Pineal cyst of the brain in adults and children

A pineal cyst is a vesicular cavity filled with fluid, namely, a glandular secretion. Such a cavity is not of a tumor nature and, as a rule, is not prone to enlargement and progression. But this is not always the case: depending on the size and location, focal symptoms may appear. Diagnosis is by MRI or neurosonography (for young children). Treatment, depending on the situation, is either not required, or consists in carrying out a surgical operation, which is important when complications develop or a progressive increase in the neoplasm.

Is a pineal cyst of the brain dangerous?

The human brain is represented by the most complex and unique structure. Scientists have been actively studying this organ for many years, but even today, many of its areas and functions are considered a mystery to science. In this case, the most unexplored structure remains the pineal gland, or pineal gland.

The activity of the pineal gland determines the change in rhythms in the human body, such as sleep and wakefulness. In addition, the pineal gland is responsible for the processes of puberty, controls behavioral features, affects homeostasis (for example, regulates the functionality of the cardiovascular apparatus). In general, the main functional directions of the pineal gland are known, but scientists still do not know many details of these processes.

As for the pathologies of the pineal gland, they can be represented by hemorrhages, parasitic diseases and neoplasms of a different nature. At the same time, the pineal cyst is a formation of a non-tumor nature, which develops in one of the lobules. In the vast majority of patients, such neoplasms are small (up to 10-12 mm in size) and do not tend to enlarge (grow).

Most doctors agree that in the absence of any clinical manifestations associated directly with cystic changes (and not with any other pathology), there is no need for global diagnosis and treatment. Nevertheless, repeated monitoring and determination of the cause of the disorder is necessary, since there are nevertheless cases of cystic growth, squeezing of adjacent structures with it, provoking the corresponding somatic and neurological disorders. [1]

Epidemiology

According to statistics, cystic transformation of the pineal gland is found in about 6% of healthy people. In the group of patients in whom such neoplasms were identified, persons suffering from recurrent migraine pains are found with a higher frequency. For example, in a study of fifty patients with a diagnosed pineal cyst, complaints of migraines were voiced by half of the participants (compared with 25% from the other group of people without similar cystic formations).

Pineal gland tumors are rare and account for 1% of all intracranial tumors in adults. However, in children, they amount to 8%. Due to the variety of tumors in this area, characteristics and epidemiology vary greatly. I will describe each according to the 2016 WHO classification. [2]

The dynamic results of magnetic resonance imaging in more than 150 patients with pineal cysts were also investigated. The average age of the participants is 40 years old (from 25 to 55 years old). The dynamics was studied for six months to 13 years. It was found that during this period the growth of neoplasms was practically absent, there were no violations and deviations. A slight increase in size was noted in only four people, while in 23 cases the cysts, on the contrary, decreased. Based on this information, the scientists concluded that asymptomatic pineal cysts in adults do not require regular diagnosis and neurosurgical consultation. A control MRI procedure one year after the detection of the violation is sufficient: in the absence of growth and pathological symptoms, further observation is unnecessary. The widespread use of MRI increases the detection rate of pineal gland cysts (PCs) in clinical neurology. In adults, the prevalence of cysts is 1.1–4.3%.[3]

During follow-up, none of the patients developed any complications from neoplasms.

Pineal cysts are more often diagnosed with:

• in patients aged 20 to 30 years;
• in female patients (about three times more often than in men).

In the overwhelming majority of cases, there is an asymptomatic existence of the pathology, which is discovered by chance, when performing an MRI or CT scan of the brain.

Causes pineal cysts

Scientists have not fully disclosed the reasons for the appearance of a pineal cyst. It is known that most often it is a congenital neoplasm, or is provoked by a disorder of hormonal balance. Also, the causes may be blockage of the outlet channels of the gland and echinococcal infection.

During the MRI, congenital blockage is visualized, symptoms of impaired fluid output are noticeable, which is caused by excessive viscosity of the secretion or tortuosity of the duct. Such a violation rarely poses a danger to the health and life of patients; it does not have a tendency to growth and malignancy.

Parasitic invasion can cause the formation of numerous or large pineal cysts. Defective structures are formed during infection with echinococcus, although such a pathology is relatively rare. Echinococcal cysts develop mainly in people who are engaged in agriculture, raising livestock.

The reasons for the congenital development of the cyst are not fully established. Often the problem is provoked by pathologies of pregnancy, drug, alcohol or nicotine addiction of the mother. In such conditions, the unborn child develops against the background of existing intrauterine hypoxia and intoxication, which has an extremely unfavorable effect on the state of the brain structures. Also, the reasons can be the chronic pathologies of the mother, which are in the stage of decompensation. 

