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Atallah O, Chaurasia B, Badary A, Maria LD, Almealawy YF, Awuah WA, Moustafa W, Ergen A, Fontanella MM. Pineal Apoplexy: Highlighting the Causes, Treatment, and Outcome. J Neurol Surg A Cent Eur Neurosurg 2025; 86:85-98. [PMID: 38788759 DOI: 10.1055/s-0044-1786538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
BACKGROUND Pineal apoplexy, alternatively referred to as pineal hemorrhage or pineal gland hemorrhagic stroke, is an infrequent pathologic condition characterized by bleeding within the pineal gland. In this review, we encompass the primary factors contributing to this uncommon ailment. METHODS The retrieval of pertinent research, including patients with pineal apoplexy, was conducted through PubMed, Google Scholar, and Scopus databases. This study exclusively incorporated comprehensive articles written in the English language. The search encompassed the MeSH terms "pineal apoplexy" and "pineal hemorrhage." RESULTS A total of 41 articles were identified, encompassing a collective sample size of 57 patients. The median age of the patients in the study was 30 years, with a range spanning from 1 to 73 years. There were 27 males, representing 47.4% of the participants. The study identified the most often reported symptoms as headache (49; 86%), nausea/vomiting (19; 33.3%), and Parinaud's syndrome (16; 28.1%). The treatment options encompass several approaches, including open resection, shunting, ventriculostomy, endoscopic aspiration, and conservative care. In the conducted study, a notable number of patients, amounting to 45 cases (78.9%), indicated an amelioration of their symptoms upon their discharge. CONCLUSION Data from a cohort of 57 cases provide insights into symptoms, lesions, treatments, and outcomes. Management approaches range from conservative measures to surgical interventions, with prognosis hinged on timely intervention. This investigation serves as a valuable resource for clinicians and researchers, underscoring the need for early diagnosis before permanent neurologic dysfunction happens and tailored treatments for optimal outcomes in pineal apoplexy cases.
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Affiliation(s)
- Oday Atallah
- Departemnt of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal
| | - Amr Badary
- Departemnt of Neurosurgery, Klinikum Dessau, Dessau-Roßlau, Germany
| | - Lucio De Maria
- Unit of Neurosurgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
- Department of Neurosurgery, University of Brescia, Brescia, Italy
| | | | | | - Wahab Moustafa
- Departemnt of Neurosurgery, Klinikum Dessau, Dessau-Roßlau, Germany
| | - Anil Ergen
- Department of Neurosurgery, Derince Research Hospital, Kocaeli, Turkey
| | - Marco Maria Fontanella
- Unit of Neurosurgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
- Department of Neurosurgery, University of Brescia, Brescia, Italy
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Atallah O, Badary A, Almealawy YF, Sanker V, Andrew Awuah W, Abdul-Rahman T, Alrubaye SN, Chaurasia B. Non-colloid-cyst primary brain tumors: A systematic review of unexpected fatality. J Clin Neurosci 2024; 119:129-140. [PMID: 38029695 DOI: 10.1016/j.jocn.2023.11.022] [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: 10/10/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE Primary brain tumors have the potential to present a substantial health hazard, ultimately resulting in unforeseen fatalities. Despite the enhanced comprehension of many diseases, the precise prediction of disease progression continues to pose a significant challenge. The objective of this study is to investigate cases of unexpected mortality resulting from primary brain tumors and analyze the variables that contribute to such occurrences. METHODS This systematic review explores research on individuals diagnosed with primary brain tumors who experienced unexpected deaths. It uses PRISMA standards and searches PubMed, Google Scholar, and Scopus. Variables considered include age, gender, symptoms, tumor type, WHO grade, postmortem findings, time of death - time taken from first medical presentation or hospital admission to death, comorbidity, and risk factors. RESULTS This study examined 46 studies to analyze patient-level data from 76 individuals with unexpected deaths attributed to intracranial lesions, deliberately excluding colloid cysts. The cohort's age distribution showed an average age of 37 years, with no significant gender preference. Headache was the most common initial symptom. Astrocytomas, meningiomas, and glioblastoma were the most common lesions, while the frontal lobe, temporal lobe, and cerebellum were common locations. Meningiomas and astrocytomas showed faster deaths within the first hour of hospital admission. CONCLUSION The etiology of unforeseen fatalities resulting from cerebral tumors elucidates an intricate and varied phenomenon. Although unexpected deaths account for a very tiny proportion of total fatalities, it is probable that their actual occurrence is underestimated as a result of underreporting and misdiagnosis.
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Affiliation(s)
- Oday Atallah
- Departemnt of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Amr Badary
- Departemnt of Neurosurgery, Klinikum Dessau, Dessau-Roßlau, Germany
| | | | - Vivek Sanker
- Department of Neurosurgery, Trivandrum Medical College, Kerala, India
| | | | | | | | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj ,Nepal.
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Atallah O, Kumar CR, Das S, Maurya VP, Agrawal A. Sudden death in patients with pineal cyst: Evidence from autopsy studies. J Neurosci Rural Pract 2023; 14:593-598. [PMID: 38059255 PMCID: PMC10696342 DOI: 10.25259/jnrp_421_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 08/23/2023] [Indexed: 12/08/2023] Open
Abstract
Pineal cysts are usually benign, fluid-filled sacs and most pineal cysts are asymptomatic. Sudden death specifically related to pineal cysts is extremely uncommon. A literature review of the pertinent databases, including PubMed, Google Scholar, Scopus, and Web of Science, was carried out to review the existing literature describing sudden death in patients with pineal cysts. In the evaluation of 49 articles, it was found that four reports discussed the unexpected death of patients who had pineal cysts. A total of four cases of sudden death and a pineal cyst were reported. There were 75% females and a mean age of 29 (range: 20-45). Cyst size on average was 1.3 cm (1.2-1.5). In each case, the cause of death and the involvement of important brain structures were confirmed by autopsy results. A pathological analysis of the pineal region and the surrounding brain tissue revealed a variety of lesions. Vascular malformation was found in one case, adding another layer of complexity to the study of sudden death syndrome. In this research, the authors highlight the fact that patients with pineal cysts can experience serious, even fatal, complications. Increased vigilance and early detection through neuroimaging and neurological assessments are required due to the wide variety of clinical manifestations and underlying mechanisms. To explain the mechanism and enhance the management and prevention of sudden deaths associated with pineal cysts, additional research with larger sample sizes is required.
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Affiliation(s)
- Oday Atallah
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Chegondi Ranjith Kumar
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Saikat Das
- Department of Neurosurgery and Radiation Oncology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Ved Prakash Maurya
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amit Agrawal
- Department of Neurosurgery and Radiation Oncology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Wangaryattawanich P, Rutman AM, Petcharunpaisan S, Mossa-Basha M. Incidental findings on brain magnetic resonance imaging (MRI) in adults: a review of imaging spectrum, clinical significance, and management. Br J Radiol 2023; 96:20220108. [PMID: 35522780 PMCID: PMC9975529 DOI: 10.1259/bjr.20220108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 04/19/2022] [Accepted: 04/29/2022] [Indexed: 01/27/2023] Open
Abstract
Utilization of brain MRI has dramatically increased in recent decades due to rapid advancement in imaging technology and improving accessibility. As a result, radiologists increasingly encounter findings incidentally discovered on brain MRIs which are performed for unrelated indications. Some of these findings are clinically significant, necessitating further investigation or treatment and resulting in increased costs to healthcare systems as well as increased patient anxiety. Moreover, management of these incidental findings poses a significant challenge for referring physicians. Therefore, it is important for interpreting radiologists to know the prevalence, clinical consequences, and appropriate management of these findings. There is a wide spectrum of incidental findings on brain MRI such as asymptomatic brain infarct, age-related white matter changes, microhemorrhages, intracranial tumors, intracranial cystic lesions, and anatomic variants. This article provides a narrative review of important incidental findings encountered on brain MRI in adults with a focus on prevalence, clinical implications, and recommendations on management of these findings based on current available data.
