Pineal cyst

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Synonyms
Pineal cyst
ICD-10
D35. 4

A pineal cyst is a benign cystic mass in the region of the Pineal gland. More than 80 % of pineal cysts are less than 10 mm in size and very rarely show progression on follow-up imaging.

Epidemiology

Pineal cysts are found in 1.8 % to 4.3 % of all cranial MRI examinations and therefore frequently present as asymptomatic incidental findings[^1][^8]. Autopsy studies suggest that pineal cysts are present in up to 40 % of the population[^9] [^10].

Symptoms

Larger pineal cysts can compress the of the cerebral aqueductHydrocephalus.

Imaging

Depending on their morphology and size, pineal cysts may be visible on both CT and MRI. MRI is the gold standard for imaging.

CT

Small pineal cysts may frequently be overlooked on CT imaging because they have the same attenuation as cerebrospinal fluid.

Pineal cyst on CT
Sagittal CT showing a partially calcified pineal cyst.

MRI

MRI is the gold standard for diagnosis. On the noncontrast T1-weighted sequence, signal intensity may vary depending on the protein content of the cyst contents and may appear isointense to mildly hyperintense compared with the Cerebrospinal fluid. On the T2-weighted sequence, Hyperintensity is frequently observed. On contrast-enhanced T1-weighted imaging, enhancement of the cyst wall of up to a maximum of 2 mm may be seen in some cases. Nodular irregularities with contrast enhancement may indicate another mass[^2].

Pineal cyst on MRI, CISS sequence
Sagittal CISS MRI sequence of a patient with a pineal cyst.
Pineal cyst on MRI
Sagittal MRI showing a pineal cyst (red arrow).
Pineal cyst on axial MRI
Axial T2-weighted MRI of the skull showing a pineal cyst.

Asymptomatic pineal cysts

Asymptomatic pineal cysts measuring less than 2 cm in diameter with a typical imaging appearance, a wall thickness of ≤ 2 mm, and no irregularities or nodular contrast enhancement are considered unlikely to grow[^2]. However, the natural history cannot be predicted with certainty. In adults, the risk of cyst growth is approximately 4 % at 6 months of follow-up[^3], and in children it is approximately 11 % at 10 months of follow-up[^4]. Based on these data, early follow-up imaging a few months after the initial diagnosis should be considered[^2] to rule out rapid growth and subsequently increase the follow-up interval.

Symptomatic pineal cysts

Symptoms

Pineal cysts may become symptomatic due to hydrocephalus, with symptoms such as headache, nausea, vomiting, and lethargy[^6]. Papilledema, Parinaud syndrome, or visual impairment may also occur[^6] [^7].

Surgical treatment

Surgical treatment is generally necessary only in extremely rare cases, when the pineal cyst obstructs CSF outflow and consequently causes hydrocephalus, or when symptoms such as headache or visual disturbances occur[^8]. In symptomatic pineal cysts, surgical intervention is the treatment of choice[^2]. Pineal cysts can be resected, for example, via an infratentorial supracerebellar approach[^5] [^11].

Video

Microsurgical resection of a pineal cyst

Operative video of microsurgical resection of a pineal cyst via a supracerebellar infratentorial approach.

Download video 137.34 MB

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Who created and updated this article, and which changes are documented.