Risk factors

The main factors affecting the occurrence of a pineal cyst include several points. First: a neoplasm can form with blockage or stenosis of the excretory canals of the gland. This can happen:

• after traumatic brain injury;
• with neuroinfections;
• with autoimmune processes;
• with hormonal imbalance;
• with cerebrovascular pathologies.

The second factor is the ingestion of echinococcus into the body. When it penetrates into the tissue of the pineal gland, this parasite forms a capsule, which thus becomes a cystic formation. This type of violation is relatively rare, but it has special risks.

The third factor is excessive blood supply to the pineal gland, which can lead to hemorrhage. [4]

As for congenital cystic neoplasms, they are most often found:

• in children with other intrauterine pathologies;
• with diagnosed fetal hypoxia or trauma during labor;
• in infants with postnatal infectious diseases.

Pathogenesis

What is a pineal cyst made of? Its walls are represented by three layers:

• inner layer of fibrillar glial tissue, often with hemosiderin particles;
• the middle layer - the parenchyma of the pineal gland, may or may not contain areas of calcification;
• thin outer layer of fibrous (connective) tissue.

In many cases, the formation of pineal cysts is caused by hormonal changes, since such neoplasms are often found in young female patients. Such pathological elements at first actively increase and then subside. In male patients, the cyst condition is more stable: intensive growth is usually absent.

The cystic content is represented by a protein substance that differs from the cerebrospinal fluid on tomographic images. Blood may be present.

The cystic walls are prone to active accumulation of contrast. [5]

With the active growth of the neoplasm, it is possible to disrupt the flow of cerebrospinal fluid as a result of overlapping (occlusion) of the cerebrospinal fluid canals, which leads to the development of hydrocephalus.

Symptoms pineal cysts

The overwhelming majority of the detected pineal cysts are small (less than 10 mm in eight out of ten patients), therefore, they do not manifest themselves clinically. If pathological symptoms nevertheless appear, then most often this occurs in female representatives over the age of 35.

Cystic formations with pronounced sizes can exert mechanical pressure on the quadruple plate, which entails squeezing of the upper colliculus and the development of spinal midbrain syndrome (vertical gaze paralysis). If pressure is exerted on the Sylvian canal, which is located in the region of the third and fourth ventricles, then obstructive hydrocephalus may develop.

If intraosseous hemorrhage occurs, then the formation also increases in size: this pathology is called apoplexy of the pineal cyst. [6]

The appearance of such symptoms is possible:

• headache;
• disorders of the organs of vision;
• loss of the ability to translate gaze up and down;
• inconsistency of muscle movements in the absence of muscle weakness (ataxia);
• emotional instability;
• mental impairment;
• dizziness, nausea;
• disorders from hormonal status (delayed puberty, secondary form of parkinsonism, etc.).

First signs

The first signs of a disorder in a pineal cyst can appear only when the formation continues to grow and begins to press on nearby brain structures and vessels.

Symptoms in a similar situation can be represented by the following manifestations:

• Pain in the head, prolonged, frequent, of unknown origin, independent of general well-being, weather conditions, etc.
• Dizziness and nausea, persistent or paroxysmal, sometimes with vomiting.
• Deterioration of visual and auditory function, blurred eyes, double vision.

In severe cases, there may be uncertainty of gait, slurred speech, muscle hypertonia, convulsions, deterioration of orientation on the ground, loss of reading skills, etc. Similar symptoms may be associated with increased intracranial pressure, which is also accompanied by drowsiness, inattention, loss of appetite, disc edema optic nerve.

Acute development of occlusive hydrocephalus, as a complication of the pathological course of cystic neoplasm, manifests itself as signs of increased intracranial pressure. These signs include:

• headache (especially in the morning);
• nausea with vomiting (after vomiting, the headache may decrease);
• severe drowsiness (preceded by a sudden worsening of neurological symptoms);
• stagnant discs of the optic nerves (the condition is provoked by an increase in pressure in the subarachnoid space, as well as a change in the axoplasmic current);
• phenomena of axial dislocation of the brain (depression of consciousness is possible up to a deep coma, oculomotor disorders are found, sometimes a forced position of the head is noted).

With a slow increase in hydrocephalus (chronic course), a triad of signs attracts attention:

• development of dementia;
• violation of voluntary movement when walking (apraxia), or paresis of the lower extremities;
• urinary incontinence (the most late and unstable symptom).

Patients become drowsy, inert, lack of initiative. Short-term memory (especially numeric) suffers. Monosyllabic prevails in speech, often inadequacy.[7]

Pineal cyst of the pineal gland

The pineal area is a complex anatomical area that includes the pineal gland, adjacent brain structures, spinal spaces, and vasculature. The pineal gland is localized behind the third cerebral ventricle, in front and below it is the posterior cerebral commissure, in front and above - the adhesion of the leashes, below - the quadruple plate and plumbing, slightly above and behind - the corpus callosum roller. Directly behind the gland, a quadruple cistern is localized, which forms the cavity of the intermediate sail, lying on top of the pineal gland and going in front below the arch.

