversely, the frequency of the latter was found to be 4% from the literature review. Notably, in our population, polymicrogyria was in the perisylvian area in all 14 cases, and it was bilateral in 10/14.

CONCLUSIONS

Brain abnormalities are very common in PKS and occur much more frequently than previously reported. Bilateral perisylvian polymicrogyria was a main aspect of our population. Our findings provide an additional tool for early diagnosis.Further studies to investigate the possible correlations with both genotype and phenotype may help to define the etiopathogenesis of the neurologic phenotype of this syndrome.

Paediatric pineal region cysts: enigma or impaired neurofluid system?

PURPOSE

Pineal region cysts (PCs) may affect the tectum and aqueduct and cause deep central vein congestion. Beside headaches, PC often causes a broad range of symptoms, leading to prolonged diagnosis and therapy. The aims of this study are to reveal parameters that might explain the ambiguity of the symptoms and to identify factors in association with the respiration-driven neurofluid system.

METHODS

This retrospective study included 28 paediatric patients (mean age 11.6 years) who received surgical treatment and 18 patients (mean age 11.3 years) who were followed conservatively. Symptoms, time to diagnosis, cyst size, ventricular indices, head circumference and postoperative outcome, were analysed. Four patients were investigated for CSF dynamics with real-time MRI. The mean follow-up time was 1.6 years.

RESULTS

The most common early onset symptoms were headaches (92%), blurred vision (42.8%), sleep disturbances (39.3%) and vertigo (32.1%). Tectum contact was observed in 82% of patients, and MRI examinations revealed that imaging flow void signals were absent in 32.1% of patients. The maximal cyst diameters were 13.7 × 15.6 mm (mean). Together with a postoperative flow void signal, 4 patients recovered their respiration-driven CSF aqueductal upward flow, which was not detectable preoperatively. After surgery the main symptoms improved.

CONCLUSION

Despite proximity to the aqueduct with frequently absent flow void signals, hydrocephalus was never detected. Data from real-time MRI depicted a reduced preoperative filling of the ventricular CSF compartments, indicating a diminished fluid preload, which recovered postoperatively.

Perinatal asphyxia and hypothermic treatment from the endocrine perspective

Introduction

Perinatal asphyxia is one of the three most important causes of neonatal mortality and morbidity. Therapeutic hypothermia represents the standard treatment for infants with moderate-severe perinatal asphyxia, resulting in reduction in the mortality and major neurodevelopmental disability. So far, data in the literature focusing on the endocrine aspects of both asphyxia and hypothermia treatment at birth are scanty, and many aspects are still debated. Aim of this narrative review is to summarize the current knowledge regarding the short- and long-term effects of perinatal asphyxia and of hypothermia treatment on the endocrine system, thus providing suggestions for improving the management of asphyxiated children.

Results

Involvement of the endocrine system (especially glucose and electrolyte disturbances, adrenal hemorrhage, non-thyroidal illness syndrome) can occur in a variable percentage of subjects with perinatal asphyxia, potentially affecting mortality as well as neurological outcome. Hypothermia may also affect endocrine homeostasis, leading to a decreased incidence of hypocalcemia and an increased risk of dilutional hyponatremia and hypercalcemia.

Conclusions

Metabolic abnormalities in the context of perinatal asphyxia are important modifiable factors that may be associated with a worse outcome. Therefore, clinicians should be aware of the possible occurrence of endocrine complication, in order to establish appropriate screening protocols and allow timely treatment.

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

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.

Clinical, Endocrine and Neuroimaging Findings in Girls With Central Precocious Puberty

CONTEXT

The etiology of central precocious puberty (CPP) includes a spectrum of conditions. Girls younger than age 6 years with CPP should undergo cranial magnetic resonance imaging (MRI), but it remains controversial whether all girls who develop CPP between the ages of 6 and 8 years require neuroimaging examination.

OBJECTIVE

To investigate the frequency of brain MRI abnormalities in girls diagnosed with CPP and the relationship between maternal factors, their age at presentation, clinical signs and symptoms, hormonal profiles, and neuroimaging findings.

METHODS

Data were collected between January 2005 and September 2019 from 112 girls who showed clinical pubertal progression before 8 years of age who underwent brain MRI.

