Pineal cyst resection in the absence of ventriculomegaly or Parinaud's syndrome: clinical outcomes and implications for patient selection.
OBJECTIVE
Surgical indications for patients with pineal cysts are controversial. While the majority of patients harboring a pineal cyst require no treatment, surgery is a well-accepted option for a subset of those patients with secondary hydrocephalus or Parinaud's syndrome. The majority of pineal cysts are identified incidentally during workup for other potential conditions, which may or may not be related to the presence of the cyst. In the absence of clear obstruction of CSF pathways, the treatment of presumed symptomatic pineal cysts is debatable. To clarify the role of surgery in these borderline cases, the authors reviewed their experience with resection of pineal cysts in the absence of ventriculomegaly or Parinaud's syndrome.


METHODS
The authors retrospectively reviewed medical records and imaging of all patients surgically treated between 2001 and 2014 with a pineal cyst in the absence of ventriculomegaly and Parinaud's syndrome. The presenting symptoms, preoperative cyst size, preoperative radiographic aqueductal compression, extent of resection, and radiographic and clinical follow-up were documented.


RESULTS
Eighteen patients (14 female and 4 male; mean age 24 years, range 4-47 years) underwent cyst resection in the absence of ventriculomegaly or Parinaud's syndrome. Presenting symptoms included headache (17 patients), visual disturbances (10 patients), gait instability (5 patients), dizziness (5 patients), episodic loss of consciousness (2 patients), and hypersomnolence (1 patient). The mean preoperative cyst diameter was 1.5 cm (range 0.9-2.2 cm). All patients had a complete resection. At a mean clinical follow-up of 19.1 months (range postoperative to 71 months), 17 (94%) patients had resolution or improvement of their presenting symptoms.


CONCLUSIONS
The authors' results suggest that ventriculomegaly and Parinaud's syndrome are not absolute requisites for a pineal cyst to be symptomatic. Analogous to colloid cysts of the third ventricle, intermittent occlusion of cerebrospinal fluid pathways may cause small pineal cysts to become intermittently symptomatic. A select cohort of patients with pineal cysts may benefit from surgery despite a lack of hydrocephalus or other obvious compressive pathology.
Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona;|Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and.
M Yashar S
MY
Kalani
Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona;
David A
DA
Wilson
Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and.
Nicolas Olmo
NO
Koechlin
Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and.
Hazem J
HJ
Abuhusain
Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and.|Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
Brian J
BJ
Dlouhy
Manuri P
MP
Gunawardena
Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and.
Kyoko
K
Nozue-Okada
Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; and.
Charles
C
Teo
D000293:Adolescent; D000328:Adult; D001927:Brain Diseases / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D003560:Cysts / Q000601:surgery*; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000601:surgery; D008297:Male; D008875:Middle Aged; D015835:Ocular Motility Disorders / Q000601:surgery; D018579:Patient Selection; D010870:Pineal Gland / Q000601:surgery*; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
occipital-transtentorial approach; oncology; pineal cyst; surgery; symptomatic