The cyst, which is called pineal, in most cases is not large in size and does not manifest itself clinically. A neoplasm occurs in the pineal gland without disrupting its function. Only in rare cases, with active growth, can it block the entrance to the cerebral aqueduct, preventing the circulation of cerebrospinal fluid and causing the development of occlusive hydrocephalus.

Pineal cyst of the brain in adults

The reasons for the development of pineal cysts in adulthood are still unclear. Scientists have voiced several theories that could explain the origin of the violation.

One of these theories involves the formation of a pathological element due to ischemic or degenerative processes in the glial layer. Some experts believe that cystic formations are a consequence of the necrosis of the pineal gland parenchyma. However, the reason for such processes of necrosis is also still not clear. Other theories of scientists are based on the influence of hemorrhages, hormonal changes, etc. Many such neoplasms are congenital in nature, they are simply discovered by chance at an older age.

The overwhelming majority of such cysts (more than 80%) are small in size - their diameter does not exceed 10 mm. These neoplasms are predominantly asymptomatic. Neurological symptoms can appear when such dimensions reach 15 millimeters or more.

Symptomatic cysts are rare. In this regard, experts do not have extensive information on this issue. As a rule, the very appearance of symptoms and their nature reflect the effect of the neoplasm on nearby structures: the midbrain, internal venous vessels, Galen's vein, and visual hillocks. Since the space in this area is extremely limited, it can be expected that even a few millimeters of additional cystic enlargement can cause the appearance of a symptomatic picture, which is most often represented by headache, oculomotor disorders, signs of increased intracranial pressure or the development of hydrocephalus.

Pineal cyst in women

Pineal cysts are found almost three times more often in women than in men. Many experts attribute this to hormonal characteristics. Studies have shown that many cases of such cystic elements began their development during the onset of puberty, but over the years such neoplasms appear less and less. Thus, we can assume the hormone-dependent nature of the emergence and growth of the pineal cyst. Moreover, in women, the development of neoplasms is often associated with such hormonal factors as pregnancy and the monthly cycle.[8]

Pregnancy with pineal cyst

Pregnancy is not a contraindication for a woman who has a pineal cyst that does not manifest itself in any way, with an asymptomatic course and no tendency to increase.

If the patient is diagnosed with hydrocephalus, or she underwent a CSF shunt surgery, then the situation is somewhat different. Pregnancy in such conditions has a lot of risks of complications - for example, there is often a dysfunction of the shunt caused by an increase in intra-abdominal pressure due to the constantly enlarging uterus.

Since the period of pregnancy affects the functional state of the peritoneal-ventricular shunt, doctors have developed a special tactics of medical and obstetric management. During the entire period, up to the postpartum stage, the condition of the expectant mother is carefully monitored, all the necessary diagnostic procedures for monitoring are performed.[9]

Can you give birth with a pineal cyst?

With an asymptomatic neoplasm, childbirth is carried out in the usual manner, taking into account other existing pathologies.

If a peritoneal-ventricular shunt with normal function is present, it is recommended to practice vaginal delivery with a shortened second period. Caesarean section with general anesthesia is indicated for impaired shunt function and increased intracranial pressure.

The method of magnetic resonance imaging is recommended as a safe and effective way to determine the efficiency of the shunt and, in general, to assess the state of the cerebral system of the ventricles. If there is a functional occlusion of the shunt, then drug therapy is carried out, with the obligatory observance of bed rest and manual pumping procedures.

If an increase in the size of the cerebral ventricles is detected, a surgical operation is prescribed. If we are talking about pregnancy in the I-II trimesters, then the operation is performed as if the woman was not pregnant. During the third trimester, alternative methods may be used - in particular, ventriculoatrial bypass grafting or endoscopic triventriculocisternostomy. These methods allow you to prevent the provocation of premature birth and additional trauma to the uterus.

Pineal cyst in a child

When a woman, after examining her child, hears the diagnosis "congenital cyst of the pineal gland of the brain", then this causes not only anxiety, but sometimes fear. Let's say right away that in many cases such a condition is not so much a pathology as an individual feature, therefore it does not pose a danger and does not require treatment.

The formation of such cystic formations can be associated with both infections transferred by a woman during pregnancy, and a complicated course of this period, or complex labor. But more often than not, the reason remains unknown. For the majority of epiphyseal cysts, their further development is not characteristic, and even more so, their transformation into an oncological process.

In infants under one year of age, the presence of such a cyst can be easily determined by ultrasound diagnostics. Children's age up to one year is the most favorable period for performing such a procedure, when the fontanelle is not yet completely closed.