RESULTS

MRI was normal in 47 (42%) idiopathic (I) scans, 54 (48%) patients had hypothalamic-pituitary anomalies (HPA) and/or extra-HP anomalies (EHPA), and 11 (10%) had brain tumors or tumor-like conditions (BT/TL), including 3 with neurological signs. Associated preexisting disorders were documented in 16. Girls with BT/TL had a higher LH peak after GnRH test (P = 0.01) than I, and those older than age 6 years had a higher craniocaudal diameter of the pituitary gland (P = 0.01); their baseline FSH and LH (P = 0.004) and peak FSH (P = 0.01) and LH (P = 0.05) values were higher than I. Logistic regression showed maternal age at menarche (P = 0.02) and peak FSH (P = 0.02) as BT/TL risk factors.

CONCLUSIONS

MRI provides valuable information in girls with CPP by demonstrating that fewer than half have a normal brain MRI and that few can have significant intracranial lesions after the age of 6, despite the absence of suggestive neurological signs.

Case report: Fluctuating tumor markers in a boy with gonadotropin-releasing hormone-independent precocious puberty induced by a pineal germ cell tumor

GnRH-independent precocious puberty (GIPP) can be the presenting clinical picture experienced by patients with secreting germ cell tumor (GCT). Indeed, as luteinizing hormone (LH) and human chorionic gonadotropin (hCG) share identical α-subunits and similar β-subunits, an increased secretion of β-hCG may result in a precocious activation of Leydig cells. Though the co-occurrence of raised β-hCG levels and signs of precocious virilization usually prompts a complete oncological work-up, the diagnostic and therapeutic management of GCT-induced GIPP may be challenging. We report the case of a 6.2 year-old boy presenting with clinical and biochemical findings consistent with GIPP (discrepancy between overt virilization and pre-pubertal testicular volume, suppressed gonadotropins and remarkably raised testosterone). Brain imaging detected a bilobed cyst of the pineal gland, while serum and cerebrospinal baseline assessment initially ruled out raised alpha-fetoprotein or β-hCG levels. Nevertheless, a strict biochemical follow-up highlighted a fluctuant trend of tumor markers, with a more aggressive behavior and recurrent erections occurring as a result of unpredictable phases of raised testosterone and serum/cerebrospinal β-hCG, followed by sudden spontaneous decrease. Accordingly, a secreting pineal GCT was suspected. Given the fluctuating trend of tumor markers, surgery was initially kept on hold and a combined treatment with bicalutamide (androgen receptor blocker) and anastrozole (aromatase inhibitor) was undertaken in order to prevent the patient from experiencing further virilization and excessive bone age maturation. Subsequently, a progression in the size of the pineal tumor prompted surgical resection and a diagnosis of secreting GCT was histologically confirmed. Accordingly, the patient was started on adjuvant chemo- and radiotherapy. Antineoplastic treatment was followed by persistent and remarkable decrease of tumor markers and by a complete pubertal arrest. We reported the challenging diagnosis of a secreting pineal GCT in a patient with GIPP and a fluctuating trend of tumor markers, testosterone levels and associated clinical signs, hence prompting the indication for a systematic assessment and a strict monitoring whenever a patient with GnRH-independent precocious puberty shows clinical or radiological markers potentially consistent with a GCT.

In and around the pineal gland: a neuroimaging review

Lesions arising in or around the pineal gland comprise a heterogeneous group of pathologies ranging from benign non-neoplastic cysts to highly malignant neoplasms. Pineal cysts are frequently encountered as an incidental finding in daily radiology practice but there is no universal agreement on the criteria for, frequency of, and duration of follow-up imaging. Solid pineal neoplasms pose a diagnostic challenge owing to considerable overlap in their imaging characteristics, although a combination of radiological appearances, clinical findings, and tumour markers allows for narrowing of the differential diagnosis. In this review, we describe the radiological anatomy of the pineal region, clinical symptoms, imaging appearances, and differential diagnosis of lesions arising in this area, and highlight the clinical management of these conditions.

Management of pineal and colloid cysts

The widespread use of MRI has led to the increasingly frequent diagnosis of pineal and colloid cysts. While most are small and incidental, do not require long-term monitoring and will never need treatment, they are a cause of patient anxiety and clinician uncertainty regarding the optimal management-particularly for larger cysts or those with an atypical appearance. Occasionally pineal cysts, and more commonly colloid cysts, cause hydrocephalus that requires urgent neurosurgical treatment. More recently the non-hydrocephalic symptomatic pineal cyst has been described in the neurosurgical literature but there is controversy over this entity and its management. This review addresses the difficulties in managing pineal and colloid cysts and provides a pragmatic framework for the practising clinician.

Is there any relationship between autism and pineal gland volume?

