Surgical Resection of Pineal Cyst for Intractable Headache: An Evolving Concept?

Background Pineal cysts are remarkably common entities and are largely asymptomatic. Increasingly, a small subset of patients with pineal cysts is appreciated to have intractable headache as the primary symptom, without associated hydrocephalus or tectal compression leading to Parinaud’s syndrome, and may experience lasting headache control with surgical resection of the pineal cyst. We present the indications, surgical considerations, pathology, and outcomes in a series of pineal cyst patients with intractable headaches and explore the potential pathophysiology of headache in this context.

Methods We retrospectively reviewed the history, surgical considerations, and clinical outcome for five patients (four females and one male; mean age of 38 years) who underwent surgical resection of pineal cysts for intractable headache. We further analyzed the evolution in surgical technique for this pathology and indication for surgery. We also reviewed the pathologic material in these cases.

Results Mean duration of symptoms prior to surgery was 49 months. All patients failed to achieve adequate control of pain after multiple headache medications and had been evaluated by at least one neurologist. Serial MRIs demonstrated stable size of cyst for all patients prior to surgery, with mean cyst size of 10 mm (range: 6–14 mm) in maximal dimension. No case was associated with radiographic evidence of obstructive hydrocephalus; one patient experienced double vision despite lack of overt tectal compression on MRI from her 6 mm cyst. Four cases were performed in the semisitting position, while one patient with a patent foramen ovale was positioned three-quarter prone. Gross total resection was achieved in all cases using microscopic technique in one case, endoscopic-assisted microscopic technique in one case, and a purely endoscopic approach in three cases. In each case, an encapsulated lesion with viscous internal material was encountered. There were no complications. Headache improvement was reported in all patients at a median of 2 weeks, with continued headache control in four patients after an average follow-up of 12 months (range: 2–39 months).

Conclusion Surgery for pineal cysts is usually reserved for instances of hydrocephalus and/or tectal compression, or demonstrated growth over time. In the absence of these scenarios, surgery remains controversial. We present a series of such patients with medically intractable headaches where surgery was undertaken after extensive collaboration with headache neurologists who had agreed on a medically refractory status. The viscous and semisolid nature of the cysts was a surprising finding, rendering complete resection preferable to attempted fenestration and suggesting that, in some patients, these lesions can be pain generators. While the series is small, it also represents an evolution of surgical technique in one center which may be broadly applicable.