Neurosonography (ultrasound examination of the brain) is especially recommended for premature babies, as well as newborns who, for one reason or another, are undergoing intensive therapy. Difficult childbirth, complicated during pregnancy, intrauterine or intrapartum fetal hypoxia - these are also indications for ultrasound diagnostics.

Experts believe that finding a pineal cyst in a baby should not be a cause for concern. As a rule, such formations do not cause pathology. True, it is advisable to conduct a second study after a while in order to determine the possible dynamics of the process. Most likely, medical supervision may be required for a certain period.

With unfavorable dynamics, if the formation increases, and the pressure of the fluid in it increases, there is a possibility of a change in the position of the surrounding tissues and their compression. A similar violation manifests itself in symptoms such as seizures, neurological symptoms. In severe cases, the process can be aggravated by the development of hemorrhagic stroke. If indicated, such a child will be prescribed a surgical intervention in one of the existing ways: it can be microneurosurgical, bypass or endoscopic surgery.[10]

Pineal cyst in a teenager

Magnetic resonance imaging of the brain can be prescribed for schoolchildren and adolescents, if there is a suspicion of the development of pathology, to diagnose possible painful conditions. For example, an MRI is prescribed for a teenager:

• with age-related developmental disabilities;
• with incomprehensible and sudden behavioral changes;
• with regular dizziness;
• with chronic head pain;
• with constant fainting or light-headedness;
• with increasing deterioration in visual or auditory function;
• with convulsive attacks;
• with neurological symptoms.

In these situations, the diagnosis is mandatory. This allows you to identify not only pathological cysts, but also hemorrhages, hydrocephalus, epilepsy, meningitis and meningoencephalitis, etc.

Why can a congenital cyst form? In the process of cerebral development, the walls of the third ventricle protrude and grow, forming a diverticulum - it is from it that the pineal gland is subsequently formed. If such a formation process is disrupted for any reason, incomplete obliteration may occur, a cavity appears. A small similar deviation does not apply to pathological, treatment is not carried out.[11]

Psychosomatics

Scientists do not exclude the influence of psychological factors on the appearance and growth of neoplasms in the body. This also applies to the pineal cyst. And the point is not that a person thinks about the possibility of getting sick and is afraid of it, but that long-term and strong negative feelings are reflected in the state of the brain cells.

According to the studies, in each of the patients, the onset of the development of any tumor processes in the body was preceded by events accompanied by severe resentment, anger or deep disappointment. From this we can conclude: you can get rid of the problem by neutralizing the internal imbalance.

It is believed that cystic formation is a concentration of feelings of hopelessness, hopelessness. The disease starts from the moment when the patient ceases to believe in his own strength, in his loved ones, is disappointed in humanity as a whole.

According to scientists, the following people most often get sick:

• keeping their feelings to themselves, unable to protect themselves and protect themselves from negativity;
• those who do not love themselves, consider themselves “flawed,” wrong;
• overly emotionally experiencing losses;
• those who are not in contact with their own parents.

Depression and negative emotions begin to put pressure on the immune defense, suppress it, which adversely affects the state of the whole organism, even at the cellular level. Immunity is upset, which entails changes in the structure and functionality of cells.

As a rule, such patterns should be identified by the doctor during the conversation with the patient.

Pineal cyst and insomnia

Sleep can be called a state of complete rest in the body, in which the most optimal conditions are noted for a person to rest and recover. Including, his nervous system must be restored. Muscles relax, all kinds of sensitivity weaken, reflexes are inhibited. However, with some pathologies occurring in the brain, such relaxation is not observed, insomnia occurs, and the quality of sleep is disturbed.[12]

If the pineal cyst is large, then it can really negatively affect the functioning of the nervous system and sleep. The following signs may be noted:

• difficult stage of falling asleep;
• shallow sleep, with restlessness and frequent awakenings;
• early morning awakening.

We are not talking about absolute insomnia: although the patient does not get enough sleep, he sleeps at least about 5-5.5 hours a day. Drowsiness is much more common in patients, especially in the daytime, regardless of the quality of night sleep.

How does pineal cyst affect immunity?

The human brain is directly related to its immune system, since there are two-way functional and anatomical connections between these structures. Therefore, it can be assumed that any pathology of the brain, including the pineal cyst, can affect the functionality of the immune system, and vice versa. However, for such an effect to take place, the cyst must be large enough to exert pressure on nearby tissues. If these sizes are insignificant, then immunity is unlikely to suffer: this is the opinion of doctors.

The cyst is not a tumor, therefore it does not cause suppression of the immune defense, in contrast to malignant primary and metastatic tumor processes in the brain.

Complications and consequences

The vast majority of patients with pineal cyst do not have any serious consequences and complications. The probability of a malignant transformation is almost zero.

