Serial follow-up MRI of indeterminate cystic lesions of the pineal region: experience at a rural tertiary care referral center. AJR Am J Roentgenol. 2009;193:533-537. [PMID: 19620453 DOI: 10.2214/ajr.08.1906]

Pineal cyst: results of long-term MRI surveillance and analysis of growth and shrinkage rates

OBJECTIVE

Pineal cyst (PC) is a relatively common true cyst in the pineal gland. Its long-term natural course remains ill defined. This study aims to evaluate the long-term natural history of PC and examine MRI risk factors for cyst growth and shrinkage to help better define which patients might benefit from surgical intervention.

METHODS

The records and MRI of 409 consecutive patients with PC were retrospectively examined (nonsurgical cohort). Cyst growth and shrinkage were defined as a ≥ 2-mm increase and decrease in cyst diameter in any direction, respectively. In addition to size, MRI signal intensity ratios were analyzed.

RESULTS

The median radiological follow-up period was 10.7 years (interquartile range [IQR] 6.4-14.3 years). The median change in maximal diameter was -0.6 mm (IQR -1.5 to 1.3 mm). During the observation period, cyst growth was confirmed in 21 patients (5.1%). Multivariate logistic regression analysis revealed that only age (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93-0.99, p < 0.01) was significantly associated with cyst growth. No patient required resection during the observation period. Cyst shrinkage was confirmed in 57 patients (13.9%). Multivariate analysis revealed that maximal diameter (OR 1.22, 95% CI 1.12-1.35, p < 0.01) and cyst CSF T2 signal intensity ratio (OR 9.06, 95% CI 1.38-6.62 × 101, p = 0.02) were significantly associated with cyst shrinkage.

CONCLUSIONS

Only 5% of PCs, mainly in patients younger than 50 years of age, have the potential to grow, while cyst shrinkage is more likely to occur across all age groups. Younger age is associated with cyst growth, while larger diameter and higher signal intensity on T2-weighted imaging are associated with shrinkage. Surgery is rarely needed for PCs, despite the possibility of a certain degree of growth.

A deep phenotyping experience: up to date in management and diagnosis of Malan syndrome in a single center surveillance report

Background

Malan syndrome (MALNS) is a recently described ultrarare syndrome lacking guidelines for diagnosis, management and monitoring of evolutive complications. Less than 90 patients are reported in the literature and limited clinical information are available to assure a proper health surveillance.

Results

A multidisciplinary team with high expertise in MALNS has been launched at the “Ospedale Pediatrico Bambino Gesù”, Rome, Italy. Sixteen Italian MALNS individuals with molecular confirmed clinical diagnosis of MALNS were enrolled in the program. For all patients, 1-year surveillance in a dedicated outpatient Clinic was attained. The expert panel group enrolled 16 patients and performed a deep phenotyping analysis directed to clinically profiling the disorder and performing critical revision of previously reported individuals. Some evolutive complications were also assessed. Previously unappreciated features (e.g., high risk of bone fractures in childhood, neurological/neurovegetative symptoms, noise sensitivity and Chiari malformation type 1) requiring active surveillance were identified. A second case of neoplasm was recorded. No major cardiovascular anomalies were noticed. An accurate clinical description of 9 new MALNS cases was provided.

Conclusions

Deep phenotyping has provided a more accurate characterization of the main clinical features of MALNS and allows broadening the spectrum of disease. A minimal dataset of clinical evaluations and follow-up timeline has been proposed for proper management of patients affected by this ultrarare disorder.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-022-02384-9.

Neuroimaging of paediatric pineal, sellar and suprasellar tumours: a guide to differential diagnosis

INTRODUCTION

Pineal, sellar and suprasellar tumours in children comprise a wide range of diseases with different biological behaviours and clinical management. Neuroimaging plays a critical role in the diagnosis, treatment planning and follow up of these patients, but imaging interpretation can prove challenging due to the significant overlap in radiological features.

MATERIALS AND METHOD

A review of the literature was performed by undertaking a search of the MEDLINE and EMBASE databases for appropriate MeSH terminology. Identified abstracts were screened for inclusion and articles meeting the objectives of the review were included.

RESULTS AND CONCLUSION

In this article, we review radiological appearances of common and uncommon pineal, sellar and suprasellar tumours occurring in the paediatric population. We discuss the importance of anatomical localization, clinical information and cerebrospinal fluid tumour markers, and propose a practical approach to differential diagnosis. Lastly, we discuss future directions and prospective new imaging strategies to support state-of-the-art patient care.

Prevalence Rate of Coexisting Rathke Cleft Cysts and Pineal Cysts: A Multicenter Cross-Sectional Study

BACKGROUND

Rathke cleft cysts (RCCs) are benign sellar lesions originating from remnants of primitive ectoderm. They have not been previously linked to other cystic lesions, such as pineal cysts (PCs). Our objective was to perform a multicenter cross-sectional neuroimaging study to examine prevalence rates of coexisting RCC and PC.