Purpose

Abnormalities in melatonin physiology and circadian rhythm are detected in patients with autism. Melatonin is produced predominantly in the pineal gland and the amount of melatonin released is proportional to the pineal gland volume. This study aimed to examine whether the pineal gland volume in children with autism is different from that in healthy children.

Material and methods

Brain magnetic resonance images (MRI) of 120 paediatric patients with autism and 82 control paediatric subjects were examined; pineal parenchymal volume (PPV), pineal cyst rate (PCR), and total pineal gland volume (TPGV) were measured using a multimodality viewer (MMV), but only the TPGVs were measured using a tumour tracking (TT) method. Measurements were taken by 2 separate radiologists.

Results

In patients with autism, the PPV and TPGV according to MMV, and the TPGV according to TT were significantly lower, and the PCR was significantly higher. Moreover, the ratio of PPV to TPGV was significantly lower in the autism patient group. In both groups, the TPGVs were significantly lower in the autism patient group than the controls among all age groups.

Conclusions

Our study was the first to examine TPGVs in detail in paediatric patients with autism using 2 different methods. Low PPV-TPGV and high PCR have been observed in autism. This study also provides comparable reference values for pineal gland size in healthy children or autistic children aged 2-17 years. These results show promising potential for further research to understand the relationship between autism pathogenesis and the pineal gland.

Pineal cysts: Does anyone need long-term follow up?

Pineal cysts are a common incidental finding on brain magnetic resonance imaging (MRI) whichfrequently prompts referral to neurosurgery. Currently, a management algorithm for patientswithout hydrocephalus, Parinaud's syndrome, or pineal apoplexy is lacking.We aimed to identifypredictive factors of pineal cyst volume change andsurgical intervention by performing retrospective chart review of 98 patients between 2005 and 2018 diagnosed with pineal cysts gleaned from our Neurosurgery clinical databases.We included patients whose initial and follow-up MRIs were available in our institutional radiology system or whose surgical pathology confirmed pineal cyst after evaluation with an initial MRI. Patients' medical records were queried for presenting symptoms, demographic, management, and pineal cyst measurements. Three dimensions (anterior-posterior, rostral-caudal, transverse) of pineal cyst size were measured and converted to cyst volume (cm³) for analysis. Fifty-five patients (mean age 26.09 ± 14.7 years) with pineal cysts met study criteria. Follow-up ranged from 4 months to 10 years. The indications for MR imaging included headache (81.8%) and vision problems (42%).Forty-eight patients who were observed had a mean volume change of 0.051 ± 0.862 cm [3] and median volume change of 0 cm [3] Patient symptoms, referral source, and age were not associated with changes in volume on follow-up. Aggregated number of symptoms did not differ between operative and observation patients. (p = 0.29). Pineal cyst volumes tend to remain stable over serial MR images, do not reliably correlate with symptoms, and do not typically require long-term follow-up.

Prevalence and Risk Factors of Incidental Findings in Brain MRIs of Healthy Neonates-The FinnBrain Birth Cohort Study

Background: Birth is a traumatic event with molding forces directed to the fetal skull, which may result in intracranial hemorrhages. However, the knowledge on prevalence and risk factors of incidental brain magnetic resonance imaging (MRI) findings in infants is still inconclusive.

Methods: The prevalence and nature of incidental MRI findings were assessed in a birth cohort of 175 asymptomatic infants. The role of delivery method as well as other potential risk factors for intracranial hemorrhages were evaluated. The infants underwent 3T MRI at the age of 2–5 weeks, and the neurological status of the infants with an incidental finding was evaluated by a pediatric neurologist. Information on the delivery method, duration of delivery, parity, used anesthesia, oxytocin induction, and Apgar score was gathered to evaluate their association with the prevalence of hemorrhages.

Results: Incidental intracranial hemorrhages were detected in 12 infants (6.9%), all following spontaneous or assisted vaginal delivery. Vacuum-assistance was found to be a risk factor for subdural hemorrhages with an odds ratio (OR) of 4.7 (95% CI [1.18; 18.9], p = 0.032). All infants were evaluated to develop normally by their clinical status.

Conclusions: Incidental intracranial hemorrhages are relatively common among infants born by vaginal delivery. They are often of little clinical significance within the first years of life and have unlikely consequences for later neurodevelopment either. Despite their benign character, investigators should be prepared to share this information with parents competently as the findings can cause parental anxiety, and especially as the popularity of MRI as a research tool is increasing.