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Affiliation(s)
| | | | | | - Mahmud Mossa-Basha
- Department of Radiology, University of North Carolina, Chapel Hill, NC, United States
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Shafqat A, AlGethami HJ, Shafqat S, Islam SSU. Pineal cyst apoplexy and memory loss: a novel complication. Radiol Case Rep 2022; 17:3739-3744. [PMID: 35965931 PMCID: PMC9363962 DOI: 10.1016/j.radcr.2022.07.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 11/16/2022] Open
Abstract
An 8-year-old boy presented to our hospital complaining of a bilateral headache associated with episodes of anterograde amnesia. He had a road traffic accident 3 years ago when a computed tomography (CT) scan revealed traumatic brain injury. In addition, a small pineal cyst (PC) was noted with minor intramural calcifications. A follow-up CT a day later demonstrated increased density in the pineal gland of 60 Hounsfield Units, suggestive of apoplectic changes in the PC. However, the patient was lost to follow-up and presented with memory loss a year and a half later, upon which CT and magnetic resonance imaging revealed enlargement of the PC. PC apoplexy is a very rare occurrence usually affecting young adult women; cases in children are rarely reported. Furthermore, PC apoplexy secondary to severe craniofacial trauma manifesting as memory loss has not yet been reported in the literature to the best of our knowledge.
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Affiliation(s)
- Areez Shafqat
- College of Medicine, Alfaisal University, Riyadh, Kingdom of Saudi Arabia
- Corresponding author.
| | - Hanin Jaber AlGethami
- Division of Neurology, Department of Pediatrics, King Salman Hospital, Riyadh, Kingdom of Saudi Arabia
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Paun L, Lavé A, Patet G, Bartoli A. Supratentorial Pediatric Midline Tumors and Tumor-like Lesions: Clinical Spectrum, Natural History and Treatment Options. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9040534. [PMID: 35455578 PMCID: PMC9032564 DOI: 10.3390/children9040534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 04/10/2023]
Abstract
Childhood Central Nervous System tumors account for 25% of all pediatric tumors. Large availability and broadening of indications to imaging has made incidental findings more common. Among these, midline lesions have different clinical relevance depending on their intrinsic pattern of behaviour and on their specific location. In this narrative review we describe the natural history and treatment options of midline lesions in children.
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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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Goehner D, Soyland D, Vuong S, Trumble E. Pineal Cyst Apoplexy in an 8-Year-Old Girl: Case Report and Literature Review. World Neurosurg 2020; 142:159-166. [PMID: 32615292 DOI: 10.1016/j.wneu.2020.06.199] [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: 05/24/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pineal cysts are common, typically asymptomatic, and are usually found incidentally in adults. In rare cases, pineal cyst apoplexy occurs as a result of an acute cystic hemorrhage. This situation can result in acute onset of severe headaches, acute obstructive hydrocephalus, mass effect on the midbrain, and even death. Pineal apoplexy is most common in women of reproductive age, whereas pediatric cases continue to be less prevalent. Pineal cyst apoplexy remains a rare entity with ≥30 cases presented in the literature to date. CASE DESCRIPTION We present the youngest case in the literature (an 8-year-old girl with a pineal cyst that resulted in apoplexy), her diagnostic workup, management, and follow-up. We supplement our case study with a literature review of pineal cyst apoplexy. CONCLUSIONS Pineal cyst apoplexy remains a rare clinical event in the pediatric population. Our case details the diagnosis and management of an 8-year-old girl with pineal cyst apoplexy. We also discuss our findings from our literature search for all reported cases of pineal cyst apoplexy.
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Affiliation(s)
- Dylan Goehner
- Division of Neurosurgery, Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota, USA.
| | - Dallas Soyland
- Division of Neurosurgery, Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota, USA
| | - Shawn Vuong
- Division of Neurosurgery, Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota, USA
| | - Eric Trumble
- Division of Neurosurgery, Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota, USA
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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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Majovsky M, Benes V. Natural course of pineal cysts-a radiographic study. Chin Neurosurg J 2018; 4:33. [PMID: 32922893 PMCID: PMC7398253 DOI: 10.1186/s41016-018-0142-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 10/17/2018] [Indexed: 11/10/2022] Open
Abstract
Background Pineal cysts (PCs) are a benign lesion of the pineal gland that have been known to the medical community for a long time. With a prevalence rate of approximately 1% in the general population, PC is often a reason for medical counseling. The natural course of PC morphology has not been well described. In this study, we present a longitudinal magnetic resonance imaging (MRI) study of patients with PCs, with special focus on those who showed an increase or decrease in PC size. Methods We enrolled all patients with a PC who were referred to our department between January 2000 and January 2018. Each patient underwent a clinical examination, and the patient’s age, sex, and presenting signs and symptoms were noted. MRI was performed during periodic examinations, and a clinical and radiological course was reassessed. Results In total, 133 patients (99 women, 34 men) were enrolled. The mean maximum diameter was 12.7 ± 5.2 mm (range 7–35 mm). PCs increased in size during the follow-up in seven patients (5.3%) and decreased in size in 10 (7.5%). The remaining cysts (n = 116, 87.2%) were stable over the follow-up period. Analyzing patients according to cyst size change, we found a significant difference in the mean age between the PC progression group and PC regression group (p = 0.01). The mean size of the PCs at the time of diagnosis did not differ significantly between the two groups (p = 0.81). We diagnosed two cases of pineal apoplexy. Conclusion We found that PCs are a dynamic structure that may change in size during the patient’s lifetime. Patients with an increase in PC size were significantly younger than patients with a decrease in size. Therefore, PC growth in the first, second, and third decennium is normal and does not justify medical intervention. Surgery is indicated in cases of hydrocephalus and Parinaud’s syndrome or in atypical cysts when neoplasia is suspected. The size of a PC does not predict PC behavior in terms of a future increase or decrease in size.
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Affiliation(s)
- Martin Majovsky
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, U Vojenské nemocnice 1200, Prague 6, Czech Republic
| | - Vladimir Benes
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, U Vojenské nemocnice 1200, Prague 6, Czech Republic
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Gokce E, Beyhan M. Evaluation of pineal cysts with magnetic resonance imaging. World J Radiol 2018; 10:65-77. [PMID: 30079153 PMCID: PMC6068724 DOI: 10.4329/wjr.v10.i7.65] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/29/2018] [Accepted: 05/23/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate radiological imaging findings of patients who had been found to have pineal cyst (PC) in brain magnetic resonance imaging (MRI).
METHODS A total of 9546 patients who had brain MRI examination in March 2010-January 2018 period were studied. Fifty-six patients (44 female and 12 male) found to have PC were evaluated. Eighteen of the patients had had follow-up examinations of 2-94 mo (mean 30.50 ± 28.83). PC dimensions and volume, radiological imaging features (signal intensities, contours, internal septation-loculation and contrast-enhancement features) and natural history in cases who had been followed-up were evaluated by two radiologists.
RESULTS Of 9546 patients, 5555 were female (58.2%) and 3991 male (41.8%). Age range was 1-99 (mean 43.18 ± 20.94). PC frequency was calculated to be 0.58%. Forty-four of the 56 patients (78.57%) with PC were female and 12 male (21.43%), and their age range was 5-61 (mean 31.26 ± 12.73). Thirty-five of the PCs were typical (62.50%) and 21 (37.50%) were atypical. No significant difference was found between initial and final imaging sizes of PCs which were monitored by follow-up examinations (P > 0.05).
CONCLUSION PCs are cysts which do not show clear size and natural changes and are more frequently observed in females and in adult ages. Most of them are isointense with cerebrospinal fluid on T1 and T2A weighted images, hyperintense compared to cerebrospinal fluid on fluid-attenuated inversion recovery; sequence and smoothly contoured. Their typical forms have peripheral rim and multilocular ones may have septal contrast-enhancement.
