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Harding J, Masina R, Hill A, Ansanipour A, Steele A, Kolias A, Santarius T. International web-based survey of patients with non-hydrocephalic symptomatic pineal cysts. Acta Neurochir (Wien) 2024; 166:509. [PMID: 39731656 DOI: 10.1007/s00701-024-06403-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2024] [Accepted: 12/17/2024] [Indexed: 12/30/2024]
Abstract
OBJECTIVES To report the results of an international patient-reported survey that adds to the growing body of evidence surrounding the role of surgery in the management of a subset of patients with non-hydrocephalic symptomatic pineal cyst. DESIGN An international web-based survey of health outcomes in patients with nhSPC. SUBJECTS All survey participants who self-reported a diagnosis of symptomatic pineal cyst without hydrocephalus after radiological imaging. METHODS The survey was developed in collaboration with the patient group Pineal Cyst UK. It was publicised and distributed via several online platforms and social media. Data collected included demographics, cyst size, symptom frequency and severity, number of appointments with healthcare professionals, treatment options trialled, and whether patients underwent surgery. RESULTS 543 participants (mean age 38.6 years, range 1-83) were included in the analysis, of which 82 (mean age 38.9 years, range 16-72) had undergone cyst resection. After a median period of 18.3 months between date of surgery and date of questionnaire completion, 72 (90%) of the surgical cohort reported overall improvement, and all symptoms improved overall, whereas no symptoms improved overall in the non-surgical cohort. Of the non-surgical cohort (n = 461), 269 participants received some form of conservative treatment, of whom 194 (72.1%) did not experience symptom improvement on any treatment offered. CONCLUSIONS A cohort of patients with nhSPC who participated in this international survey reports substantial and durable improvement in symptom severity and quality of life after pineal cyst resection.
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Affiliation(s)
- Jessica Harding
- Department of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Clinical School, University of Cambridge, Cambridge, UK
| | - Riccardo Masina
- Department of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | | | - Ali Ansanipour
- Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
- Green Templeton College, University of Oxford, Oxford, OX2 6HG, UK
| | - Amber Steele
- Research Strategy & Partnership Hub, Cambridge NIHR Biomedical Research Centre, Cambridge, UK
| | - Angelos Kolias
- Department of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Thomas Santarius
- Department of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
- Department of Physiology, Development, and Neuroscience, University of Cambridge, Cambridge, UK.
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Staribacher D, Kuzmin D, Britz G, Feigl GC. Surgical corridor formation by minimally invasive lateral occipital infracortical supra-/transtentorial (OICST) approach in pineal region tumor surgery: A review of 11 cases. Clin Neurol Neurosurg 2024; 236:108073. [PMID: 38091704 DOI: 10.1016/j.clineuro.2023.108073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/19/2023] [Accepted: 11/26/2023] [Indexed: 02/04/2024]
Abstract
INTRODUCTION The pineal region is a hard-to-reach part of the brain. There is no unequivocal opinion on the choice of a surgical approach to the pineal region. The surgical approaches described differ in both trajectory (infra- and supratentorial, interhemispheric) and size of craniotomy. They have advantages and disadvantages. The minimally invasive lateral occipital infracortical supra-/transtentorial (OICST) approach we have described has all the advantages of the standard supratentorial approach and minimizes its disadvantages, namely, compression and contusion of the occipital lobe. The minimally invasive craniotomy and small surgical corridor facilitate that. METHODS We describe 11 consecutive patients with various pineal region tumors (7 cases of pineal cysts, 2 cases of pinealocytoma, 1 case of medulloblastoma, and 1 case of meningioma) who were operated on in our hospital using the lateral OICST approach. Preoperative planning was performed using Surgical Theater®. The surgical corridor was formed using a retractor made from half of a syringe shortened according to the length of the surgical corridor. Preoperative lumbar drain was used. RESULTS The pineal region tumors were completely resected in all cases. The mean craniotomy size was 2.22 × 1.79 cm. No long-term neurological deficits were reported. CONCLUSIONS The use of semicircular retractors and intraoperative CSF drainage via a lumbar drain allows to form a small surgical corridor to the pineal region via minimally invasive craniotomy. This reduces traction and traumatization of the occipital lobe, as well as minimizes intra- and postoperative risks.