The degree of intensity of symptoms is directly dependent on the size of the formation: for example, cysts up to 10 mm in diameter almost always proceed without any pathological signs.

Large cysts can cause certain complaints - for example, migraine headaches, double vision, lack of coordination, nausea, indigestion, fatigue and drowsiness. If such complaints are present, then the patient is prescribed a series of diagnostic tests (MRI, biopsy, detailed blood count). The main purpose of such a diagnosis should be to determine the etiology of the disorder and differentiate with a malignant tumor. The development of hydrocephalus, a pathology that occurs as a result of the release of cerebrospinal fluid from the subarachnoid space, is also considered to be a threatening condition. Lethargy can be another rare complication in isolated patients.

As a rule, conservative treatment is not capable of resolving the pineal cyst. The only exception is the early stage of a parasitic neoplasm.

Surgical intervention is not prescribed if the cyst does not increase and there are no symptoms. [13]

With a pronounced size of the cystic formation, hydrocephalus may develop - a complication due to compression or complete crushing of the sylvian aqueduct. Almost half of the patients referred for surgical treatment had hydrocephalus, which in turn was triggered by intracystic hemorrhage. In addition, there is evidence of isolated cases of syncope and sudden death, which occurred at the time of a sharp blockage of the entrance to the brain aqueduct by a cyst.

With increasing hydrocephalus and the development of dislocation syndrome, the patient's consciousness is quickly depressed, up to a deep coma. There are oculomotor disorders. Compression processes lead to rapid respiratory depression and cardiovascular activity, which, if no assistance is provided, can lead to the death of the patient.

Diagnostics pineal cysts

The main diagnostic method for determining the pineal cyst is magnetic resonance imaging. However, in some cases, doctors have to use other diagnostic techniques - for example, if the neoplasm is large and accompanied by complex clinical symptoms, or if there is a need for differential diagnosis.

The primary stage is a consultation with a neurologist, passing tests and tests to check reflexes, the degree of skin sensitivity, to assess motor ability. If the patient notes a violation of visual function, then he is recommended to consult an ophthalmologist.

Instrumental diagnostics can include the following technical procedures:

• Electroneurography is a specific type of study to assess the conduction velocity of an electrical impulse along peripheral nerves. The procedure allows you to determine the degree of nerve damage, as well as the distribution and form of the pathological process. This method requires some preparation of the patient: on the eve of the diagnosis, one should not take sedatives, smoke and drink alcohol and coffee.
• Computed tomography is one of the types of X-ray examination, which involves layer-by-layer visualization of the required area of the brain. In some cases, it can serve as an analogue of MRI.
• Electromyography is a study of the functionality of the nerve tissue, which helps to assess the extent of nerve damage and determine the violation of the motor neuron.
• Echoencephaloscopy is one of the harmless ultrasound methods that allows you to assess the state of the functional and anatomical structures of the brain.
• Lumbar puncture - is performed to remove particles of the cerebrospinal fluid and further study it for the presence of atypical cells.

Laboratory research includes:

• general clinical tests of blood and urine;
• blood for tumor markers.

A blood test for a pineal cyst is not decisive: it is done mainly to assess the general condition of the body, since its results show signs of inflammation (increased ESR and leukocyte levels) and anemia (decreased hemoglobin levels).

Pineal cyst on MRI

The classic version of the pineal cyst is usually small (up to 10 mm) and one chamber. The diameter of an asymptomatic formation can reach 5-15 mm, and symptomatic cysts sometimes increase even up to 45 mm, almost completely replacing the pineal gland.

Every practicing radiologist knows what a pineal cyst looks like on MRI: such a neoplasm is voluminous, with liquid contents, with clear configurations. Peripheral calcifications are often present (in about every fourth case). In many patients, the image shows a peripheral contrast accumulation that looks like a thin and even "border". The cyst can change the location of the course of the internal cerebral venous vessels, pushing them up.[14]

The following typical signs are noted:

• T1 weighted images:
  • the typicality of an iso-intensive or hypointense signal compared with the brain parenchyma;
  • in more than half of cases, the signal is hyperintensity compared with cerebrospinal fluid;
  • uniformity of the signal.
• T2 weighted images:
  • high signal intensity;
  • lower intensity compared to cerebrospinal fluid.
• FLAIR:
  • high signal intensity, often not completely suppressed.
• DWI / ADC:
  • no diffusion restriction.
• T1 weighted images with contrast enhancement (contrast medium with gadolinium):
  • more than half of the cystic formations accumulate contrast;
  • the contrast accumulates mainly in the form of a refined (less than a couple of millimeters) and an even border (full or partial);
  • there is a possibility of diffuse contrast enhancement of the intracystic fluid by substances with gadolinium in the distant phase (1-1.5 h), as a result of which the neoplasm becomes similar to a solid volumetric element;
  • sometimes it is possible to detect atypical nodal contrast enhancement, or to determine the signs of intracystic hemorrhage.