Incidental Brain MRI Findings in Children: A Systematic Review and Meta-Analysis

BACKGROUND

The detection of incidental findings on children's brain MR imaging poses various practical issues because the life-long implications of such findings may be profound.

PURPOSE

Our aim was to assess the prevalence and characteristics of incidental brain MR imaging findings in children.

DATA SOURCES

Electronic databases (PubMed, EMBASE, and Cochrane) were searched for articles published between 1985 to July 2018, with the following search terms: "incidental," "findings," "brain," "MR imaging."

STUDY SELECTION

Inclusion criteria were the following: 1) patients younger than 21 years of age, 2) healthy children without any clinical condition, 3) MR images obtained with at least a 1.5T magnet, 4) original articles, and 5) a methodologic quality score of ≥10.

DATA ANALYSIS

Two observers independently extracted data and assessed data quality and validity. The number and type of incidental findings were pooled. Heterogeneity was assessed using the Cochran Q statistic and the I² statistic.

DATA SYNTHESIS

Seven studies were included, reporting 5938 children (mean age, 11.3 ± 2.8 years). Incidental findings were present in 16.4% (99% CI, 9.8-26.2; Q = 117.5, I²= 94.9%) of healthy children, intracranial cysts being the most frequent (10.2%, 99% CI, 3.1-28.5; Q = 306.4, I² = 98.0%). Nonspecific white matter hyperintensities were reported in 1.9% (99% CI, 0.2-16.8; Q = 73.6, I² = 94.6%), Chiari 1 malformation was found in 0.8% (99% CI, 0.5-1.3; Q = 7.6, I² = 60.5%), and intracranial neoplasms were reported in 0.2% (99% CI, 0.1-0.6; Q = 3.4, I² = 12.3%). In total, the prevalence of incidental findings needing follow-up was 2.6% (99% CI, 0.5-11.7; Q = 131.2, I² = 95.4%). Incidental findings needing specific treatment were brain tumors (0.2%) and cavernomas (0.2%).

LIMITATIONS

Limitations were no age stratification or ethnicity data and variation in the design of included studies.

CONCLUSIONS

The prevalence of incidental findings is much more frequent in children than previously reported in adults, but clinically meaningfull incidental findings were present in <1 in 38 children.

Pineal cyst surveillance in adults - a review of 10 years' experience

Objective: Pineal cysts are common benign incidental findings in adults. There are no commonly accepted criteria for follow up or indications for intervention. We looked at our outcomes for this condition to explore their natural history and review our surveillance criteria.Method: Retrospective review of multidisciplinary team meetings at a tertiary neurosurgical centre over 10 years. Data relating to demographics, presenting symptoms, maximum diameter, duration of surveillance, final diagnosis and overall outcome were extracted from electronic patient records and available MRI. Data were analysed using IBM SPSS version 24.Result: Seventy-seven pineal cysts were identified. Female to male ratio was 1.43, female mean age was 38.6 and male mean age was 50.4. An increase in referral frequency was observed over the study period (mean increase of 1.4 cases per year). Presenting symptoms of headache in 45% and visual and hearing symptoms in 38.5% were recorded and baseline mean maximum diameter was 13.4mm. 20 patients were discharged on presentation, 54 were booked for at least one follow-up scan with a median follow up period of 14 months. The mean change in maximum diameter was 0.04mm over 18 months. Three patients (3.9%) underwent endoscopic biopsy and CSF diversion for cysts all more than 20mm with radiological evidence of hydrocephalus. In 100% of cases, the initial MDT diagnosis and final diagnosis were concordant.Conclusions: No patient under surveillance required surgical treatment and those managed surgically were symptomatic with large cysts and hydrocephalus on presentation. A majority of pineal cysts remained unchanged during the MRI follow-up, therefore our review suggests that routine follow-up of pineal cysts is not necessary in the absence of unusual radiological characteristics or related clinical symptoms.