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Affiliation(s)
| | - Dzmitry Kuzmin
- Department of Neurosurgery, General Hospital Bamberg, Bamberg, Germany
| | - Gavin Britz
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Guenther C Feigl
- Department of Neurosurgery, General Hospital Bamberg, Bamberg, Germany; Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany; Department of Neurological Surgery, Houston Methodist Hospital, Houston, TX, USA.
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Ludwig HC, Dreha-Kulaczewski S, Bock HC. Paediatric pineal region cysts: enigma or impaired neurofluid system? Childs Nerv Syst 2023; 39:3457-3466. [PMID: 37261536 PMCID: PMC10684616 DOI: 10.1007/s00381-023-06000-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/18/2023] [Indexed: 06/02/2023]
Abstract
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.
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Affiliation(s)
- Hans C Ludwig
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
| | - Steffi Dreha-Kulaczewski
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Hans Christoph Bock
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
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McDowell MM, Kim S, Greene S. Clinical and Radiographic Features of Pineal Cysts in Pediatric and Young Adult Patients. World Neurosurg 2023; 176:e719-e727. [PMID: 37315894 DOI: 10.1016/j.wneu.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/04/2023] [Accepted: 06/04/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Michael M McDowell
- Division of Neurological Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Song Kim
- Division of Neurological Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Stephanie Greene
- Division of Neurological Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Guadix SW, Marianayagam NJ, Weidman EK, Yuan M, Liechty B, Greenfield JP, Souweidane MM. Defining Occult High-Risk Cysts of the Pineal Region: A Case Series. Oper Neurosurg (Hagerstown) 2023; 24:572-581. [PMID: 36716050 DOI: 10.1227/ons.0000000000000620] [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: 04/29/2022] [Accepted: 11/08/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Absence of hydrocephalus on neuroimaging may impart a false sense of security for patients with pineal cysts. In this case series, we characterize a subset of patients with pineal cysts having an occult presentation. Unifying features of worsening paroxysmal headaches suggesting intermittent obstructive hydrocephalus and radiographic evidence of third ventricular invagination characterize these patients as high risk. OBJECTIVE To define features of occult, high-risk pineal cysts and outcomes of endoscopic cyst fenestration. METHODS Charts were retrospectively reviewed for patients with pineal cysts evaluated at our institution between 2018 and 2021 who underwent endoscopic cyst fenestration. To capture cysts presenting as occult, patients were excluded if hydrocephalus was noted at presentation. Relevant clinical history, imaging, operative data, and clinical outcomes were reviewed. RESULTS Of 50 pineal cyst patients, 4 satisfied inclusion criteria. All patients presented with worsening paroxysmal headaches. In addition, 75% (3/4) also experienced intermittent syncope. Patients exhibited no hydrocephalus (n = 3) or fluctuating ventricular size on longitudinal imaging (n = 1). In all cases, high-resolution sagittal 3-dimensional T2 magnetic resonance imaging demonstrated invagination of the cyst anteriorly into the posterior third ventricle. All patients underwent endoscopic cyst fenestration with complete symptom resolution (mean follow-up of 20.6 months; range 3.5-37.4 months). CONCLUSION The clinical history for occult, high-risk pineal cysts is notable for worsening paroxysmal headaches and episodic alterations of consciousness suggesting intermittent obstructive hydrocephalus. Because ventricular size can appear normal on standard imaging protocols, clinical suspicion should trigger workup with high-resolution magnetic resonance imaging designed to detect these cysts. Endoscopic cyst fenestration is a safe and efficacious management strategy.