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Affiliation(s)
- Erkan Gokce
- Department of Radiology, Gaziosmanpaşa University, School of Medicine, Tokat 60100, Turkey
| | - Murat Beyhan
- Department of Radiology, Tokat State Hospital, Tokat 60100, Turkey
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Sudden and Unexpected Death During Sexual Activity, Due to a Glial Cyst of the Pineal Gland. Am J Forensic Med Pathol 2018; 39:157-160. [PMID: 29570483 DOI: 10.1097/paf.0000000000000396] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cysts of the pineal gland are benign lesions. Often asymptomatic, in the majority of cases they are discovered incidentally during brain magnetic resonance imaging or autopsy. Sporadically, however, they may cause such symptoms as chronic headache, loss of consciousness, corticospinal and sensory impairment, and, in some cases, even sudden death. A 45-year-old woman, in apparently good health, collapsed and died suddenly, after reaching orgasm while engaged in sexual intercourse. According to the circumstantial account of her relatives, the woman suffered from severe headaches, which were exacerbated by certain types of physical strain, such as sexual activity. Postmortem examination revealed no external injuries or internal diseases except for a cystic lesion of the pineal gland. Microscopically, the wall of the cyst consisted of a layer of glial tissue surrounded by an area of pineal elements. A complete forensic approach concluded that the cause of death was fatal cardiorespiratory failure resulting from midbrain compression due to a nonneoplastic pineal gland cyst, exacerbated by sexual activity. In this case, the intracranial pressure increase, secondary to Valsalva maneuver during climax, may further aggravate compression on the brainstem, thus concurring to determine the death.
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Abramov IT, Pitskhelauri DI, Serova NK. [Pineal cyst]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2017; 81:113-120. [PMID: 28914878 DOI: 10.17116/neiro2017814113-120] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
UNLABELLED A pineal cyst (PC) is a benign neoplasm in the pineal region, or more precisely in the pineal body. Most cysts are incidental findings and are not associated with symptoms typical of patients seeking medical advice. Symptomatic cysts are discovered less often and, depending on the clinical picture, require different treatment approaches. MATERIAL AND METHODS We analyzed the literature data about the clinical picture, diagnosis, and treatment of PCs for more than a century (1914-2016). CONCLUSION To date, there is no single approach for managing PC patients. The indications for surgical treatment of symptomatic PCs are still not fully defined. It remains unclear which PC cases should be followed-up, and how often control examinations should be performed. More research of PCs is needed to develop new approaches to treatment of PC patients.
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Affiliation(s)
- I T Abramov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - N K Serova
- Burdenko Neurosurgical Institute, Moscow, Russia
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Starke RM, Cappuzzo JM, Erickson NJ, Sherman JH. Pineal cysts and other pineal region malignancies: determining factors predictive of hydrocephalus and malignancy. J Neurosurg 2016; 127:249-254. [PMID: 27767399 DOI: 10.3171/2016.8.jns16220] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Cystic lesions of the pineal gland are most often uncomplicated benign lesions with typical MRI characteristics. The authors aimed to study pineal lesion characteristics on MRI to better distinguish benign pineal cysts from other pineal region malignancies as well as to determine which characteristics were predictive of the latter malignancies. They also aimed to study risk factors predictive of hydrocephalus or malignancy in patients harboring these lesions. METHODS The authors performed a retrospective review of a prospectively compiled database documenting the outcomes of patients with suspected pineal cysts on MRI who had presented in the period from 1998 to 2004. Inherent patient and lesion characteristics were assessed in a univariate logistic regression analysis to predict the following dependent variables: development of hydrocephalus, biopsy-confirmed malignancy, and intervention. Possible inherent patient and lesion characteristics included age, sex, T1 and T2 MRI signal pattern, contrast enhancement pattern, presence of cyst, presence of blood, complexity of lesion, presence of calcification, and duration of follow-up. Inherent patient and lesion characteristics that were predictive in the univariate analysis (p < 0.15) were included in the multivariable logistic regression analysis. RESULTS Of the 79 patients with benign-appearing pineal cysts, 26 (33%) were male and 53 (67%) were female, with a median age of 38 years (range 9-86 years). The median cyst radius was 5 mm (range 1-20 mm). Two patients (2.5%) had evidence of calcifications, 7 (9%) had multicystic lesions, and 25 (32%) had some evidence of contrast enhancement. The median follow-up interval was 3 years (range 0.5-13 years). Seven patients (9%) had an increase in the size of their lesion over time. Eight patients (10%) had a hemorrhage, and 11 patients (14%) developed hydrocephalus. Nine (11%) received ventriculoperitoneal shunts for the development of hydrocephalus, and 12 patients (16%) were found to have malignancies following biopsy or resection. In the multivariate analysis, contrast enhancement on MRI (OR 1.6, 95% CI 2.86-74.74, p = 0.013) and hemorrhage (OR 26.9, 95% CI 3.4-212.7, p = 0.022) were predictive of hydrocephalus. Increasing lesion size and hydrocephalus were near perfect predictors of malignancy and thus were removed from multivariate analysis. In addition, contrast enhancement on MRI (OR 8.8, 95% CI 2.0-38.6, p = 0.004) and hemorrhage (OR 6.8, 95% CI 1.1-40.5, p = 0.036) were predictive of malignancy. CONCLUSIONS Although cystic abnormalities of the pineal gland are often benign lesions, they are frequently monitored over time, as other pineal region pathologies may appear similarly on MRI. Patients with growing lesions, contrast enhancement, and hemorrhage on MRI are more likely to develop hydrocephalus and have malignant pathology on histological examination and should therefore be followed up with serial MRI with a lower threshold for neurosurgical intervention.
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Affiliation(s)
- Robert M Starke
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | | | - Jonathan H Sherman
- Department of Neurological Surgery, The George Washington University, Washington, DC
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Nevins EJ, Das K, Bhojak M, Pinto RS, Hoque MN, Jenkinson MD, Chavredakis E. Incidental Pineal Cysts: Is Surveillance Necessary? World Neurosurg 2016; 90:96-102. [PMID: 26944882 DOI: 10.1016/j.wneu.2016.02.092] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 02/21/2016] [Accepted: 02/22/2016] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The natural history of incidental pineal cysts is poorly understood. Neurosurgeons and neuroradiologists are more frequently faced with this disease in the advent of higher-resolution magnetic resonance imaging (MRI) scanning. We aim to suggest a suitable surveillance strategy for these patients. METHODS All patients who had MRI of the brain between June 2007 and January 2014 (n = 42,099) at The Walton Centre for Neurology and Neurosurgery were included. Radiologic reports containing the terms "pineal" and "cyst" were reviewed to identify patients. RESULTS A total of 281 patients were identified with pineal cysts. The principal indication for head MRI was headache (50.2%), although no symptoms were deemed attributable to pineal disease. A total of 178 patients (63.3%) were female, and the age at diagnosis ranged from 16 to 84 years. The median size of pineal cyst at diagnosis was 10 mm. A total of 181 patients had subsequent follow-up at a median time of 6 months (range, 1-68). Eleven pineal cysts (6%) changed size during the follow-up period. Four patients had a reduction in cyst size; the median change was 2.5 mm. A further 7 pineal cysts increased in cyst size; the median change was 2 mm. No patients developed complications. CONCLUSIONS Incidental pineal cysts typically show a benign course. In the adult population, they do not require long-term neurosurgical follow-up, because pineal cysts tend to remain a stable size. In asymptomatic patients, we recommend a single follow-up MRI scan at 12 months to confirm diagnosis. The patient should then be discharged if the cyst remains stable.