Conservative management of retinoblastoma: Challenging orthodoxy without compromising the state of metastatic grace. "Alive, with good vision and no comorbidity"

Retinoblastoma is lethal by metastasis if left untreated, so the primary goal of therapy is to preserve life, with ocular survival, visual preservation and quality of life as secondary aims. Historically, enucleation was the first successful therapeutic approach to decrease mortality, followed over 100 years ago by the first eye salvage attempts with radiotherapy. This led to the empiric delineation of a window for conservative management subject to a "state of metastatic grace" never to be violated. Over the last two decades, conservative management of retinoblastoma witnessed an impressive acceleration of improvements, culminating in two major paradigm shifts in therapeutic strategy. Firstly, the introduction of systemic chemotherapy and focal treatments in the late 1990s enabled radiotherapy to be progressively abandoned. Around 10 years later, the advent of chemotherapy in situ, with the capitalization of new routes of targeted drug delivery, namely intra-arterial, intravitreal and now intracameral injections, allowed significant increase in eye preservation rate, definitive eradication of radiotherapy and reduction of systemic chemotherapy. Here we intend to review the relevant knowledge susceptible to improve the conservative management of retinoblastoma in compliance with the "state of metastatic grace", with particular attention to (i) reviewing how new imaging modalities impact the frontiers of conservative management, (ii) dissecting retinoblastoma genesis, growth patterns, and intraocular routes of tumor propagation, (iii) assessing major therapeutic changes and trends, (iv) proposing a classification of relapsing retinoblastoma, (v) examining treatable/preventable disease-related or treatment-induced complications, and (vi) appraising new therapeutic targets and concepts, as well as liquid biopsy potentiality.

Neuroimaging in emergency: a review of possible role of pineal gland disease

The pineal gland can be involved in a variety of neoplastic and congenital masses and tumors. Pineal gland neoplasms occur more frequently in children, accounting for 3-8% of intracranial tumors in the pediatric population. Pineal cysts are small lesions usually asymptomatic and encountered incidentally. Pathologic processes involving the pineal region produce signs and symptoms related to the mass effect on the adjacent structures and invasion of surrounding structures. These include several acute symptoms, such as increased intracranial pressure syndrome from obstruction of the aqueduct and consequent hydrocephalus, and Parinaud syndrome. Pineal apoplexy is rare and refers to the sudden neurological deterioration following hemorrhage in the pineal gland, most commonly into a pineal cyst. Knowledge of the clinical presentation and imaging features of these lesions is essential to narrow the differential diagnosis, especially when presenting with acute onset.

Sleep disorders in children with incidental pineal cyst on MRI: a pilot study

INTRODUCTION

For several years, pineal cysts have been considered an incidental finding on brain MRI's even though research and case reports have shown a possible association of pineal cysts with headaches and sleep disturbances. This pilot study aims to evaluate sleep disorders in school-age children with an incidental pineal cyst in an otherwise normal brain MRI.

METHOD

Children aged 6-12 years, who were referred for evaluation of headaches, tics, or syncope, and had an incidental pineal cyst on an otherwise normal brain MRI were included and compared to a control group of children with the same referral reasons but with a normal MRI and to a cohort of normal controls. The Sleep Disturbance Scale for Children (SDSC) was administered to the parents. Exclusion criteria included use of medications that affect sleep, seizures, brain abnormalities, tumors, or comorbid medical conditions that affect sleep.

RESULTS

Eighteen children (11 females) with pineal cysts, 19 children with normal MRI, and 100 age- and sex-matched controls were included in our study. There were statistically significant differences in the total SDSC score (with a difference of 10 between the median scores) and in two of the six domains of this scale. Children with pineal cysts scored significantly higher in the domains of disorders of excessive sleepiness and disorders of initiating and maintaining sleep than the two control groups. The scores in these two domains correlated significantly with the size of the cyst.

CONCLUSION

School-age children with pineal cysts have significantly increased levels of sleepiness and difficulty with sleep initiation and maintenance.

Twenty-Five Diagnoses on Midline Images of the Brain: From Fetus to Child to Adult

Midsagittal images of the brain provide a wealth of anatomic information and may show abnormalities that are pathognomonic for particular diagnoses. Using an anatomy-based approach, the authors identify pertinent anatomic structures to serve as a checklist when evaluating these structures. Subregions evaluated include the corpus callosum, pituitary gland and sellar region, pineal gland and pineal region, brainstem, and cerebellum. The authors present 25 conditions with characteristic identifiable abnormalities at midsagittal imaging. Midsagittal views from multiple imaging modalities are shown, including computed tomography, ultrasonography, and magnetic resonance (MR) imaging. Standard MR imaging sequences are shown, as well as fetal MR and sagittal diffusion-weighted images. To demonstrate these conditions, fetal, neonatal, childhood, adolescent, and young adulthood images are reviewed. The differentiation of normal variants is guided by the understanding of anatomy and pathology. When a specific diagnosis is not possible, the authors present information to evaluate differential considerations and discuss when follow-up imaging may be indicated. The authors hope each case will clarify a pertinent differential diagnosis, appropriately guide patient management, and improve understanding of normal anatomy and identification of pathologic entities. It is in these hopes that the authors have presented a checklist of pertinent anatomy and pathologic entities that can build on existing search patterns. Improved confidence and accuracy in the evaluation of midsagittal images will benefit physicians and patients. ^©RSNA, 2018.