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Affiliation(s)
- Sergio W Guadix
- Department of Neurological Surgery, Weill Cornell Medical Center, NewYork Presbyterian Hospital, New York, New York, USA
| | - Neelan J Marianayagam
- Department of Neurological Surgery, Weill Cornell Medical Center, NewYork Presbyterian Hospital, New York, New York, USA
| | - Elizabeth K Weidman
- Department of Radiology, Weill Cornell Medical Center, NewYork Presbyterian Hospital, New York, New York, USA
| | - Melissa Yuan
- Department of Ophthalmology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Benjamin Liechty
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical Center, NewYork Presbyterian Hospital, New York, New York, USA
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, Weill Cornell Medical Center, NewYork Presbyterian Hospital, New York, New York, USA
| | - Mark M Souweidane
- Department of Neurological Surgery, Weill Cornell Medical Center, NewYork Presbyterian Hospital, New York, New York, USA
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Feigl GC, Britz G, Staribacher D, Kuzmin D. The Minimally Invasive Lateral Occipital Infracortical Supra-/Transtentorial Approach in Surgery of Lesions of the Pineal Region: A Possible Alternative to the Standard Approaches. World Neurosurg 2023; 172:e151-e164. [PMID: 36608790 DOI: 10.1016/j.wneu.2022.12.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/28/2022] [Accepted: 12/29/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The pineal region is an anatomical region that is difficult to access surgically, especially when it comes to removing neoplasms. Four main surgical approaches to this region are used as standards nowadays: infratentorial supracerebellar, occipital supra-/transtentorial, interhemispheric, and transventricular approaches. All methods have both advantages and disadvantages and are associated to any extent with intra- and postoperative risks. We have developed a lateral minimally invasive occipital infracortical supra-/transtentorial (OICST) approach, which retains the advantages of the standard occipital transtentorial approach while improving tumor exposure and minimizing its disadvantages. METHODS We describe 7 consecutive cases of successful complete removals of pineal tumor formations of various quality and size (3 pineal cysts, 2 pineocytomas, 1 meningioma, 1 medulloblastoma) using the OICST approach developed by us. Preoperative 3-dimensional and virtual reality-modeling and the use of a special retractor also contributed to reducing the size of the surgical approach. RESULTS All patients underwent surgery for removal of a lesion in the pineal region and suffered from no new and permanent neurological deficits postoperatively. The mean size of the craniotomies was 2.3 × 1.85 cm. The minimally invasive approach developed by us carries the advantages of the standard occipital transtentorial approach, but minimizes its disadvantages. The main disadvantage of the standard occipital approach is excessive retraction of the occipital lobe, which is frequently associated with visual neurological deficits. Also, with occipital approach, the Rosenthal vein lying along the surgical corridor is frequently not good visible since the tumor is approached from its tip rather than side which limits the overview of the surgical field and can pose a risk. Damage to this vein can cause infarction of the basal ganglia. By approaching the pineal region from more laterally the size of the craniotomy can significantly be reduced, excessive retraction of the occipital lobe can be avoided and the risk of damage to large deep veins can be minimized. The cosmetic outcome with a small skin incision of only about 3 cm is also a very good side effect of this minimally invasive technique. CONCLUSIONS The minimally invasive lateral OICST approach described by us can be successfully used in the surgery of pineal neoplasms. Reducing the size of the craniotomy does not limit the possibility of complete removal of tumors of various sizes and tissue consistency, and also minimizes the risks of both intra- and postoperative complications.
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Affiliation(s)
- Guenther C Feigl
- Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany; Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA; Department of Neurosurgery, General Hospital Bamberg, Bamberg, Germany.
| | - Gavin Britz
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | | | - Dzmitry Kuzmin
- Department of Neurosurgery, General Hospital Bamberg, Bamberg, Germany
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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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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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Surgical treatment of symptomatic pineal cysts without hydrocephalus-meta-analysis of the published literature. Acta Neurochir (Wien) 2022; 164:61-77. [PMID: 34854993 PMCID: PMC8761144 DOI: 10.1007/s00701-021-05054-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 10/29/2021] [Indexed: 11/16/2022]
Abstract
Background 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. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-021-05054-0.
