Clinical implications of pineal cyst resection in the absence of hydrocephalus or clear neurological signs: a case series.

Background: Pineal cysts are benign lesions found in 1-4% of the population. While surgery is indicated for patients with symptoms related to hydrocephalus or signs of tectal compression, most patients present with non-specific symptoms such as headaches, psychiatric disturbances, sleep dysregulation, dizziness, and fatigue, among others, where the role for surgery remains unclear. Although the etiology of these symptoms is not fully understood, the habenula, which is anatomically and functionally linked to the pineal gland, may contribute to these symptoms through its role in circadian rhythms, pain modulation, and neurotransmitter regulation.

Methods: We retrospectively reviewed patients who underwent pineal cyst resection at our center between January 2020 and December 2024. Patients presenting with hydrocephalus or concomitant conditions were excluded.

Results: Seven female patients (median age 27, range 19-42) were analyzed. The most common preoperative symptom was headaches, present in all patients, followed by fatigue, dizziness, memory problems, and psychiatric symptoms. Postoperatively, 85.7% (6/7) had complete headache resolution, while one (14.3%) had partial relief. Cognitive symptoms, including memory and concentration problems, improved in 66.6% (2/3) of cases, and psychiatric symptoms improved in 66% (4/6). The median follow-up was 24 months, with no new neurological deficits at the final follow-up.

Conclusions: Surgical resection can lead to significant improvements in non-specific symptoms including headaches, psychiatric disturbances, and cognitive issues in a subset of pineal cyst patients with severe refractory symptoms. These findings support the role of surgical intervention for such carefully selected patients and highlight the need for further investigation into the pathophysiology of these symptoms.