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Affiliation(s)
- Edward J Nevins
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom.
| | - Kumar Das
- Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Maneesh Bhojak
- Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Rohan S Pinto
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Mohammed N Hoque
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Michael D Jenkinson
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom; Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Emmanuel Chavredakis
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
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Magnetic resonance imaging biomarkers indicate a central venous hypertension syndrome in patients with symptomatic pineal cysts. J Neurol Sci 2016; 363:207-16. [PMID: 27000252 DOI: 10.1016/j.jns.2016.02.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 02/15/2016] [Accepted: 02/16/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND While most pineal cysts (PCs) are asymptomatic, some PCs are accompanied with symptoms of variable severity. We suggested that symptom severity in symptomatic patients with non-hydrocephalic PCs relates to venous compression causing central venous hypertension. This study explored whether possible magnetic resonance imaging (MRI) biomarkers of central venous hypertension could differentiate the severity of symptoms in individuals with non-hydrocephalic PCs. METHODS The study included all individuals with PCs and MRI available for analysis followed conservatively within the department from 2003 to 2014. Severity of symptoms at follow-up were assessed from a questionnaire. Suggested MRI biomarkers indicative of central venous hypertension were explored, in addition to MRI measures of cyst size, aqueduct stenosis, and tectal compression. RESULTS The study included 66 patients. As compared to the 27/66 patients (41%) with "None-Moderate" symptoms at follow-up, the 39/66 patients (59%) with "Much-Severe" symptoms presented with significantly altered indices of central venous hypertension (tectum-splenium-cyst ratio and indices of thalamic and periventricular edema). PC grading based on MRI biomarkers of central venous hypertension differentiated the severity of symptoms. CONCLUSION The results indicate an association between severity of symptoms and MRI biomarkers of central venous hypertension in symptomatic individuals with non-hydrocephalic PCs.
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An Autopsy Case of Sudden Unexpected Death Due to a Glial Cyst of the Pineal Gland. Am J Forensic Med Pathol 2014; 35:186-8. [DOI: 10.1097/paf.0000000000000107] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Update on the management of pineal cysts: Case series and a review of the literature. Neurochirurgie 2014; 61:201-7. [PMID: 24907165 DOI: 10.1016/j.neuchi.2013.08.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 08/13/2013] [Accepted: 08/30/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The natural history of pineal cysts still remains unclear. Incidental pineal cysts have become more common which raises the question of their management. Symptomatic pineal cysts may require a surgical solution but therapeutic indications have not yet been clearly established. METHOD From 1986 to 2012, 26 patients with pineal cysts were identified. Their medical records were retrospectively assessed focusing on the initial symptoms, imaging characteristics of the cyst, management strategy, operative technique and their complications, as well as the latest follow-up. A systematic review of the literature is also presented. RESULTS Twenty-six patients with pineal cysts were identified. The mean age was 23.5 years ranging from 7 to 49 years. Symptoms included intracranial hypertension with obstructive hydrocephalus in 18 cases and oculomotor anomalies in 12 cases. Two adult cases presented with non-specific headaches and did not require surgery. Twenty patients were operated via a suboccipital transtentorial approach with total removal of the cyst in 70% of the cases, while the remaining 4 cases were treated with an intraventricular endoscopic marsupialization associating a third ventriculostomy. Four patients required a preoperative ventriculo-peritoneal shunt due to life-threatening obstructive hydrocephalus. Overall, peri-operative mortality was nil. In the two non-operated patients, the cyst remained stable and no recurrences were observed in all operated patients with a mean follow-up of 144 months. CONCLUSION In the majority of incidental pineal cysts, a clinical and imaging follow-up is sufficient but occasionally not required especially in adults as very rare cases of increase in size have been reported.
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Kahilogullari G, Massimi L, Di Rocco C. Pineal cysts in children: case-based update. Childs Nerv Syst 2013; 29:753-60. [PMID: 23283557 DOI: 10.1007/s00381-012-2011-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 12/17/2012] [Indexed: 02/08/2023]
Abstract
PURPOSE Pineal cysts (PC) are found in children as often asymptomatic and without change in their size over the time. However, there are some debatable issues about their evolution and management in the pediatric population. The aim of the present paper is to update the information regarding pathogenesis, clinical presentation, and management of these lesions. METHODS All the pertinent literature was reviewed, and a meta-analysis of operated on cases was carried out. An illustrative case regarding the clinical evolution of a 13-year-old girl is also presented. RESULTS AND CONCLUSIONS PC are often asymptomatic and do not evolve over the time. However, since there is a certain risk of clinical and/or radiological progression, or even sudden and severe clinical onset (apoplexy), both a clinical and radiological follow-up is recommended in the pediatric age. The surgical excision is usually limited to symptomatic patients or to cases with clear radiological evolution.
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Yamamoto K, Omodaka T, Watanabe R, Kodaira M. A hemorrhagic pineal cyst with a bacterial meningitis-like manifestation and benign outcome. Intern Med 2013; 52:2817-20. [PMID: 24334592 DOI: 10.2169/internalmedicine.52.0451] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pineal cysts are a common incidental finding in imaging studies, and the majority of such cysts are asymptomatic. However, hemorrhaging pineal cysts, which are considered to be rare, are often associated with severe symptoms. We herein describe the case of a 58-year-old patient with the novel manifestation of a bleeding pineal cyst, who had a benign outcome without any surgical treatment. Although the clinical manifestations resembled those of bacterial meningitis, magnetic resonance images suggested chemical meningitis caused by an intracystic hemorrhage and rupture of the pineal cyst.
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Affiliation(s)
- Kanji Yamamoto
- Department of Neurology, Nagano Municipal Hospital, Japan
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21
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Abstract
Pineal cysts (PCs) are benign and often asymptomatic lesions of the pineal region that are typically small and do not change in size over time. PCs appear as small, well circumscribed, unilocular masses that either reside within or completely replace the pineal gland. This article reviews and discusses the characteristic features of PCs-clinical, histological, and identifiable by various imaging modalities-which assist clinicians in narrowing the differential diagnosis for pineal lesions.
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22
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Ayhan S, Bal E, Palaoglu S, Cila A. Pineal cyst apoplexy: report of an unusual case managed conservatively. Neurol Neurochir Pol 2012; 45:604-607. [PMID: 22212992 DOI: 10.1016/s0028-3843(14)60129-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Pineal cyst apoplexy is a very rare entity with previously reported symptoms of severe frontal or occipital headache, gaze paresis and visual field defects, nausea or vomiting, syncope, ataxia, hearing loss and sudden death. The treatment options for symptomatic pineal cysts are observation, shunting, aspiration via stereotactic guidance or endoscopy, third ventriculostomy, ventriculocysternostomy, and/or surgical resection by craniotomy and microsurgery. Here, the authors report an unusual case of a 28-year-old male patient with pineal cyst apoplexy, presenting with headache, insomnia, and sexual dysfunction symptoms who is being managed conservatively and observed for two years by an academic tertiary care unit.
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Affiliation(s)
- Selim Ayhan
- Department of Neurosurgery, Hacettepe University School of Medicine, Ankara, Turkey.
| | - Ercan Bal
- Department of Neurosurgery, Hacettepe University School of Medicine, Ankara, Turkey
| | - Selcuk Palaoglu
- Department of Neurosurgery, Hacettepe University School of Medicine, Ankara, Turkey
| | - Aysenur Cila
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
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Rosenstengel C, Baldauf J, Müller JU, Schroeder HWS. Sudden intraaqueductal dislocation of a third ventricle ependymoma causing acute decompensation of hydrocephalus. J Neurosurg Pediatr 2011; 8:154-7. [PMID: 21806356 DOI: 10.3171/2011.5.peds10414] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report an unusual sudden intraaqueductal dislocation of a third ventricle ependymoma causing acute loss of consciousness, and they detail its neuroendoscopic treatment. This case is unique and has never been described in the literature before. The patient suffered from headache and recurrent nausea. Admission MR images revealed a contrast-enhancing lesion within the posterior part of the third ventricle. During the course of the day of admission, the patient suddenly became comatose. Emergency MR imaging demonstrated a deeply intraaqueductal dislocation of the pedicled tumor, with complete obstruction of the aqueduct and ventricular dilation. Immediate surgical intervention with endoscopic third ventriculostomy and complete tumor removal was performed. After surgery, the patient made a rapid recovery. In this case, the authors presume a sudden intraaqueductal dislocation of the ependymoma caused by aspiration of the tumor as a result of the caudal CSF flow.