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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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Arkar U, Kučan R, Perković Benedik M, Hostnik T, Vipotnik Vesnaver T, Loboda T, Bošnjak R, Osredkar D. Clinical and Radiological Characteristics of Non-Benign Pineal Cyst Lesions in Children. Front Neurol 2021; 12:722696. [PMID: 34512533 PMCID: PMC8430827 DOI: 10.3389/fneur.2021.722696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background: With the increasing availability and advances in brain imaging, pineal cyst lesions (PCL) are becoming a common finding in the pediatric population. In the absence of evidence-based guidelines, optimal diagnostic and therapeutic approaches have not been established, and there is a risk of under- or overtreatment of these patients. Objectives: The aim of our study was to evaluate the clinical presentation and radiological features of PCL in a cohort of pediatric patients and to identify clinical parameters more commonly associated with neoplasms in the pineal region. In addition, the prevalence of PCL in the pediatric population of Slovenia was estimated. Methods: In this observational, cohort study, children treated at University Children's Hospital, Ljubljana, Slovenia in the period 1997–2016 were included if PCL was found on brain imaging. We analyzed indications for referral to a neurologist, clinical signs and symptoms, radiological features, treatment and outcome. Results: The cohort consisted of 143 children with PCL. Pineocytoma was suspected in 31 children (21.7%). Six children underwent surgery – pineocytoma was confirmed in two cases and germinoma in one (2/3 of these children had signs of increased intracranial pressure (ICP), while PCL was benign in the remaining 4 cases. Only 2 PCL enlarged during the study period, both <2mm, none of these children developed neoplasm. Two children had PCL >20mm in diameter; both showed signs of increased ICP, one patient was found to have a germinoma of the pineal region, while the other had no neoplasm. Conclusions: Most PCL do not change their features during radiological follow-up and even atypical PCL are very rarely associated with a malignant neoplasm of the pineal region. A PCL larger than 20 mm and signs of increased ICP were identified as potential markers for selecting patients at risk.
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Affiliation(s)
- Ula Arkar
- Department of Pediatric Neurology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Rok Kučan
- Department of Pediatric Neurology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Mirjana Perković Benedik
- Department of Pediatric Neurology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tadeja Hostnik
- Department of Pediatric Neurology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Tanja Loboda
- Department of Pediatric Neurology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Roman Bošnjak
- Department of Neurosurgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Damjan Osredkar
- Department of Pediatric Neurology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, Center for Developmental Neuroscience, University of Ljubljana, Ljubljana, Slovenia
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Majovsky M, Netuka D, Lipina R, Mraček J, Beneš V. Pineal Apoplexy: A Case Series and Review of the Literature. J Neurol Surg A Cent Eur Neurosurg 2021; 83:31-38. [PMID: 34077982 DOI: 10.1055/s-0041-1723813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pineal apoplexy is a rare condition, with unknown incidence and clinical significance. To elucidate this clinical condition, we analyzed our own case series and performed a review of the literature. METHODS We enrolled all patients with a hemorrhagic pineal apoplexy who were referred to our department between January 2000 and January 2020. Hemorrhagic pineal apoplexy was defined as the presence of fluid-fluid levels inside the pineal cyst (PC) on an axial or sagittal magnetic resonance scan. In one patient, after PC apoplexy, we performed a circadian melatonin sampling from peripheral blood to determine the function of the pineal gland. The PubMed database was searched for publications using the terms "pineal" and "apoplexy." RESULTS Eight patients were enrolled, of which three patients underwent surgical treatment and five patients were managed conservatively. One patient was tested for circadian melatonin secretion. Results confirmed melatonin secretion with preserved physiologic circadian rhythm.Our search of the literature led us to 31 studies that comprised 30 patients with apoplectic PC, 9 with apoplectic pineal tumor, and 1 with bleeding into the normal pineal gland. Most patients presented with headache, nausea, and vomiting, less frequently with acute hydrocephalus and gaze palsy. Twenty patients with a PC underwent resection or aspiration. Two patients underwent shunt placement as the only procedure and five received both shunt and surgical removal. Six patients with a PC were observed without surgical treatment. All the nine patients with a pineal tumor were operated on. In indicated cases, four patients received radiation therapy and one received chemotherapy. CONCLUSION Clinical significance of hemorrhagic pineal apoplexy ranges from an asymptomatic course to rapid deterioration and death. In patients with mild symptoms, observation is indicated, whereas surgical treatment is reserved for severe cases presenting with obstructive hydrocephalus and includes cerebrospinal fluid diversion, resection of apoplectic pineal lesions, or both.