Follow-up of pineal cysts in children: is it necessary?

PURPOSE

Pineal cysts are common incidental findings in children undergoing magnetic resonance imaging (MRI). Several studies have suggested MRI follow-up if the cyst is larger than 10 mm. However, cysts do not usually change during follow-up. Prevalence, growth, and structure of the pineal cysts were analyzed to decide if follow-up MRI is necessary.

METHODS

A retrospective review between 2010 and 2015 was performed using 3851 MRI examinations of children aged 0-16 years to detect pineal cysts having a maximum diameter ≥ 10 mm. Eighty-one children with pineal cysts were identified and 79 of them had been controlled by MRI. Cysts were analyzed for the size, growth, and structure.

RESULTS

A total of 1.8% of the children had a pineal cyst with a diameter ≥ 10 mm. Cysts were present in 48 girls (59.3%) and 33 boys (40.7%). Most pineal cysts (70/79) did not significantly grow during the follow-up (median 10 months, range 3-145 months). A total of 11.4% (9/79) of the cysts grew with the biggest change measured from the outer cyst wall sagittal anteroposterior dimension (mean 3.4 mm ± 1.7 mm). Only one cyst grew more than 5 mm. We found no factors correlating with the cyst growth among 9 cysts that grew > 2 mm.

CONCLUSIONS

A majority of pineal cysts remained unchanged during the MRI follow-up. Results of this study suggest that routine MRI follow-up of pineal cysts is not necessary in the absence of unusual radiological characteristics or related clinical symptoms.

Adolescent Development of Cortical and White Matter Structure in the NCANDA Sample: Role of Sex, Ethnicity, Puberty, and Alcohol Drinking

Brain structural development continues throughout adolescence, when experimentation with alcohol is often initiated. To parse contributions from biological and environmental factors on neurodevelopment, this study used baseline National Consortium on Alcohol and NeuroDevelopment in Adolescence (NCANDA) magnetic resonance imaging (MRI) data, acquired in 674 adolescents meeting no/low alcohol or drug use criteria and 134 adolescents exceeding criteria. Spatial integrity of images across the 5 recruitment sites was assured by morphological scaling using Alzheimer's disease neuroimaging initiative phantom-derived volume scalar metrics. Clinical MRI readings identified structural anomalies in 11.4%. Cortical volume and thickness were smaller and white matter volumes were larger in older than in younger adolescents. Effects of sex (male > female) and ethnicity (majority > minority) were significant for volume and surface but minimal for cortical thickness. Adjusting volume and area for supratentorial volume attenuated or removed sex and ethnicity effects. That cortical thickness showed age-related decline and was unrelated to supratentorial volume is consistent with the radial unit hypothesis, suggesting a universal neural development characteristic robust to sex and ethnicity. Comparison of NCANDA with PING data revealed similar but flatter, age-related declines in cortical volumes and thickness. Smaller, thinner frontal, and temporal cortices in the exceeds-criteria than no/low-drinking group suggested untoward effects of excessive alcohol consumption on brain structural development.

Pineal cysts-A benign association with familial retinoblastoma

Patients with familial/heritable retinoblastoma (RB) are at increased risk of developing second malignancies throughout life, including a pineoblastoma (trilateral RB [TRB]) in early childhood. Current guidelines recommend regular surveillance brain imaging for those with heritable RB until 5 years of age. The presence of pineal cysts has been reported in patients with RB. Pineal cysts are thought to arise due to focal degeneration of the pineal gland and can be found incidentally. The finding of pineal abnormalities including cysts in children with RB on imaging is disconcerting, as it raises the possibility of an underlying malignancy, specifically a pinealoblastoma. The authors reviewed the imaging findings and clinical significance of pineal cysts in 69 patients diagnosed with RB at our center between December 1999 and November 2015. Twenty-six patients had pineal cysts found on brain magnetic resonance imaging (MRI) scans performed either at diagnosis or follow-up. Thirty-eight of 69 patients had underlying heritable RB. Nineteen of 38 familial RB patients had a pineal cyst compared with 3 out of 26 with sporadic RB (P = .004). In the majority, the imaging characteristics and size of the cysts remained stable or resolved. In this cohort, pineal cysts were detected at significantly increased frequency in heritable RB. This may be a benign association or may reflect abnormal underlying biology of pineal tissue in individuals highly susceptible to malignancy. Imaging characteristics can be helpful in distinguishing between benign and malignant lesions. The presence of a pineal cyst in patients with unilateral disease may be a useful indicator of underlying heritable RB.

