Disturbance in melatonin metabolism as a causative factor for recurrent headaches in a girl with a pineal cyst?

Headache outcomes after surgery for pineal cyst without hydrocephalus: A systematic review

Background:

Pineal cysts are common entities, with a reported prevalence between 10 and 54%. Management of pineal cysts has historically been expectant, with surgical treatment of these lesions usually reserved for patients with a symptomatic presentation secondary to mass effect. The appropriate management of pineal cysts in patients presenting with headache in the absence of hydrocephalus – often the most common clinical scenario – has been more ambiguous. Here, we report the results of a comprehensive systematic review of headache outcomes for surgically treated, non-hydrocephalic pineal cyst patients without signs of increased intracranial pressure (ICP).

Methods:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to construct a systematic review. A comprehensive search of the PubMed, Embase, Scopus, and Web of Science databases was conducted from through June 2020. Relevant English-language articles were identified using the search terms “pineal cyst” and “headache.” The following eligibility criteria were applied: the inclusion of at least one surgically-treated, non-hydrocephalic pineal cyst patient presenting with headache in the absence of hemorrhage or signs and symptoms of increased ICP. Patient demographics and post-operative headache outcomes for the included studies were extracted and summarized.

Results:

A total of 24 pineal cyst cases meeting our selection criteria were identified across 11 included studies. Postoperative improvement or resolution of headaches was reported for 23/24 patients. Our systematic review of the literature demonstrates that non-hydrocephalic patients with pineal cysts have a high rate of headache improvement following surgical intervention.

Conclusion:

The results indicate a need for further investigation of the link between headache and pineal cysts in the non-hydrocephalic patient.

Systematic review of pineal cysts surgery in pediatric patients

INTRODUCTION

We present a consecutive case series and a systematic review of surgically treated pediatric PCs. We hypothesized that the symptomatic PC is a progressive disease with hydrocephalus at its last stage. We also propose that PC microsurgery is associated with better postoperative outcomes compared to other treatments.

METHODS

The systematic review was conducted in PubMed and Scopus. No clinical study on pediatric PC patients was available. We performed a comprehensive evaluation of the available individual patient data of 43 (22 case reports and 21 observational series) articles.

RESULTS

The review included 109 patients (72% females). Ten-year-old or younger patients harbored smaller PC sizes compared to older patients (p < 0.01). The pediatric PCs operated on appeared to represent a progressive disease, which started with unspecific symptoms with a mean cyst diameter of 14.5 mm, and progressed to visual impairment with a mean cyst diameter of 17.8 mm, and hydrocephalus with a mean cyst diameter of 23.5 mm in the final stages of disease (p < 0.001). Additionally, 96% of patients saw an improvement in their symptoms or became asymptomatic after surgery. PC microsurgery linked with superior gross total resection compared to endoscopic and stereotactic procedures (p < 0.001).

CONCLUSIONS

Surgically treated pediatric PCs appear to behave as a progressive disease, which starts with cyst diameters of approximately 15 mm and develops with acute or progressive hydrocephalus at the final stage. PC microneurosurgery appears to be associated with a more complete surgical resection compared to other procedures.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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

Results of surgery in symptomatic non-hydrocephalic pineal cysts: role of magnetic resonance imaging biomarkers indicative of central venous hypertension

BACKGROUND

We have previously proposed that pineal cysts (PCs) may result in crowding of the pineal recess, causing symptoms due to compression of the internal cerebral veins and central venous hypertension. In the present study, we compared clinical outcome of different treatment modalities in symptomatic individuals with non-hydrocephalic PCs.

METHODS

The study included all patients managed surgically for non-hydrocephalic PCs in our Department of Neurosurgery over a 10-year period. We applied a questionnaire to determine occurrence of symptoms before and after surgery, which allowed the use of a grading scale for symptom severity. Magnetic resonance imaging (MRI) biomarkers indicative of central venous hypertension were assessed before and after surgery.

RESULTS

Relief of symptoms after surgery was most efficiently obtained by complete microsurgical cyst removal [n = 15; no (0/15), some (1/15) or marked (14/15) improvement], and to a lesser extent by microsurgical cyst fenestration [n = 6; no (2/6), some (4/6) or marked (0/6) improvement]. Shunt surgery was not successful [n = 6; no (5/6), some (1/6) or marked (0/6) improvement]. In all patients, the proposed MRI biomarkers gave evidence of central venous hypertension (PC grades 2-4).

CONCLUSIONS

Microsurgical cyst removal provided marked symptom relief in symptomatic individuals with non-hydrocephalic PCs and MRI biomarkers of central venous hypertension. The hypothesis that PC-induced crowding of the pineal recess may compromise venous run-off and induce a central venous hypertension syndrome deserves further study.

Magnetic resonance imaging biomarkers indicate a central venous hypertension syndrome in patients with symptomatic pineal cysts

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.