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Affiliation(s)
- Martin Majovsky
- Department of Neurosurgery and Neurooncology, First Medical School, Charles University, Military University Hospital Prague, Prague, Czech Republic
| | - David Netuka
- Department of Neurosurgery and Neurooncology, First Medical School, Charles University, Military University Hospital Prague, Prague, Czech Republic
| | - Radim Lipina
- Department of Neurosurgery, University Hospital Ostrava, Ostrava, Czech Republic
| | - Jan Mraček
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, University Hospital Pilsen - Pilsen, Czech Republic
| | - Vladimír Beneš
- Department of Neurosurgery and Neurooncology, First Medical School, Charles University, Military University Hospital Prague, Prague, Czech Republic
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13
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Jenkinson MD, Mills S, Mallucci CL, Santarius T. Management of pineal and colloid cysts. Pract Neurol 2021; 21:practneurol-2020-002838. [PMID: 34039752 PMCID: PMC8327315 DOI: 10.1136/practneurol-2020-002838] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Michael D Jenkinson
- Clinical and Molecular Cancer, University of Liverpool, Liverpool, Merseyside, UK
- Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, Liverpool, UK
| | - Samantha Mills
- Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, Liverpool, UK
| | - Conor L Mallucci
- Paediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Thomas Santarius
- Clinical and Academic Neuroscience, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
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14
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Yeung JT, Young IM, Profyris C, Katsos K, Sughrue ME, Teo C. Resection of Symptomatic Pineal Cysts Provides Durable Clinical Improvement: A Breakdown of Presenting Symptoms and Lessons Learned. World Neurosurg 2021; 150:e668-e674. [PMID: 33771749 DOI: 10.1016/j.wneu.2021.03.087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Surgical resection of symptomatic pineal cysts without hydrocephalus remains controversial because patients can present with variable symptoms. Hesitancies in surgical decision-making include determining surgical candidacy and whether results would be durable. METHODS We performed a retrospective analysis on patients who underwent resection of their pineal cysts in our practice. We examined the presenting symptomology and investigated the radiographic changes to the morphology of the cerebral aqueduct found on follow-up imaging. We examined the clinical outcomes and complications following surgical resection of symptomatic pineal cysts. RESULTS A total of 97 patients underwent resection of pineal cysts, with 84 patients who had adequate follow-up (mean: 30.5 months). The patient population were predominantly female (76%) presenting at a mean of 24 years of age. Almost half of the patients had headaches that were positional, with 82% being bilateral; 39% and 19% of patients presented with photophobia and sonophobia, respectively, concurrent with their headaches. Many patients presented with visual disturbance (73%) along with other non-headache symptoms. Surgery resulted in 89% of patients with clinical improvements of their headaches. CONCLUSIONS Pineal cysts can present with variable headache symptomatology. Surgical resection of pineal cysts in carefully selected symptomatic patients after exhaustive conservative management can be performed safely and result in durable symptomatic relief.
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Affiliation(s)
- Jacky T Yeung
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia.
| | | | - Christos Profyris
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia; Department of Neurosurgery, Helen Joseph Hospital, University of the Witwatersrand, Auckland Park, Johannesburg, South Africa
| | - Konstantinos Katsos
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Michael E Sughrue
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
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15
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Response to Letter to the Editor: Endoscopic surgical strategy of pineal cyst-associated aqueductal stenosis. Acta Neurochir (Wien) 2021; 163:741-742. [PMID: 33479813 DOI: 10.1007/s00701-021-04710-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 01/07/2021] [Indexed: 10/22/2022]
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16
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Endoscopic management of pineal cyst-associated aqueductal stenosis. Acta Neurochir (Wien) 2020; 162:2975-2982. [PMID: 32562121 DOI: 10.1007/s00701-020-04419-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/19/2020] [Indexed: 10/24/2022]
Abstract
OBJECT The purpose of this study was to evaluate whether endoscopic third ventriculostomy (ETV) and endoscopic cyst fenestration are effective minimally invasive alternatives to a craniotomy with cyst resection for the treatment of symptomatic pineal cyst-associated aqueductal stenosis. METHODS Sixteen patients with symptomatic pineal cysts were operatively managed endoscopically and these cases were retrospectively reviewed. There were 12 females and 4 males. The median age at the time of surgery was 31 years (range 3 to 62 years). RESULTS All patients presented with symptoms and imaging consistent with elevated intracranial pressure. The median maximum cyst diameter was 15 mm (range 10 mm to 27 mm). In all cases, there was mass effect on the tectum that resulted in effacement of the cerebral aqueduct and ventriculomegaly was present in 38% of cases. ETV was performed in 15 patients. Cyst fenestration was performed in 2 patients, one of which also had an ETV. Resolution of symptoms was achieved in 81% of patients with a median follow-up of 13 months. CONCLUSION This study showed that ETV is effective for symptomatic pineal cyst-associated aqueductal stenosis. Patients can be symptomatic without overt ventriculomegaly and normal ventricular volume does not preclude safe endoscopic management. Endoscopic cyst fenestration is recommended if a Perinaud syndrome is present or if ETV is not feasible.