A small pineal cyst less than 10-12 mm in size on MRI or CT looks like a single-chamber fluid formation, with the density of cerebrospinal fluid, or with the same signaling activity. Peripheral contrast enhancement is characteristic of the predominant number of cysts, and a band of calcifications ("border") is observed in approximately every fourth case.[15]

Single cysts on the pineal gland are often found accidentally during computed tomography or magnetic resonance imaging when diagnosing other pathologies from the side of the brain. In most cases, such formations are not dangerous. However, the doctor must necessarily find out not only the location and size of the pathological element, but also whether it is consistent with those neurological symptoms that are present in the patient.

Multicameral cyst of the pineal gland is characteristic of cerebral echinococcosis. This pathology can be presented in several varieties:

• solitary type, in which a single cyst of sufficiently large diametrical sizes is formed in the brain - up to 6 cm;
• racemose type, characterized by the formation of numerous conglomerates of cysts in the form of clusters.

In this situation, MRI becomes the defining diagnostic procedure. It is important to exclude an arachnoid cyst, cerebral cysticercosis, epidermoid cyst, intracranial abscess, and neoplastic processes.

An intraparenchymal cyst of the pineal gland is a formation that develops in the parenchyma of the pineal gland and is localized in the posterior parts of the third ventricle (the same pineal region that we mentioned). Such a neoplasm should be differentiated from pineocytoma, pineoblastoma and other parenchymal tumors of the pineal gland. MRI allows you to determine the disease in this case.

Differential diagnosis

A pineal cyst, especially with nodular contrast enhancement, is virtually indistinguishable from a cystic pineocytoma based on imaging techniques alone. In the area of localization of the pineal gland, other neoplasms can also develop - in particular, the disease should be differentiated with a papillary tumor, germinoma, embryonic cancer, choriocarcinoma, teratoma, arachnoid and epidermoid cysts, aneurysm of the Galen's vein, as well as metastatic brain tumors from others foci in the body.

Of course, these cases are rare. However, the results of computed tomography or magnetic resonance imaging should be shown to a qualified neuroradiologist - to assess the degree of risk and identify the disease.

Treatment pineal cysts

For the vast majority of patients, there is no need for pineal cyst treatment. Small neoplasms also do not require further regular follow-up observation, except for one repeated observation - 12 months after the first detection of pathology.

Large elements, which are accompanied by severe pathological symptoms and pose a danger to the patient, are not left untreated: they use stereotaxic removal of the neoplasm, aspirate the liquid contents, create messages with the cerebrospinal spaces, and shunt. If the pineal cyst recurs, radiation therapy is prescribed.

If the education has a tendency to increase, then the patient is continued to be observed. If the growth of the pathological element has stopped, then the observation is continued for another three years.

An unconditional indication for surgical treatment is the development of occlusive hydrocephalus and Parino syndrome. Approximately 15% of patients are offered surgery if such painful signs as persistent dizziness, trembling in the limbs, bouts of nausea and vomiting, impaired sensitivity and motor abilities, and paroxysmal loss of consciousness appear. Some experts believe that a pineal cyst can provoke a transient obstruction of the sylvian aqueduct, which is manifested by pain in the head or clouding of consciousness, especially against the background of a change in body position or with a sharp change in activity.

Although headache is becoming the most common factor driving people to seek medical attention, it may be the only symptom of a cystic disorder. Most doctors (including neurosurgeons) do not associate the presence of a cyst with the appearance of a headache, provided there is no hydrocephalus. It is indicated that severe headaches can also be explained by central venous hypertension.

Physiotherapy is usually not used for pineal cysts. [16]

Medicines

At the moment, no single tactics for treating patients with a diagnosed pineal cyst in the absence of hydrocephalus and functional disorders of the midbrain has been determined. Most likely, this is due to the lack of complete information about the natural course of the process: many nuances of the origin and development of cystic formation are unknown, the reasons for its increase have not been disclosed, the relationship between the presence of a cyst and the existing clinical picture is not always established. Not all surgeons recommend surgery to patients with nonspecific symptoms, and the effectiveness of drug therapy is also controversial. Medicines are prescribed exclusively as symptomatic therapy, depending on clinical indications:

Ibuprofen	Non-steroidal anti-inflammatory drug with analgesic effect. It is prescribed for a period of up to 5 days, 1-2 tablets every six hours. A longer course of treatment or exceeding the dosage may negatively affect the state of the digestive system.
Vasobral	Vasodilating drug that improves blood circulation and metabolism in the brain. Is taken orally, with food, 2-4 ml twice a day. The duration of the treatment course is up to 3 months. Possible side effects include nausea and dyspepsia.
Picogam	Nootropic drug with antiplatelet, tranquilizing, psychostimulating and antioxidant effects. It is taken orally, regardless of food intake, 0.05 g three times a day, for 4-8 weeks. A second course is possible in about six months. Possible side effects: allergies, slight nausea, irritability, anxiety.
Topiramate	Anticonvulsant drug with antimigraine activity. Treatment begins with the lowest possible dosage, gradually increasing until the desired effect is achieved. The frequency and duration of treatment are determined individually. Possible side effects: loss of appetite, irritability, trembling fingers, disturbed sleep, coordination and concentration.
Paracetamol	Analgesic and antipyretic. Take 1-2 tablets orally up to 4 times a day, preferably no longer than three days in a row. Side effects: allergies, nausea, abdominal pain, anemia.

Herbal treatment

If a patient develops a number of neurological symptoms against the background of a pineal cyst, then in such a situation, one should not rely on alternative methods of treatment. The fact is that similar symptoms, such as memory loss, bilateral visual impairment, muscle weakness, can be the result of processes that are dangerous to human life. Therefore, it is better to consult a doctor and follow his recommendations.

Medicinal herbs can be used to eliminate headaches, nausea, and to improve cerebral circulation.

• Echinacea extract stimulates metabolic processes in the brain, prevents complications. It is recommended to take echinacea for at least four weeks.
• Fresh burdock juice has a positive effect on blood circulation, strengthens cerebral vessels, and optimizes nerve conduction. The sap survives from the leaves, previously washed in running water. They drink it on an empty stomach, in the morning and evening, 1 tbsp. L., until a persistent improvement in well-being.
• Medicinal herbal collection is prepared from the plant immortelle, chamomile color, yarrow, calamus rhizome, calendula, St. John's wort and mint. All ingredients are taken in equal amounts. One tablespoon of the mixture is poured into a thermos with boiling water (400 ml), kept for one and a half hours, and then filtered. Take 100 ml 4 times a day half an hour before meals.

It must be remembered that treatment with alternative means is always long-term: it is important to immediately tune in to several weeks or even months of daily herbal medicine.

Surgery

Since drug treatment for pineal cyst is prescribed only for symptomatic purposes, the only radical method of getting rid of the problem is the surgical route. They turn to the help of a surgeon if the formation continues to grow, signs of hydrocephalus appear or complications in the form of bleeding, rupture, compression of brain structures. The neurosurgeon decides which method of surgical treatment to choose, depending on the situation.[17]

If the patient is admitted with impaired consciousness (coma or stupor status), then he is urgently sent for external ventricular drainage. This procedure helps to relieve the degree of compression of the brain structures and normalize intracranial pressure. A ruptured cyst or hemorrhage becomes a direct indication for surgical intervention. The patient undergoes cranial trepanation and excision of the neoplasm.[18]

If there are no complications, no impairment of consciousness, then the operation is prescribed in a planned manner, using endoscopic access. The main "advantage" of such an intervention is a quick recovery stage and relatively low trauma. During the endoscopic approach, the surgeon makes a milling hole in the cranial bone through which fluid is aspirated from the cavity. To prevent further accumulation of liquid secretion in the cavity, several holes are made to connect with the cerebrospinal space, or a cystoperitoneal bypass procedure is performed (with the installation of a special shunt).[19]

The postoperative stage consists in rehabilitation treatment, the appointment of exercise therapy, manual and reflexology. The patient is prescribed medications that improve blood circulation in the brain, as well as decongestants and absorbable drugs.

Pineal cyst removal

Today, the use of the latest technologies makes it possible to remove brain cysts using endoscopic methods that do not require opening the skull. Minimally invasive interventions do not entail violations of the integrity of the brain, completely exclude infection, reduce the risk of complications, and facilitate the recovery period. Unscheduled interventions can be performed on patients who are in a coma or stupor. It is possible to promptly lower the intracranial pressure and eliminate the compression of the brain structures. 

The following operating techniques can be used:

• Brain bypass surgery is performed to restore cerebrospinal fluid circulation, impaired due to cystic formation. The neurosurgeon uses a drainage tube made of self-absorbable material to allow fluid to drain.
• Endoscopic surgery allows you to remove the cyst through small punctures or transnasally (through the nose). The use of an endoscope with microsurgical instrumentation and an optical sensor helps to penetrate deeply located areas to perform the required manipulations.
• Drainage of the cyst helps to ensure the release of fluid if surgery is contraindicated for the patient for any reason.
• Radical cyst resection with craniotomy.