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Al-Holou WN, Terman SW, Kilburg C, Garton HJL, Muraszko KM, Chandler WF, Ibrahim M, Maher CO. Prevalence and natural history of pineal cysts in adults. J Neurosurg 2011; 115:1106-14. [PMID: 21780858 DOI: 10.3171/2011.6.jns11506] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECT We reviewed our experience with pineal cysts to define the natural history and clinical relevance of this common intracranial finding. METHODS The study population consisted of 48,417 consecutive patients who underwent brain MR imaging at a single institution over a 12-year interval and who were over 18 years of age at the time of imaging. Patient characteristics, including demographic data and other intracranial diagnoses, were collected from cases involving patients with a pineal cyst. We then identified all patients with pineal cysts who had been clinically evaluated at our institution and who had at least 6 months of clinical and imaging follow-up. All inclusion criteria for the natural history analysis were met in 151 patients. RESULTS Pineal cysts measuring 5 mm or larger in greatest dimension were found in 478 patients (1.0%). Of these, 162 patients were male and 316 were female. On follow-up MR imaging of 151 patients with pineal cyst at a mean interval of 3.4 years from the initial study, 124 pineal cysts remained stable, 4 increased in size, and 23 decreased in size. Cysts that were larger at the time of initial diagnosis were more likely to decrease in size over the follow-up interval (p = 0.004). Patient sex, patient age at diagnosis, and the presence of septations within the cyst were not significantly associated with cyst change on follow-up. CONCLUSIONS Follow-up imaging and neurosurgical evaluation are not mandatory for adults with asymptomatic pineal cysts.
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Affiliation(s)
- Wajd N Al-Holou
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-5338, USA
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Smith AB, Rushing EJ, Smirniotopoulos JG. From the archives of the AFIP: lesions of the pineal region: radiologic-pathologic correlation. Radiographics 2011; 30:2001-20. [PMID: 21057132 DOI: 10.1148/rg.307105131] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Lesions of the pineal region include a diverse group of entities. The most common neoplastic lesions are the germ cell tumors. Germ cell tumors may be hormonally active, and evaluation of serum or cerebrospinal fluid levels of oncoproteins assists in making the diagnosis. Neoplasms arising from the pineal parenchyma include the low-grade pineocytoma, pineal parenchymal tumor of intermediate differentiation, and the highly malignant pineoblastoma. Germ cell tumors and pineal parenchymal neoplasms do not have pathognomonic imaging findings, but imaging in combination with laboratory evaluation helps narrow the differential diagnosis. Neoplasms may also arise from the variety of cell types residing in the proximity of the pineal gland. These include lipomas, meningiomas, and astrocytomas. Congenital lesions such as epidermoid and dermoid cysts and lipomas can also occur. Knowledge of the variety of lesions that occur in the pineal region, their imaging appearances, and their clinical features assists in narrowing the radiologic differential diagnosis and optimizing patient treatment.
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Affiliation(s)
- Alice Boyd Smith
- Department of Radiologic Pathology, Armed Forces Institute of Pathology, Washington, DC, USA.
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27
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TrueFISP imaging of the pineal gland: more cysts and more abnormalities. Clin Neurol Neurosurg 2010; 112:204-8. [PMID: 20034731 DOI: 10.1016/j.clineuro.2009.11.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2008] [Revised: 10/13/2009] [Accepted: 11/18/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Although pineal cysts are found with a frequency of over one third in autopsy series, prevalences reported in standard magnetic resonance imaging (MRI) studies only range between 0.14% and 4.9%. With the advances in scanner technology and more sensitive high-resolution 3D-sequences, pineal cysts with atypical appearance are more frequently encountered as an incidental finding. In order to help the radiologist and the clinician to correctly interpret these incidental findings and to avoid follow-up MRI or even surgical intervention, we analysed the frequency of typical and atypical pineal cysts using standard MRI-sequences and a high-resolution 3D-trueFISP-sequence (true-Fast-Imaging-with-Steady-State-Precession). METHODS In 111 patients undergoing MRI we analysed the prevalence of pineal cysts in relation to gender and age, as well as the frequency of atypical cysts defined by thickened rim, trabeculations, or asymmetric form using three standard MRI-sequences (T1-SE (T1 weighted spin echo), T2-TSE (T2 weighted turbo spin echo), FLAIR (fluid attenuated inversion recovery)) and compared the diagnostic certainty of these standard sequences with the sensitivity of a high-resolution trueFISP MRI sequence. RESULTS Using trueFISP pineal cysts were detected more frequently than in the standard sequences (35.1% vs. 9.0% (T1-SE), 4.5% (T2-TSE) and 9.0% (FLAIR)). Diagnostic uncertainty was least frequent in trueFISP. In trueFISP, 41.0% of the detected cysts showed one or more features of atypical cysts (standard sequences: 21.4%). Highest prevalence of cysts was detected in the group of 20-30-year-old patients and decreased with increasing age. CONCLUSION High-resolution 3D-sequences like trueFISP increase the detection rate of pineal cysts to levels reported in autoptic series while decreasing the diagnostic uncertainty. Atypically configurated pineal cysts are frequently detected as an incidental finding.
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Sarikaya-Seiwert S, Turowski B, Hänggi D, Janssen G, Steiger HJ, Stummer W. Symptomatic intracystic hemorrhage in pineal cysts. Report of 3 cases. J Neurosurg Pediatr 2009; 4:130-6. [PMID: 19645546 DOI: 10.3171/2009.4.peds08309] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Pineal cysts are benign and often asymptomatic intracranial entities. Occasionally they can lead to neurological symptoms through growth or due to intracystic hemorrhage. The purpose of the current report is to describe their clinical characteristics and treatment options. In the current study, the authors illustrate the course of disease in 3 patients who developed neurological symptoms due to hemorrhage into a pineal cyst. Two of their patients had additional cerebral disease, and regular MR imaging examinations were conducted. This circumstance allowed documentation of growth and intracystic hemorrhage. After the occurrence of new neurological symptoms with severe headache, MR images showed a fluid-fluid interface due to intracystic hemorrhage. The third patient presented with acute triventricular hydrocephalus and papilledema due to aqueductal stenosis caused by intracystic hemorrhage. In all 3 cases, excision of the pineal cysts via an infratentorial/supracerebellar approach was performed. Histological examination revealed the characteristic structure of pineal cyst in all cases, with hemorrhagic residues in the form of hemosiderin deposits. All patients recovered fully after surgical removal of the cysts. Furthermore, resolution of occlusive hydrocephalus could be demonstrated in those cases with ventricular enlargement. Pineal cysts without neurological symptoms are often discovered as incidental findings on cranial MR images. In contrast, neurological symptoms such as severe headache, diplopia, or Parinaud syndrome, may occur as a result of pineal apoplexy due to intracystic hemorrhage. The authors' cases confirm that MR imaging can identify intracystic hemorrhage by a characteristic fluid-fluid interface. Their experience suggests that microsurgical resection of cysts may be an effective and curative treatment option.
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Borruat FX, Kawasaki A. Isolated Accommodation Palsy Associated with a Pineal Cyst. Report of a Case and Review of the Literature. Neuroophthalmology 2009. [DOI: 10.1080/01658100701501141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Pu Y, Mahankali S, Hou J, Li J, Lancaster JL, Gao JH, Appelbaum DE, Fox PT. High prevalence of pineal cysts in healthy adults demonstrated by high-resolution, noncontrast brain MR imaging. AJNR Am J Neuroradiol 2007; 28:1706-9. [PMID: 17885233 PMCID: PMC8134222 DOI: 10.3174/ajnr.a0656] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Although the prevalence of pineal cysts in autopsy series has been reported as being between 25% and 40%, MR studies have documented their frequency to range between 1.5% and 10.8%. The purpose of this high-resolution brain MR imaging study at 1.9T was to determine the prevalence of pineal cysts in healthy adults. MATERIALS AND METHODS Brain MR images of 100 healthy young volunteers were randomly selected from our International Consortium for Brain Mapping project data base. Cysts were detected as circular areas of isointensity relative to CSF on both 3D gradient-echo T1-weighted and 2D fast spin-echo T2-weighted images. The inner diameters of all visualized pineal cysts were measured, and a criterion of 2.0 mm of the largest inner cross-sectional diameter was used to categorize cysts as being either small cystic changes (<2.0-mm diameter) or pineal cysts (>2.0-mm diameter). RESULTS Twenty-three percent (23/100) of the volunteers had pineal cysts with a mean largest inner cross-sectional diameter of 4.3 mm (range, 2-14 mm); 13% (13/100) demonstrated cystic changes involving the pineal gland with the largest inner cross-sectional diameter of less than 2.0 mm. There was a slight female predominance. Two subjects with long-term follow-up scans showed no symptoms or changes in the size of their pineal cysts. CONCLUSION On high-resolution MR imaging, the prevalence of pineal cysts was 23% in our healthy group of adults, which is consistent with previous autopsy studies. Long-term follow-up studies of 2 cases demonstrated the stability of the cysts.