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17
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Tanaka T, Arnold L, Gabriela Mazuru D, Golzy M, Carr SB, Litofsky NS. Pineal cysts: Does anyone need long-term follow up? J Clin Neurosci 2020; 83:146-151. [PMID: 33272885 DOI: 10.1016/j.jocn.2020.10.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/21/2020] [Accepted: 10/18/2020] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Tomoko Tanaka
- Department of Neurosurgery, University of Arkansas for Medical Science, United States; Division of Pediatric Neurosurgery, Arkansas Children's Hospital Medical Center, United States; Division of Division of Neurosurgery, University of Missouri, School of Medicine, United States.
| | - Lauren Arnold
- University of Missouri, School of Medicine, United States
| | - Dana Gabriela Mazuru
- Department of Radiology, University of Missouri, School of Medicine, United States
| | - Mojgan Golzy
- Department of Health Management and Informatics, University of Missouri, School of Medicine, United States
| | - Steven B Carr
- Division of Division of Neurosurgery, University of Missouri, School of Medicine, United States
| | - N Scott Litofsky
- Division of Division of Neurosurgery, University of Missouri, School of Medicine, United States
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18
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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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19
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Choque-Velasquez J, Resendiz-Nieves JC, Baluszek S, Colasanti R, Muhammad S, Hernesniemi J. Functional status of surgically treated pineal cyst patients. Surg Neurol Int 2020; 11:359. [PMID: 33194292 PMCID: PMC7656030 DOI: 10.25259/sni_41_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 09/14/2020] [Indexed: 11/04/2022] Open
Abstract
Background:
Microsurgical removal represents a well-accepted treatment option for symptomatic benign pineal cysts (PCs). However, very few studies have quantitatively evaluated the functional status of surgically treated PC patients.
Methods:
A detailed analysis of preoperative, immediate postoperative, and long-term clinical and radiological characteristics was performed. The functional status of the patients was categorized using the modified Rankin scale (mRS) and the Chicago Chiari Outcome Scale (CCOS). In addition, a comparative analysis between pediatric and adult patients with PCs was carried out.
Results:
Overall, pediatric patients experienced better long-term mRS scores than adults. The differences between the pre-, the immediate post-, and the last postoperative mRS of the patients were statistically significant for the total population (P < 0.001). All patients obtained a CCOS of 11 or more, which reflects a good/optimal result after microneurosurgery. The type of the surgical approach was independently associated with the postoperative complications (P < 0.01), more frequently reported with the midline supracerebellar infratentorial (SCIT) approach than with its paramedian modification.
Conclusion:
The functional status of properly selected symptomatic patients with PCs may improve significantly after their surgical management through a paramedian SCIT approach in sitting position.
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Affiliation(s)
- Joham Choque-Velasquez
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland,
| | - Julio C. Resendiz-Nieves
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland,
| | - Szymon Baluszek
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland,
| | - Roberto Colasanti
- Department of Neurosurgery, Umberto I General Hospital, Universituà Politecnica delle Marche, Via Lodovico Menicucci, Ancona, Italy,
| | - Sajjad Muhammad
- Department of Neurosurgery, Central Clinical Hospital Ministry of Interior, Warsaw, Poland,
| | - Juha Hernesniemi
- Juha Hernesniemi International Center for Neurosurgery, Henan Provincial People, Zhengzhou, Henan, China
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20
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Lukewich MK, Alshafai L, Micieli JA. Spontaneous Resolution of Dorsal Midbrain Syndrome Caused by a Pineal Cyst. World Neurosurg 2020; 136:289-292. [PMID: 32001401 DOI: 10.1016/j.wneu.2020.01.144] [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: 12/31/2019] [Accepted: 01/19/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pineal lesions are common causes of dorsal midbrain syndrome and typically require surgical intervention in symptomatic patients. We describe a unique case of spontaneous resolution of dorsal midbrain syndrome resulting from a pineal gland cyst. CASE DESCRIPTION A 23-year-old woman developed a supranuclear upgaze palsy, convergence-retraction nystagmus, and light-near dissociation from a pineal gland cyst (1.0 × 1.3 × 1.2 cm) with mild mass effect on the posterior surface of the tectum. Seven days after symptom onset, she had complete, spontaneous resolution of her symptoms, and examination returned to normal. Repeat magnetic resonance imaging demonstrated an unchanged pineal cyst with new T2/fluid attenuated inversion recovery hyperintensity along the mesial surface of the left thalamus. CONCLUSIONS Dorsal midbrain syndrome resulting from a pineal cyst may spontaneously improve even without a significant change in lesion size. This suggests that observation may be an appropriate initial management strategy.