METHODS

We retrospectively queried prospectively maintained, institutional review board-approved, databases from the authors' centers. All patients undergoing transsphenoidal surgery for RCC between the years of 2011 and 2020 were included for analysis. Preoperative magnetic resonance imaging was reviewed to identify the coexistence of a PC. Patient demographics and neuroimaging characteristics were recorded. A control cohort comprised of 100 age- and sex-matched patients with nonfunctional pituitary adenoma (NFPA) who also underwent surgical intervention was utilized.

RESULTS

Eighty-four patients with RCC were identified for analysis. A coexistent PC was identified in 40.5% (n = 34) of patients with RCC compared with 14.3% (n = 12) in the NFPA cohort (P < 0.001). There was no significant difference in PC size between patients with RCC and PA (8 vs. 8.8 mm, respectively; P = 0.77). Although the majority (85.7%; n = 72) of the RCC cohort were female patients, there was no sex predominance with respect to coexisting PC in either the RCC or PA cohort.

CONCLUSIONS

This is the first study to report an increased prevalence of coexisting PC and RCC, possibly because of an embryologic link or other propensity for intracranial cyst formation. Additional studies in more generalizable populations can further explore the relation between RCC and PC, or other cyst formation.

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.

The microsurgical management of benign pineal cysts: Helsinki experience in 60 cases

Background:

Microsurgical resection represents a well-accepted management option for symptomatic benign pineal cysts. Symptoms such as a headache, hydrocephalus, and visual deficiency are typically associated with pineal cysts. However, more recent studies reported over the past years have characterized additional symptoms as a part of the clinical manifestation of this disease and represent additional indications for intervention.

Methods:

We present a retrospective review of patients with histologically confirmed benign pineal cysts that were operated on in our department between 1997 and 2015. A demographic analysis, evaluation of preoperative status, surgical treatment, as well as immediate and long-term clinical and radiological outcomes were conducted.

Results:

A total of 60 patients with benign pineal cysts underwent surgery between 1997 and 2015. Gross total resection was achieved in 58 cases. All patients except one improved in their clinical status or had made a full recovery at the time of the last follow-up. The key steps for surgical resection of pineal cysts are reported, based on an analysis of representative surgical videos.

Conclusions:

We describe in this paper one of the largest series of microsurgically treated pineal cysts. In our opinion, judicious microsurgery remains the most suitable technique to effectively deal with this disease.

Evaluation of pineal cysts with magnetic resonance imaging

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.

Follow-up of pineal cysts in children: is it necessary?

PURPOSE

Pineal cysts are common incidental findings in children undergoing magnetic resonance imaging (MRI). Several studies have suggested MRI follow-up if the cyst is larger than 10 mm. However, cysts do not usually change during follow-up. Prevalence, growth, and structure of the pineal cysts were analyzed to decide if follow-up MRI is necessary.

METHODS

A retrospective review between 2010 and 2015 was performed using 3851 MRI examinations of children aged 0-16 years to detect pineal cysts having a maximum diameter ≥ 10 mm. Eighty-one children with pineal cysts were identified and 79 of them had been controlled by MRI. Cysts were analyzed for the size, growth, and structure.

RESULTS

A total of 1.8% of the children had a pineal cyst with a diameter ≥ 10 mm. Cysts were present in 48 girls (59.3%) and 33 boys (40.7%). Most pineal cysts (70/79) did not significantly grow during the follow-up (median 10 months, range 3-145 months). A total of 11.4% (9/79) of the cysts grew with the biggest change measured from the outer cyst wall sagittal anteroposterior dimension (mean 3.4 mm ± 1.7 mm). Only one cyst grew more than 5 mm. We found no factors correlating with the cyst growth among 9 cysts that grew > 2 mm.

CONCLUSIONS

A majority of pineal cysts remained unchanged during the MRI follow-up. Results of this study suggest that routine MRI follow-up of pineal cysts is not necessary in the absence of unusual radiological characteristics or related clinical symptoms.

Conservative and Surgical Treatment of Patients with Pineal Cysts: Prospective Case Series of 110 Patients

BACKGROUND

A pineal cyst is a relatively common benign condition of the pineal gland. The clinical management of patients with a pineal cyst remains controversial, especially when patients present with nonspecific symptoms.

METHODS

We performed a prospective study between 2000 and 2016. All patients with a pineal cyst >7 mm were included. Epidemiologic data, presenting symptoms, surgical results, and radiographic and clinical follow-up were documented.

RESULTS

A total of 110 patients were enrolled in the present study. The most common presenting symptoms were tension headache (62.7%), vertigo (16.4%), migraine (12.7%), syncope (10.9%), nausea (8.2%), and diplopia (8.2%). Symptoms worsened during the follow-up period in 17 patients (15.5%), improved in 13 patients (11.8%), and remained stable in 81 patients (73.6%). The mean follow-up was 79.2 months. A pineal cyst increased in size during the follow-up in 6 patients (5.5%) and decreased in size in 9 patients (8.2%). Twenty-one patients underwent pineal cyst resection; 20 patients (95.2%) reported some improvement in their presenting symptoms, and 10 patients (47.6%) were symptom free after the surgery.