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  • Text changed: “The pineal cyst is a benign cystic mass in the area of the Pineal gland . Over 80% of pineal cysts are less than 10 mm in size and very rarely show progression in follow-up imaging.”“A pineal cyst is a benign cystic mass lesion in the region of the Pineal gland . More than 80 % of pineal cysts are smaller than 10 mm and only very rarely show progression on follow-up imaging.”
  • Text changed: “Pineal cysts are found in 1.8% to 4.3% of all cranial MRI scans and therefore very often occur as asymptomatic incidental findings[^1][^8]. Autopsy studies suggest that a pineal cyst is present in up to 40% of the population[^9] [^10].”“Pineal cysts are found in 1.8 % to 4.3 % of all cranial MRI examinations and therefore commonly occur as asymptomatic incidental findings[^1][^8]. Autopsy studies suggest that up to 40 % of the population may have a pineal cyst[^9] [^10].”
  • Text changed: “Larger pineal cysts can lead to compression of the aqueduct and a consequent hydrocephalus .”“Larger pineal cysts may cause compression of the Aqueduct and consequent Hydrocephalus .”
  • Text changed: “Depending on their manifestation and size, pineal cysts can be visible in both CT and MRI imaging. The gold standard for imaging depiction is MRI.”“Depending on their appearance and size, pineal cysts may be visible on both CT and MRI. MRI is the gold standard for imaging assessment.”
  • Text changed: “Small pineal cysts can often be overlooked on CT imaging due to their similar intensity to cerebrospinal fluid.”“Small pineal cysts may frequently be missed on CT imaging because they have the same attenuation as cerebrospinal fluid.”
  • Text changed: “The gold standard for diagnosis is MRI. In the native T1 sequence, signal intensity can vary depending on the protein content of the cyst fluid and appear isointense to slightly hyperintense compared to cerebrospinal fluid . In the T2 sequence, a hyperintensity is often seen. In the T1 sequence with contrast agent, an enhancement in the cyst wall of up to a maximum of 2 mm can be seen in some cases. Nodular irregularities with contrast agent uptake may indicate another space-occupying lesion[^2].”“MRI is the gold standard for diagnosis. On noncontrast T1-weighted sequences, the signal intensity may vary depending on the protein content of the cyst contents and may appear isointense to slightly hyperintense compared with Cerebrospinal fluid . On T2-weighted sequences, Hyperintensity is commonly seen. On contrast-enhanced T1-weighted sequences, enhancement of the cyst wall up to a maximum of 2 mm may be seen in some cases. Nodular irregularities with contrast enhancement may indicate a different mass lesion[^2].”
  • Text changed: “Asymptomatic Pineal Cysts”“Asymptomatic pineal cysts”
  • Text changed: “In asymptomatic pineal cysts with a diameter of less than 2 cm and a typical imaging appearance with a wall thickness ≤ 2 mm and without irregularities or nodular contrast agent uptake, it is assumed that they do not show growth[^2]. However, the natural course cannot be predicted with certainty. In adults, the risk of cyst growth is about 4% at 6 months follow-up[^3] and in children about 11% at 10 months follow-up[^4]. Based on these data, it should be considered to conduct an early follow-up imaging after a few months of initial diagnosis[^2] to rule out rapid growth and subsequently increase the follow-up control interval.”“Asymptomatic pineal cysts with a diameter of less than 2 cm and a typical imaging appearance, with a wall thickness ≤ 2 mm and without irregularities or nodular contrast enhancement, are not expected to show growth[^2]. However, the natural course cannot be predicted with certainty. In adults, the risk of cyst growth is approximately 4 % at 6-month follow-up[^3], and in children approximately 11 % at 10-month follow-up[^4]. Based on these data, early follow-up imaging a few months after the initial diagnosis should be considered[^2] to rule out rapid growth and subsequently increase the follow-up interval.”
  • Text changed: “Symptomatic Pineal Cysts”“Symptomatic pineal cysts”
  • Text changed: “Pineal cysts can present symptomatically with hydrocephalic symptoms such as headaches, nausea, vomiting, and lethargy[^6]. It may also lead to papilledema, Parinaud syndrome or visual impairments[^6] [^7].”“Pineal cysts may become symptomatic with hydrocephalus-related symptoms such as headache, nausea, vomiting, and lethargy[^6]. Papilledema, Parinaud syndrome , or visual impairment may also occur[^6] [^7].”
  • Text changed: “Surgical Treatment”“Surgical treatment”
  • Text changed: “Surgical intervention is usually only necessary in extremely rare cases when the pineal cyst leads to an obstruction of cerebrospinal fluid flow and a consequent hydrocephalic buildup, or to symptoms such as headaches or visual disturbances[^8]. In symptomatic pineal cysts, surgical intervention is the therapy of choice[^2]. Pineal cysts can be resected, for example, via an infratentorial supracerebellar approach [^5] [^11].”“Surgical treatment is generally necessary only in extremely rare cases when the pineal cyst obstructs cerebrospinal fluid outflow, resulting in hydrocephalus, or causes symptoms such as headache or visual disturbances[^8]. In symptomatic pineal cysts, surgical intervention is the treatment of choice[^2]. Pineal cysts may, for example, be resected via an infratentorial supracerebellar approach [^5] [^11].”

Article created on · Alaric Steinmetz

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