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Affiliation(s)
- Mark K Lukewich
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Laila Alshafai
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan A Micieli
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Kensington Vision and Research Centre, Toronto, Ontario, Canada.
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21
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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] [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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22
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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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23
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Pineal Cyst without Hydrocephalus: Clinical Presentation and Postoperative Clinical Course After Infratentorial Supracerebellar Resection. World Neurosurg 2019; 129:e530-e537. [DOI: 10.1016/j.wneu.2019.05.200] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/22/2019] [Accepted: 05/23/2019] [Indexed: 11/24/2022]
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24
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Storey M, Lilimpakis K, Grandal NS, Rajaraman C, Achawal S, Hussain M. Pineal cyst surveillance in adults - a review of 10 years' experience. Br J Neurosurg 2019; 34:565-568. [PMID: 31264489 DOI: 10.1080/02688697.2019.1635989] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Mathew Storey
- Department of Neurosurgery, Hull Royal Infirmary, Hull, UK
| | | | | | | | | | - Masood Hussain
- Department of Neurosurgery, Hull Royal Infirmary, Hull, UK
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25
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Choque-Velasquez J, Resendiz-Nieves JC, Rezai Jahromi B, Colasanti R, Raj R, Lopez-Gutierrez K, Tynninen O, Niemelä M, Hernesniemi J. The microsurgical management of benign pineal cysts: Helsinki experience in 60 cases. Surg Neurol Int 2019; 10:103. [PMID: 31528441 PMCID: PMC6744767 DOI: 10.25259/sni-180-2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 04/05/2019] [Indexed: 11/09/2022] Open
Abstract
Background: Microsurgical resection represents a well-accepted management option for symptomatic benign pineal cysts. Symptoms such as a headache, hydrocephalus, and visual deficiency are typically associated with pineal cysts. However, more recent studies reported over the past years have characterized additional symptoms as a part of the clinical manifestation of this disease and represent additional indications for intervention. Methods: We present a retrospective review of patients with histologically confirmed benign pineal cysts that were operated on in our department between 1997 and 2015. A demographic analysis, evaluation of preoperative status, surgical treatment, as well as immediate and long-term clinical and radiological outcomes were conducted. Results: A total of 60 patients with benign pineal cysts underwent surgery between 1997 and 2015. Gross total resection was achieved in 58 cases. All patients except one improved in their clinical status or had made a full recovery at the time of the last follow-up. The key steps for surgical resection of pineal cysts are reported, based on an analysis of representative surgical videos. Conclusions: We describe in this paper one of the largest series of microsurgically treated pineal cysts. In our opinion, judicious microsurgery remains the most suitable technique to effectively deal with this disease.