CONCLUSION

We present the largest clinical series of patients with pineal cysts. Surgery, if indicated properly, is a legitimate treatment modality for symptomatic patients with satisfactory results. Relief of symptoms, even nonspecific ones, is achieved in the majority of cases. Simple growth of the cyst in the first decades of life is a part of the natural course and should not be considered as an indication for surgery.

MR imaging of brain pilocytic astrocytoma: beyond the stereotype of benign astrocytoma

BACKGROUND

Pilocytic astrocytoma (PA) is the most common pediatric brain glioma and is considered the prototype of benign circumscribed astrocytoma. Despite its low malignancy, the CT and MRI features of brain PA may resemble those of much more aggressive brain tumors. Misdiagnosis of PA is particularly easy when it demonstrates MR morphological and non-morphological findings that are inconsistent with its non-aggressive nature and that overlap with the features of more aggressive brain tumors.

METHOD

Basing on the evidence that the variation in the histological, genetic, and metabolic "fingerprint" for brain PA is dependent on tumor location, and the hypothesis that tumor location is related to the broad spectrum of morphological and non-morphological MR imaging findings, the authors discuss the MR imaging appearance of brain PA using a location-based approach to underline the typical and less typical imaging features and the main differential diagnosis of brain PA. A brief summary of the main pathological and clinical features, the natural history, and the treatment of brain PA is also provided.

RESULT

A combination of morphological and non-morphological MR imaging features and a site-based approach to differential diagnosis are required for a pre-operative diagnosis. The new "cutting-edge" MR imaging sequences have the potential to impact the ease and confidence of pediatric brain tumor interpretation and offer a more efficient diagnostic work-up.

CONCLUSIONS

Although the typical imaging features of brain pilocytic astrocytoma make radiological diagnosis relatively easy, an atypical and more aggressive appearance can lead to misdiagnosis. Knowing the broad spectrum of imaging characteristics on conventional and advanced MR imaging is important for accurate pre-operative radiological diagnosis and correctly interpreting changes during follow-up.

Incidental Pineal Cysts: Is Surveillance Necessary?

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.

Incidental pineal cysts in children who undergo 3-T MRI

BACKGROUND

Pineal cysts, both simple and complex, are commonly encountered in children. More cysts are being detected with MR technology; however, nearly all pineal cysts are benign and require no follow-up.

OBJECTIVE

To discover the prevalence of pineal cysts in children at our institution who have undergone high-resolution 3-T MRI.

MATERIALS AND METHODS

We retrospectively reviewed 100 consecutive 3-T brain MRIs in children ages 1 month to 17 years (mean 6.8 ± 5.1 years). We evaluated 3-D volumetric T1-W imaging, axial T2-W imaging, axial T2-W FLAIR (fluid attenuated inversion recovery) and coronal STIR (short tau inversion recovery) sequences. Pineal parenchymal and cyst volumes were measured in three planes. Cysts were analyzed for the presence and degree of complexity.

RESULTS

Pineal cysts were present in 57% of children, with a mean maximum linear dimension of 4.2 mm (range 1.5-16 mm). Of these cysts, 24.6% showed thin septations or fluid levels reflecting complexity. None of the cysts demonstrated complete T2/FLAIR signal suppression. No cyst wall thickening or nodularity was present. There was no significant difference between the ages of children with and without cysts. Cysts were more commonly encountered in girls than boys (67% vs. 52%; P = 0.043). There was a slight trend toward increasing pineal gland volume with age.

CONCLUSION

Pineal cysts are often present in children and can be incidentally detected by 3-T MRI. Characteristic-appearing pineal cysts in children are benign, incidental findings, for which follow-up is not required if there are no referable symptoms or excessive size.

Pineal cysts in children: case-based update

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.

Pineal cysts in children

OBJECTIVE: To describe the prevalence and characteristics of pineal cysts found on MRI in children. METHODS: This is a retrospective monocentric study of all brain magnetic resonance imaging (MRI) examinations performed under the same technical conditions for checking the idiopathic nature of short stature (ISS group, n = 116) and for the investigation of central precocious puberty (CPP) over a 3-year period (n = 56). Dimensions, wall and septal thickness, number of locules, signal intensity, and the presence of a solid component were analysed. Ten of 19 cysts were re-evaluated (follow-up interval 4-28 months). The prevalence of the pineal cysts was compared between the two groups using χ2 and Fisher's exact tests, and a significance threshold of p < 0.05. RESULTS: The prevalence of cysts was comparable in the two groups, CPP (10.7%) and ISS (11.2%). Cyst characteristics were similar in the two groups and 74% had thin septations. None of the cysts changed on follow-up. None of the children with pineal cysts exhibited neurological signs. CONCLUSION: Benign pineal cysts are a common finding in young children. High-resolution MRI demonstrates that these cysts are often septated. This pattern is a normal variant and does not require follow-up MR imaging or IV contrast media.

Prevalence and natural history of pineal cysts in adults

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.

From the archives of the AFIP: lesions of the pineal region: radiologic-pathologic correlation

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.