The optimal surgical method is selected by the attending physician. Radiosurgery such as gamma knife, cyber knife, or radiation therapy are usually not performed. Such methods can only be used to remove a cyst-like tumor in the pineal zone.[20]

Today, there is a clear tendency to improve the operations performed: this is necessary not only for the effectiveness of treatment, but also to reduce the scale of surgical trauma. Endoscopic surgery is fully suitable for this purpose.[21]

Clinical facilities currently use the following technologies for patients with pineal cysts:

• Transnasal (through the nose) endoscopic neurosurgery is practiced in specialized surgical conditions with a variable illumination spectrum, additional monitors for each of the surgeons. The intervention is carried out through the nasal passages using a special neuronavigation system that allows you to fully control the location of the instrumentation in the area of the operating field, as well as the position of vital anatomical structures (arterial trunks, optic nerves, etc.). All this helps to perform the operation without further adverse postoperative consequences. Such an intervention is safe for the patient and significantly shortens the duration of inpatient treatment compared to other surgical techniques.
• Ventricular endoscopy is performed in the area of the ventricles of the brain using special high-tech equipment. During the operation, the neurosurgeon has the opportunity to qualitatively examine the internal cerebral cavities, revise the cyst and radically remove it. Ventricular endoscopy is prescribed for congenital and acquired cystic neoplasms, for hydrocephalus with occlusion at the level of the third ventricle, cerebral aqueduct, and fourth ventricle.
• Transcranial endoscopy involves the use of a neuroendoscope. The intervention is carried out by means of a mini-access in the form of a cosmetic skin incision with a trepanation window of no more than 20-25 mm. This technology can significantly reduce brain injury with optimal visualization of the painful area, as well as perform the intervention with minimal blood loss. An additional "plus" is an excellent cosmetic result.

Prevention

Acquired forms of pineal cysts are most often the result of inflammatory processes, trauma, vascular and infectious pathologies. Therefore, it becomes clear that only correct and timely treatment of all kinds of diseases and traumatic injuries can be the optimal prevention of the development of cystic formations in the brain. In the course of treatment of inflammatory, infectious and vascular pathologies, one should not forget about resorption and neuroprotective therapy.

To prevent the development of congenital cysts, it is necessary:

• correct pregnancy management;
• adequate management of labor;
• prevention of fetal hypoxia;
• prevention of the development of placental insufficiency;
• explanatory work with expectant mothers, pregnant women regarding the need to maintain a healthy lifestyle;
• prevention of intrauterine infection;
• prohibiting a pregnant woman from taking certain medicines;
• special control with a negative Rh factor in the expectant mother.

Forecast

The overwhelming majority of cases of pineal cysts have a favorable prognosis: it was found that in 70-80% of patients, such neoplasms do not increase or even decrease in size during the life period.

Experts note that in the absence of symptoms associated with the presence of a pineal cyst, no therapeutic and surgical measures should be taken. Periodically - about once every three years - you can perform control diagnostics in the form of computed tomography or magnetic resonance imaging. However, this is not always necessary: in the absence of education growth, it is sufficient to observe patients only in the clinical spectrum. [22]

Magnetic resonance imaging is necessary if the cyst has diametrical dimensions exceeding 10-12 mm: in such a situation, the pathology should be diagnosed with cystic pineocytoma.

Disability

By itself, the pineal cyst cannot be the basis for setting a patient with disability. In order for a person to be recognized as disabled and assigned an appropriate disability group, he must have persistent (that is, those that do not lend themselves to either conservative or surgical treatment) and obvious violations of the body's functionality.

As a rule, minor disorders in the form of migraines, visual impairment do not become grounds for assigning a disability group.

A patient is recognized as disabled if, as a result of a pineal cyst, he develops the following persistent symptoms:

• epileptic seizures;
• movement disorders in the form of para-, hemi and tetraparesis;
• severe disorders of the pelvic organs (for example, urinary and / or fecal incontinence);
• severe disorders of the vestibular apparatus;
• progressive mental disorders;
• bilateral deterioration (loss) of auditory function, bilateral pronounced deterioration (loss) of vision.

The assessment of the presence or absence of signs of disability (indications for the installation of disability) in a patient is carried out only at the end of the necessary treatment course, and not earlier than 4 months after the start of treatment (or not earlier than 4 months after the surgery).

Pineal cyst and the army

Pineal cyst in the overwhelming majority of cases does not cause concern: seizures, pain, auditory and visual disturbances are extremely rare. A cyst is not a cancer. Therefore, in order to determine the suitability of a conscript for military service, doctors need to assess the functional ability of the body, the severity of the disorders (if any). For example, they will carefully study all possible emotional, mental, neurological and other clinical abnormalities.

If, during an MRI scan, a pineal cyst was found in a patient, but at the same time it does not manifest itself clinically (does not bother), then for this pathology the conscript is considered fit for military service - with only some restrictions regarding the type of troops. If the neoplasm demonstrates moderate or severe disorders of the nervous system, then the young person has the right to count on being exempt from the draft. An appropriate category is assigned if damage to the nervous system is proven.