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Affiliation(s)
- Joham Choque-Velasquez
- Departments of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Julio C Resendiz-Nieves
- Departments of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Behnam Rezai Jahromi
- Departments of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Roberto Colasanti
- Departments of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona.,Departments of Neurosurgery, Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Rahul Raj
- Departments of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Kenneth Lopez-Gutierrez
- Departments of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Olli Tynninen
- Department of Pathology, University of Helsinki and HUSLAB, Helsinki University Hospital, Helsinki, Finland
| | - Mika Niemelä
- Departments of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Juha Hernesniemi
- Departments of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Juha Hernesniemi International Center for Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
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26
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Pitskhelauri DI, Konovalov AN, Abramov IT, Danilov GV, Pronin IN, Alexandrova EV, Serova NK, Sanikidze AZ. Pineal Cyst-Related Aqueductal Stenosis as Cause of Intractable Headaches in Nonhydrocephalic Patients. World Neurosurg 2018; 123:e147-e155. [PMID: 30468924 DOI: 10.1016/j.wneu.2018.11.096] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 11/10/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Pineal cysts (PCs) are histologically benign lesions of the pineal gland. Although the majority of PCs are asymptomatic, some cases are ambiguous and accompanied by nonspecific symptoms of variable severity. We suggested that disabling headache in nonhydrocephalic patients with PCs is associated with cerebral aqueduct (CAq) stenosis. METHODS A retrospective analysis was conducted in patients with PCs suffering from headache without secondary hydrocephalus who underwent surgical resection at Burdenko Neurosurgery Center between 1995 and 2016. All available medical records and radiographic images were retrospectively assessed in these patients. The comparison groups included 22 patients with nonoperated PCs and 25 healthy individuals. Specific magnetic resonance imaging measures were selected to assess the morphometry of the CAq and degree of the stenosis. RESULTS In 25 patients (82%) we observed clinical improvement after surgery in a follow-up period. Among those with improvement, 10 of them (40%) experienced total relief and 15 of them (60%) had marked headache diminishment. In 5 patients the headache remained persistent. The preoperative rostral CAq diameter appeared to be significantly narrower (P = 0.0011045), and the preoperative rostral/caudal diameter ratio (Rd/Cd) was found to be lower (P = 0.004391) in patients who recovered from headache versus those who did not. CONCLUSION The results indicate a statistically significant relationship between the changes in the CAq morphometrics and the clinical outcome in postoperative period. Surgical removal of symptomatic pineal cysts in patients without hydrocephalus can be considered as an effective treatment. However, a thorough preoperative examination and patient selection should be conducted in every case.
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Affiliation(s)
- David I Pitskhelauri
- Department of Neurooncology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Alexander N Konovalov
- Department of Neurooncology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Irakliy T Abramov
- Department of Neurooncology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia.
| | - Gleb V Danilov
- Department of Neurooncology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Igor N Pronin
- Department of Neuroradiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Evgeniya V Alexandrova
- Department of Neurology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Nataliya K Serova
- Department of Neuroopththalmology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Alexander Z Sanikidze
- Department of Neurooncology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
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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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28
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DelRosso LM, Martin K, Ferri R. A not so incidental finding in a 12-year old with sleepiness and headaches. Sleep Med 2018; 43:31-33. [PMID: 29482808 DOI: 10.1016/j.sleep.2017.11.1123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 10/03/2017] [Accepted: 11/10/2017] [Indexed: 12/16/2022]
Affiliation(s)
- Lourdes M DelRosso
- University of California, San Francisco, CA, USA; Benioff Children's Hospital Oakland, CA, USA.
| | | | - Raffaele Ferri
- Sleep Research Centre, Oasi Research Institute IRCCS, Troina, Italy
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29
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Is surgery for pineal cysts safe and effective? Short review. Neurosurg Rev 2017; 41:119-124. [PMID: 28702847 DOI: 10.1007/s10143-017-0876-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 06/20/2017] [Accepted: 06/28/2017] [Indexed: 01/11/2023]
Abstract
In this short review, the authors performed a database search and summarize current knowledge of the management of patients with pineal cysts (PCs) and investigate the role of surgical treatment. The scientific literature on the surgical treatment of PCs is sparse and encompasses only case series with little over 200 operated patients combined. All included papers reported favorable results after pineal cyst surgery with improvement of symptoms in most patients. Microsurgical resection of PCs, preferably using the supracerebellar-infratentorial approach, could be considered as a viable treatment option in symptomatic patients. Even patients with non-specific symptoms are reported to improve after surgery. However, evidence offered by this literature review is very limited and therefore our conclusions must be tempered by the restricted set of data. For ethical reasons, a randomized controlled trial is not an acceptable approach, and therefore patient registry could be a useful tool to identify a subset of symptomatic patients that might benefit from pineal cyst resection.
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