Traitement endoscopique d’un volumineux kyste bénin symptomatique de la région pinéale responsable d’une hydrocéphalie obstructive

Natural Progression of Pineal Cysts in Relation to Headache: A Prospective Observational Study

BACKGROUND

Pineal cysts are a frequent, potentially incidental finding in routine imaging studies. Their relationship with headache has been a matter of some controversy. In this prospective observational study, we sought to track the clinical and radiological trajectory of pineal cysts in both patients with and without concurrent headache.

METHODS

A cohort study was conducted in patients referred to the Department of Neurosurgery at Karolinska Hospital for evaluation of a pineal cyst ≥ 5 mm between June 2005 and April 2017. Patients were stratified according to headache status and classified according to standard criteria. Development in cyst size and degree of aqueduct stenosis, as well as clinical progression of headache, was tracked.

RESULTS

157 cysts were identified (50 males and 107 females, mean age: 37 years), 103 of which were in patients primarily assessed for headaches. Cyst size remained stable over the follow-up period. There was no relationship between cyst size, the presence or progression of headache, nor with amenability to treatment. No relationship between the mass effect of the quadrigeminal plate and headache was observed. Of 13 patients treated with melatonin, 7 (53%) reported a subsequent decrease in headache severity.

CONCLUSIONS

A major proportion of seemingly incidental pineal cysts referred for neurosurgical evaluation were detected during work-up for headache. Furthermore, the size and symptoms associated with cysts remain stable over time, barring intervention. The therapeutic implications and relationship with other factors such as melatonin remain to be explored.

Exclusively endoscopic management of complicated pineal cysts in young children: Definitive treatment through single burr-hole technique

Background:

The management of complicated symptomatic pineal cysts in the pediatric population is challenging and variable. Surgical management may include treatment of hydrocephalus alone, or direct treatment of the cyst with or without direct hydrocephalus management. This is typically done through craniotomy-based microsurgical approaches to the pineal region or an endoscopic transventricular approach.

Methods:

We present a stepwise minimally invasive technique to treat complicated pineal cysts in young children associated with an obstructive hydrocephalus in a single procedure through third ventriculostomy combined with an intraventricular marsupialization of the pineal cyst through a single burr-hole using stereotactic navigation.

Results:

Two young patients with over 2 years of follow-up have done well without complication using this technique. Other literature reports for complex pineal cysts in pediatric patients are reviewed and this technique is not previously described for this population.

Conclusion:

Endoscopic third ventriculostomy and cyst marsupialization using a single burr-hole and stereotactic navigation for symptomatic or enlarging pineal cysts in children allow for minimally invasive management, a rapid recovery, short hospital stay, and durable outcome owed to redundant CSF flow pathways.

Some questions provoked by a chronic headache (with mixed migraine and cluster headache features) in a woman with a pineal cyst. Answers from a literature review

The main known function of the pineal gland in humans is the production of melatonin. Benign cysts of the gland have been related to headache, although the mechanism of production of this assumed clinical manifestation has not been clearly determined, due to the lack of large prospective studies. The question is complicated by the fact that pineal cysts are frequently found on brain magnetic resonance imaging. Much has been published about the possible role of benign pineal cysts in the pathophisiology of headaches and the potential of melatonin in headache therapy, as well as in other disorders. The aim of this article is to review the current state of the suject. We have tried to place accurately the relation between headache and pineal cysts based on the available evidence, as well as the actual role of melatonin in physiology and pharmacology, more specifically in headache therapy. We include a clinical case to illustrate the subject.