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Affiliation(s)
- Y Pu
- Research Imaging Center, The University of Texas Health Science Center at San Antonio, TX, USA.
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Leveque S, Derrey S, Martinaud O, Freger P, Proust F. [Pineal cyst: usefulness of endoscopic treatment]. Neurochirurgie 2007; 53:95-9. [PMID: 17507051 DOI: 10.1016/j.neuchi.2007.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2005] [Accepted: 03/01/2007] [Indexed: 11/30/2022]
Abstract
Glial cysts of the pineal gland are usually benign and asymptomatic. They develop from the pineal parenchyma and contain liquid. The diagnosis is made by magnetic resonance imaging. In contrast large cysts can be symptomatic due to compression of the aqueduct of Sylvius, compression of the midbrain tectum or mass effect in the posterior fossa. We report the case of a symptomatic cyst treated by an endoscopic procedure.
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Affiliation(s)
- S Leveque
- Service de neurochirurgie, CHU de Rouen, boulevard Gambetta, 76031 Rouen cedex, France
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Patel AJ, Fuller GN, Wildrick DM, Sawaya R. Pineal cyst apoplexy: case report and review of the literature. Neurosurgery 2006; 57:E1066; discussion E1066. [PMID: 16284546 DOI: 10.1227/01.neu.0000179990.46401.66] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE AND IMPORTANCE Although most pineal cysts are clinically benign and asymptomatic, some can become symptomatic. Of the various symptomatic presentations, apoplexy is the rarest and most ill-defined. A comprehensive search of publications in the English language yielded 18 cases of pineal cyst apoplexy. We reviewed the literature to compare symptomatology and management strategies and their outcomes. CLINICAL PRESENTATION A 29-year-old woman with a 1-month history of headaches presented with an acute worsening of her symptoms with a severe occipital headache and trouble focusing when reading. Her neurological examination was otherwise normal. Magnetic resonance imaging showed pineal cyst apoplexy and accompanying hydrocephalus. INTERVENTION A left paramedian craniotomy with a transcallosal, transchoroidal approach using an intraoperative neuronavigation system was used to resect a pineal cyst. Postoperative imaging showed complete removal of the cyst and resolution of the hydrocephalus. Follow-up imaging at 12 months demonstrated no evidence of recurrence or any hydrocephalus. The patient has remained asymptomatic for 18 months. CONCLUSION Pineal cyst apoplexy should always be considered when following a patient with a pineal cyst that becomes symptomatic. The most common symptom was severe headache of sudden onset or acute worsening. Other signs of hydrocephalus may or may not be present. Magnetic resonance imaging is essential to making a diagnosis. Although we believe that surgical resection is the most effective approach because it minimizes the risk for recurrence and complication, stereotactic aspiration has been used successfully to treat this condition.
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Affiliation(s)
- Akash J Patel
- Department of Neurosurgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030-4950, USA
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Nimmagadda A, Sandberg DI, Ragheb J. Spontaneous involution of a large pineal region hemorrhagic cyst in an infant. Case report. J Neurosurg 2006; 104:275-8. [PMID: 16619640 DOI: 10.3171/ped.2006.104.4.275] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report the case of a newborn presenting at birth with macrocephaly and a large pineal region hemorrhagic cyst without neurological deficit. No neurosurgical intervention was performed, and subsequent imaging studies demonstrated complete involution of the cyst.
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Affiliation(s)
- Anitha Nimmagadda
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Florida, USA
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Abstract
Pineal hemorrhage only occurs in rare cases, and this known to have several different causes such as germ cell tumors, pineal cysts and vascular malformations, including the cavernous malformations. Pineal cavernous malformations are extremely rare: to date only fifteen cases have been reported worldwide. Although the diagnosis of pineal cavernous malformation is not easy because of the extreme rareness of this condition, the presence of this lesion can be suspected based on its typical radiological findings. Case 1. A 42-year- old man presented with a limitation in his upward gazing. Radiologic examinations showed acute hemorrhage in the pineal region. He underwent ventriculo-peritoneal (VP) shunting but the patient's condition deteriorated after the shunting surgery. We operated and totally removed the tumor and the hemorrhages via an occipital-transtentorial approach. Case 2. A 37-year-old man presented with diplopia. Radiologic examinations showed acute hemorrhage in the third ventricle. He underwent VP shunting, and after this procedure the diplopia was aggravated. We operated and totally removed the tumor and the hemorrhages via an occipital-transtentorial approach. If there is no doubt about the pineal cavernous malformation on MR imaging, we strongly recommend early surgical intervention without performing a risky biopsy. In this study, we describe our experiences for the diagnosis of cavernous malformations in the pineal region with special emphasis on the radiological aspects and the clinical course of this disease.
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Affiliation(s)
- Dong-Seok Kim
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu-Won Shim
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Tae-Gon Kim
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jong-Hee Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Gou Park
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Joong-Uhn Choi
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Metellus P, Fuentes S, Levrier O, Adetchessi T, Dufour H, Donnet A, Grisoli F. Traitement endoscopique d’un volumineux kyste bénin symptomatique de la région pinéale responsable d’une hydrocéphalie obstructive. Neurochirurgie 2005; 51:173-8. [PMID: 16389903 DOI: 10.1016/s0028-3770(05)83473-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Asymptomatic non neoplastic cysts of the pineal region are common incidental findings in adults. On the contrary, voluminous and symptomatic cysts of the pineal region are rare and their management are not well defined. We present the case of a 32-year-old woman suffering who suffered from mild intracranial hypertension, gait disturbance and vertigo for one year. The neuroradiological workup showed a voluminous cyst of the pineal region responsible for an obstructive hydrocephalus. An endoscopic etiological treatment was decided. The operation consisted in a marsupialization of the cyst in the third ventricle with a stereotactic guidance system. A frozen section of the cyst wall failed to show tumoral cells. Immediate postoperative course was uneventful. Intracranial hypertension symptoms resolved in 24 hours. Clinical examination and neuropsychological testing were normal at two years postoperatively. The two years follow-up cerebral MRI demonstrated a remnant cystic cavity without mass effect and the patency of the aqueduct of Sylvius. Endoscopic treatment of symptomatic pineal cysts constitutes an interesting therapeutic alternative in the management of this pathology.
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Affiliation(s)
- Ph Metellus
- Département de Neurochirurgie, Hôpital de La Timone, 264, rue Saint-Pierre, 13385 Marseille Cedex 05.
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Avery GJ, Lind CRP, Bok APL. Successful conservative operative management of pineal apoplexy. J Clin Neurosci 2004; 11:667-9. [PMID: 15261249 DOI: 10.1016/j.jocn.2003.11.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2003] [Accepted: 11/17/2003] [Indexed: 11/30/2022]
Abstract
A 71-year-old woman presented with obstructive hydrocephalus caused by a haemorrhagic pineal mass. A right ventriculo-peritoneal shunt was inserted with successful treatment of the hydrocephalus and resolution of symptoms and signs. Post-operative MRI both as an inpatient and at 5 and 18 months showed no contrast enhancement of the lesion and there was resolution of the radiographic abnormality. She remains symptom-free at 18 months. Previous reports have advocated resection of the pineal lesion, but this patient has done well with CSF shunting and MRI surveillance.