Spectrum of intracranial incidental findings on pediatric brain magnetic resonance imaging: What clinician should know?

Intracranial incidental findings on magnetic resonance imaging (MRI) of the brain continue to generate interest in healthy control, research, and clinical subjects. However, in clinical practice, the discovery of incidental findings acts as a “distractor”. This review is based on existing heterogeneous reports, their clinical implications, and how the results of incidental findings influence clinical management. This draws attention to the followings: (1) the prevalence of clinically significant incidental findings is low; (2) there is a lack of a systematic approach to classification; and discusses (3) how to deal with the detected incidental findings based a proposed common clinical profile. Individualized neurological care requires an active discussion regarding the need for neuroimaging. Clinical significance of incidental findings should be decided based on lesion’s neuroradiologic characteristics in the given clinical context. Available evidence suggests that the outcome of an incidentally found “serious lesion in children” is excellent. Future studies of intracranial incidental findings on pediatric brain MRI should be focused on a homogeneous population. The study should address this clinical knowledge based review powered by the statistical analyses.

MRI-based assessment of the pineal gland in a large population of children aged 0-5 years and comparison with pineoblastoma: part II, the cystic gland

Introduction

Pineal cysts are a common incidental finding on brain MRI with resulting difficulties in differentiation between normal glands and pineal pathologies. The aim of this study was to assess the size and morphology of the cystic pineal gland in children (0–5 years) and compare the findings with published pineoblastoma cases.

Methods

In this retrospective multicenter study, 257 MR examinations (232 children, 0–5 years) were evaluated regarding pineal gland size (width, height, planimetric area, maximal cyst(s) size) and morphology. We performed linear regression analysis with 99 % prediction intervals of gland size versus age for the size parameters. Results were compared with a recent meta-analysis of pineoblastoma by de Jong et al.

Results

Follow-up was available in 25 children showing stable cystic findings in 48 %, cyst size increase in 36 %, and decrease in 16 %. Linear regression analysis gave 99 % upper prediction bounds of 10.8 mm, 10.9 mm, 7.7 mm and 66.9 mm², respectively, for cyst size, width, height, and area. The slopes (size increase per month) of each parameter were 0.030, 0.046, 0.021, and 0.25, respectively. Most of the pineoblastomas showed a size larger than the 99 % upper prediction margin, but with considerable overlap between the groups.

Conclusion

We presented age-adapted normal values for size and morphology of the cystic pineal gland in children aged 0 to 5 years. Analysis of size is helpful in discriminating normal glands from cystic pineal pathologies such as pineoblastoma. We also presented guidelines for the approach of a solid or cystic pineal gland in hereditary retinoblastoma patients.

Electronic supplementary material

The online version of this article (doi:10.1007/s00234-016-1683-0) contains supplementary material, which is available to authorized users.

The prevalence of pineal cyst in patients with cerebral palsy

PURPOSE

Pineal cysts are common incidental findings during magnetic resonance imaging (MRI) examinations. The etiology of pineal cyst development is still unclear. We aimed to determine whether there is an association between periventricular leukomalacia and pineal cyst prevalence.

METHODS

Clinical and MRI data of 201 patients with periventricular leukomalacia (110 female, 91 male; mean age, 6 years; range, 2-18 years) and 687 control patients (355 female, 332 male; mean age, 6 years¸ range, 2-18 years) who did not have any evidence of periventricular leukomalacia were independently evaluated by two radiologists for presence or absence of pineal cyst.

RESULTS

Pineal cysts were detected in 32.3% of the study group (65/201) and 8.4% of the control group (58/687) (P < 0.001). Patients with periventricular leukomalacia were more likely to have a pineal cyst. In terms of pineal cyst detection on MRI, interobserver reliability was high between the two radiologists.

CONCLUSION

The prevalence of pineal cysts is higher in patients with periventricular leukomalacia. We suggest that an ischemic process may have a role in the etiopathogenesis of pineal cyst development.

Prospective analysis on brain magnetic resonance imaging in children

BACKGROUND

Previous studies have addressed the prevalence of incidental findings in adult populations. There are few studies following paediatric patients, most of data were retrieved retrospectively. We conducted a prospective study to determine the prevalence of incidental, pathologic and normal findings in a symptomatic paediatric population.