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Affiliation(s)
- Gary J Avery
- Department of Neurosurgery, Auckland Hospital, Auckland, New Zealand
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McNeely PD, Howes WJ, Mehta V. Pineal apoplexy: is it a facilitator for the development of pineal cysts? Can J Neurol Sci 2003; 30:67-71. [PMID: 12619788 DOI: 10.1017/s031716710000247x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The radiographic identification of pineal cysts has increased dramatically within the last two decades due to the advent of magnetic resonance imaging. Pineal cysts are often found incidentally with only a minority of these lesions ever becoming symptomatic and requiring treatment. Many theories attempting to explain the pathogenesis of these cysts exist. METHODS We describe a case of a 12-year-old girl who presents with a pineal hemorrhage of unknown etiology with associated hydrocephalus. RESULTS Her hydrocephalus was initially treated with an external ventricular drain followed by a third ventriculostomy. She had no evidence of elevated beta human chorionic gonadotropin or alpha-fetoprotein within the serum or cerebrospinal fluid. Follow-up imaging at seven weeks revealed resolution of her hemorrhage, however, there was development of a progressive cystic lesion within the pineal region. In order to make a definitive tissue diagnosis, a supracerebellar infratentorial surgical approach with complete resection was performed. During the resection, brownish fluid was aspirated from the cyst and the cyst wall was removed. The pathological diagnosis was a pineal cyst. CONCLUSIONS Although cases have been described of pineal apoplexy with an underlying cyst, this case describes the development of a progressive pineal cyst secondary to a hemorrhage. This case demonstrates that pineal hemorrhage may be a promotor for the development or progression of pineal cysts.
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Affiliation(s)
- P D McNeely
- IWK Children's Hospital, Dalhousie University, Division of Neurosurgery, Halifax, Nova Scotia, Canada
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Kobayashi S, Kamagata M, Nakamura M, Nakazato Y, Sasaki T. Pineal apoplexy due to massive hemorrhage associated with cavernous angioma: case report. SURGICAL NEUROLOGY 2001; 55:365-71. [PMID: 11483199 DOI: 10.1016/s0090-3019(01)00461-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Pineal apoplexy is a rare apoplectic event in the pineal region with various possible causes. We report a case of massive hemorrhage in the pineal region associated with a cavernous angioma, and discuss the pathogenesis of pineal apoplexy. CASE DESCRIPTION An 11-year-old girl presented with nausea and vomiting persisting for 1 week. Neuroimaging revealed enlarged ventricles and a 4 cm round mass in the pineal region consistent with hematoma. Two weeks after cerebrospinal fluid drainage, the mass was totally removed via the occipital transtentorial approach. The postoperative course of the patient was uneventful. Magnetic resonance imaging after the operation confirmed two paraventricular lesions with surrounding hemosiderin rings, characteristic of cavernous angioma. Histologic examination showed large hematomas and numerous vascular spaces lined by a single layer of endothelium. The diagnosis was pineal apoplexy associated with cavernous angioma, based on the histologic and radiological findings. CONCLUSIONS Pineal cavernous angiomas are extremely rare, with only fourteen cases reported previously. We recommend total removal of the causative lesion in cases of pineal apoplexy to prevent repeated bleeding or life-threatening massive hemorrhage.
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Affiliation(s)
- S Kobayashi
- Department of Neurosurgery, Gunma University School of Medicine, Gunma, Japan
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Barboriak DP, Lee L, Provenzale JM. Serial MR imaging of pineal cysts: implications for natural history and follow-up. AJR Am J Roentgenol 2001; 176:737-43. [PMID: 11222216 DOI: 10.2214/ajr.176.3.1760737] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of this study was to examine the frequency of change in size of pineal cysts on serial MR studies. MATERIALS AND METHODS Thirty-two patients (19 females, 13 males) with a diagnosis of pineal cyst at any time who underwent brain MR imaging more than once in a period of at least 6 months were identified by computerized search of radiology reports. Four patients underwent MR imaging to follow up pineal cysts, whereas the remaining patients were imaged for a variety of indications, including intracerebral neoplasms. Measurements of maximal cyst dimension on both initial and latest follow-up studies were obtained in all patients, and cyst volumes were calculated in 23 patients. RESULTS Length of follow-up ranged from 6 months to 9 years. All cysts were considered incidental and none were treated. Maximal cyst dimensions ranged from 0.5 to 2.2 cm. On average, there was no significant change in cyst volume. The maximal dimension of the cyst did not change in 24 (75%) of 32 patients. Two cysts resolved completely on follow-up, three cysts decreased by 2-4 mm, two cysts enlarged by 2-3 mm, and one cyst formed and grew to 1.2 cm. CONCLUSION Whereas the size of pineal cysts as a whole remained unchanged on serial MR studies, cysts may either form or involute in individual patients. Small increases in cyst size did occur but were not associated with specific clinical findings. These findings suggest that typical pineal cysts may be followed up on a clinical basis alone rather than on imaging.
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Affiliation(s)
- D P Barboriak
- Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710, USA
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Kang HS, Kim DG, Han DH. Large glial cyst of the pineal gland: a possible growth mechanism. Case report. J Neurosurg 1998; 88:138-40. [PMID: 9420087 DOI: 10.3171/jns.1998.88.1.0138] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The authors report on a patient who presented with a large symptomatic glial cyst of the pineal gland communicating with the third ventricle. The hole between the ventricle and the cyst, suspected on magnetic resonance images, was found at surgery. The to-and-fro flow mechanism is considered to be involved in the pathogenesis of growth in this unusual large glial cyst of the pineal gland, although this mechanism cannot be applied universally.
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Affiliation(s)
- H S Kang
- Department of Neurosurgery, Seoul National University College of Medicine, Korea
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Mena H, Armonda RA, Ribas JL, Ondra SL, Rushing EJ. Nonneoplastic pineal cysts: a clinicopathologic study of twenty-one cases. Ann Diagn Pathol 1997; 1:11-8. [PMID: 9869821 DOI: 10.1016/s1092-9134(97)80004-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Twenty-one cases of nonneoplastic pineal cyst are presented. The patients were 13 women and 8 men, with a median age of 33 years. Sixteen patients were symptomatic. Symptomatic cysts had an average size of 16.5 mm. In most cases, symptoms and signs were related to increased intracranial pressure, cerebrospinal fluid obstruction, neuroophthalmologic dysfunction, brainstem and cerebellar compression, and mental status changes. Uncommon clinical presentations in three cases were related to increased cyst size caused by hemorrhage, sudden death, and postural syncope and loss of consciousness. Imaging studies showed a uniform hypodense or hypointense, nonenhancing pineal mass with occasional peripheral calcification and associated with hydrocephalus, aqueductal compression, tectal deformity, and hemorrhage within the cavity, in decreasing order of frequency. Fourteen patients underwent open cyst resection. Histologically, the intact lesions show a unilocular or multilocular cavity, surrounded by a wall comprised of variable amounts of glial tissue, remnants of pineal gland, and an external fibrous capsule. Follow-up information showed 12 patients alive and well without recurrence between 26 and 144 postoperative months. One patient who underwent stereotactic drainage had a recurrence. One symptomatic patient who did not have surgery died suddenly of causes related to the cyst. The present study supports the role of surgical excision for the treatment of symptomatic pineal cysts to obtain adequate tissue for diagnosis and relief of symptoms. The use of histochemical and immunohistochemical studies may prove useful in the distinction of these lesions with astrocytomas and cystic pineal parenchymal tumors.
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Affiliation(s)
- H Mena
- Department of Neuropathology, Armed Forces Institute of Pathology, Washington, DC 20306-6000, USA
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Abstract
The authors present 2 unusual cases of hemorrhagic pineal cysts. CT/MR imaging characteristics are shown.
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Affiliation(s)
- R A Koenigsberg
- Department of Radiological Sciences, Medical College of Pennsylvania, Philadelphia 19129, USA
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Abstract
Asymptomatic cysts of the pineal gland are found frequently by radiological examination of the brain or at postmortem examination. Symptomatic cysts are rare, and may require surgical intervention. Sudden death due to a cystic lesion of the pineal gland is very rare. A case of a 22 year old man who collapsed and died unexpectedly is reported. Postmortem examination revealed a glial cyst of the pineal gland and evidence of chronic obstructive hydrocephalus. Deaths from colloid cysts and pineal gland cysts are rare, but should be considered where no other cause of death is evident, especially with a history of headaches. Their small size, and their possible rupture on dissection can make them difficult to detect if a careful examination is not undertaken.
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Affiliation(s)
- C M Milroy
- Department of Forensic Pathology, University of Sheffield
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Fain JS, Tomlinson FH, Scheithauer BW, Parisi JE, Fletcher GP, Kelly PJ, Miller GM. Symptomatic glial cysts of the pineal gland. J Neurosurg 1994; 80:454-60. [PMID: 8113858 DOI: 10.3171/jns.1994.80.3.0454] [Citation(s) in RCA: 88] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Small asymptomatic cysts of the pineal gland represent a common incidental finding in adults undergoing computerized tomography or magnetic resonance (MR) imaging or at postmortem examination. In contrast, large symptomatic pineal cysts are rare, being limited to individual case reports or small series. The authors have reviewed 24 cases of large pineal cysts. The mean patient age at presentation was 28.7 years (range 15 to 46 years); 18 were female and six male. Presenting features in 20 symptomatic cases included: headache in 19; nausea and/or vomiting in seven; papilledema in five; visual disturbances in five (diplopia in three, "blurred vision" in two, and unilateral partial oculomotor nerve palsy in one); Parinaud's syndrome in two; hemiparesis in one; hemisensory aberration in one; and seizures in one. Four lesions were discovered incidentally. Magnetic resonance imaging typically demonstrated a 0.8- to 3.0-cm diameter mass (mean 1.7 cm) with homogeneous decreased signal intensity on T1-weighted images, increased signal intensity on T2-weighted images, and a distinct margin. Hydrocephalus was present in eight cases. The cysts were surgically excised via an infratentorial/supracerebellar approach (23 cases) or stereotactically biopsied (one case). Histological examination revealed a cyst wall 0.5 to 2.0 mm thick comprised of three layers: an outer fibrous layer, a middle layer of pineal parenchymal cells with variable calcification, and an inner layer of hypocellular glial tissue often exhibiting Rosenthal fibers and/or granular bodies. Evidence of prior hemorrhage, mild astrocytic degenerative atypia, and disorganization of pineal parenchyma were often present. Postoperative follow-up review in all 24 cases (range 3 months to 10 years) revealed no complications in 21, mild ocular movement deficit in one, gradually resolving Parinaud's syndrome in one, and radiographic evidence of a postoperative venous infarct of the superior cerebellum with ataxia of 1 week's duration in one. Of the patients referred for study, the cysts were most often initially misdiagnosed as a pineocytoma in eight and a pilocytic astrocytoma in three. Only two patients were correctly diagnosed as having pineal cysts. This stresses the importance of recognizing the histopathological spectrum of pineal cysts, as well as correlation with radiographic findings, if a correct diagnosis is to be attained.
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Affiliation(s)
- J S Fain
- Department of Laboratory Medicine, Mayo Clinic, Rochester, Minnesota
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Musolino A, Cambria S, Rizzo G, Cambria M. Symptomatic cysts of the pineal gland: stereotactic diagnosis and treatment of two cases and review of the literature. Neurosurgery 1993; 32:315-20; discussion 320-1. [PMID: 8437673 DOI: 10.1227/00006123-199302000-00025] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
We report two cases of pineal gland cysts, both in young girls, causing aqueductal stenosis and symptomatic hydrocephalus, which were diagnosed and treated by Talairach's stereotactic method. This procedure permitted aspiration of the cyst content, normalization of aqueductal stenosis, and a differential histological diagnosis. Postoperative computed tomographic scan examination showed a stable reduction of the cystic volume and a complete clearance of the hydrocephalus. At present, the two patients are clinically normal and are leading a productive life (follow-up, 42 and 40 mo). It is important that this kind of nonneoplastic lesion be identified, in order to avoid confusion with pineal tumors and possible inappropriate treatment. Pineal cysts rarely become symptomatic. Up to the present, only 27 symptomatic cases have been described in the literature. Of those, signs of intracystic bleeding were found in 17 of the 21 cases in which the cyst contents were known. Moreover, in our own two cases, numerous hemosiderin-laden macrophages were present in the cystic fluid. We think, therefore, that intracystic bleeding has been the determining factor for the occurrence of symptoms in most of these cases. The authors underline the advantages of this type of stereotactic management, which can provide both diagnosis and treatment and thus avoid the possible risks of surgical excision and/or of radiotherapy.
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Affiliation(s)
- A Musolino
- Istituto di Scienze Neurologiche e Neurochirurgiche, Neurochirurgia 2, Università di Messina, Italy
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Abstract
The authors present a series of six patients with large symptomatic benign pineal cysts and review the 27 patients previously reported in the literature. Patients with symptomatic pineal cysts most often present with one of three syndromes: 1) paroxysmal headache with gaze paresis; 2) chronic headache, gaze paresis, papilledema, and hydrocephalus; or 3) pineal apoplexy with acute hydrocephalus. Surgical intervention with radical cyst removal is the treatment of choice for all symptomatic pineal cysts. Complete cyst removal is desirable; however, radical subtotal resection is appropriate if the cyst cannot be easily separated from the quadrigeminal plate. Ventricular shunting should be reserved for patients with persistent hydrocephalus after cyst resection.
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Affiliation(s)
- J H Wisoff
- Division of Pediatric Neurosurgery, New York University Medical Center, New York
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Klein P, Rubinstein LJ. Benign symptomatic glial cysts of the pineal gland: a report of seven cases and review of the literature. J Neurol Neurosurg Psychiatry 1989; 52:991-5. [PMID: 2677249 PMCID: PMC1031840 DOI: 10.1136/jnnp.52.8.991] [Citation(s) in RCA: 95] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Seven cases of clinically symptomatic benign glial cyst of the pineal gland are reported. The cysts' size ranged from 1.0-4.5 cm in diameter. They were characterised by a golden or, less frequently, brown-reddish proteinaceous or haemorrhagic fluid content. The cyst wall, up to 2 mm thick, consisted of clusters of normal pineal parenchymal cells, often compressed and distorted, surrounded by reactive gliotic tissue which sometimes contained Rosenthal fibres. The presenting clinical features included headache (6/7), signs of raised intracranial pressure, partial or complete Parinaud's syndrome (5/7), cerebellar deficits (2/7), corticospinal and corticopontine fibre (2/7) or sensory (1/7) deficits, and emotional disturbances (2/7). CT and MRI (in 2/7 cases) scans showed a hypodense or nonhomogeneous lesion in the region of the pineal gland, with or without contrast enhancement. Surgical excision resulted in complete clearance of the symptoms in 5/7 patients. The previous literature is reviewed and the clinicopathological correlations and the possible pathogenetic mechanisms are discussed. The need to distinguish this benign lesion from other mass lesions of the pineal region, in particular from pinealocytoma, is stressed.
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Affiliation(s)
- P Klein
- Department of Neurology, University of Virginia School of Medicine, Charlottesville 22908
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Osborn RE, Deen HG, Kerber CW, Glass RF. A case of hemorrhagic pineal cyst: MR/CT correlation. Neuroradiology 1989; 31:187-9. [PMID: 2747899 DOI: 10.1007/bf00698853] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A 30-year-old male had a headache for one month and was evaluated with both computed tomography (CT) and magnetic resonance (MR). These scans demonstrated an obstructing pineal cyst containing layered acute and subacute blood products by MR criteria. The concurrent scans allowed correlation between CT and MR findings in this rare complication of an unusual entity, explained his headache (and the development of later upward gaze paresis), provided a precise surgical/anatomic approach, and gave a good final clinical result. The report illustrates appropriate CT and MR images and pathological specimen.
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Affiliation(s)
- R E Osborn
- Department of Radiology, Naval Hospital, San Diego, California
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