METHODS

The subjects of this prospective single centre study are 436 children aged 0-18 years with clinical symptoms and subsequent first brain MRI. Normal, incidental as well as pathologic MRI findings are documented in association with age, gender, neurological examination and previous investigations (CCT, EEG). Secondary outcome parameters are defined as MRI results and their implications. Two board-certified radiologists prospectively analysed MR images without knowing the result from each other.

RESULTS

The 436 patients with brain MRI were categorized into three groups as follows: 155 (35.5%) patients had normal findings, 163 (37.4%) had incidental findings and 118 (27.1%) had pathological findings in brain MRI. When adding patients with pathologic and incidental findings we report even more (47.9%). We analysed the correlation between neurologic examination and MRI result and it was significant (p-value 0.0008). The p-value for concordance of both radiology reports was <0.001 and therefore highly significant.

CONCLUSION

To our knowledge this is the first prospective paediatric study reporting the prevalence of normal, pathologic and incidental findings in brain MRI in symptomatic children. Incidental findings are common in paediatric patients but we report the highest prevalence. Our data may help guiding management decision in a consistent and clinically appropriate manner.

Diffusion characteristics of pediatric pineal tumors

BACKGROUND

Diffusion weighted imaging (DWI) has been shown to be helpful in characterizing tumor cellularity, and predicting histology. Several works have evaluated this technique for pineal tumors; however studies to date have not focused on pediatric pineal tumors.

OBJECTIVE

We evaluated the diffusion characteristics of pediatric pineal tumors to confirm if patterns seen in studies using mixed pediatric and adult populations remain valid.

MATERIALS AND METHODS

This retrospective study was performed after Institutional Review Board approval. We retrospectively evaluated all patients 18 years of age and younger with pineal tumors from a single institution where preoperative diffusion weighted imaging as well as histologic characterization was available.

RESULTS

Twenty patients (13 male, 7 female) with pineal tumors were identified: seven with pineoblastoma, four with Primitive Neuroectodermal Tumor (PNET), two with other pineal tumors, and seven with germ cell tumors including two germinomas, three teratomas, and one mixed germinoma-teratoma. The mean apparent diffusion coefficient (ADC) values in pineoblastoma (544 ± 65 × 10⁻⁶ mm²/s) and pineoblastoma/PNET (595 ± 144 × 10⁻⁶ mm²/s) was lower than that of the germ cell tumors (1284 ± 334 × 10⁻⁶ mm²/s; p < 0.0001 vs pineoblastoma). One highly cellular germinoma had an ADC value of 694 × 10⁻⁶ mm²/s.

CONCLUSION

ADC values can aid in differentiation of pineoblastoma/PNET from germ cell tumors in a population of children with pineal masses.

Physiologic pineal region, choroid plexus, and dural calcifications in the first decade of life

BACKGROUND AND PURPOSE

Calcifications of the pineal, habenula, choroid plexus, and dura are often physiologic. In the modern CT era with thin-section images and multiplanar reformats, intracranial calcifications have become more conspicuous. We aimed to discover the CT prevalence of pineal region, choroid plexus, and dural calcifications in the first decade of life.

MATERIALS AND METHODS

Five hundred head CTs from different patients (age range, 0-9 years) encountered during a consecutive 6-month period at a single academic children's hospital were reviewed retrospectively after excluding examinations with artifacts and pineal region masses/hemorrhage. All studies were performed on a 320-detector CT, with 0.5-mm collimation and a 512 × 512 matrix. Five-millimeter reformatted axial, sagittal, and coronal images were analyzed for location and extent of intracranial calcifications.

RESULTS

The mean age was 3.5 ± 5.7 years (range, 0-9 years). There were 285 males (57%) and 215 females (43%). Pineal calcifications were present in 5% (n = 25; age range, 3.2-8.9 years; median, 7 years). Habenular calcifications were found in 10% (n = 50; age range, 2.8-8.8 years; median, 7 years). Twelve percent (n = 58) had choroid plexus calcifications, (age range, 0.1-8.8 years). Dural calcifications were rare, present in 1% (n = 6; age range, 2.9-8.7 years).

CONCLUSIONS

Physiologic intracranial calcifications may be found in the first decade, principally in children older than 5 years. Most epithalamic calcifications are habenular. Pineal and habenular calcifications were never present in children younger than 3 and 2 years, respectively. Choroid plexus calcifications may be present in the very young. Dural calcifications are rare.