BACKGROUND: To examine published data and assess evidence relating to safety and efficacy of surgical management of symptomatic pineal cysts without hydrocephalus (nhSPC), we performed a systematic review of the literature and meta-analysis. METHODS: Following the PRISMA guidelines, we searched Pubmed and SCOPUS for all reports with the query 'Pineal Cyst' AND 'Surgery' as of March 2021, without constraints on study design, publication year or status (PROSPERO_CRD:42,021,242,517). Assessment of 1537 hits identified 26 reports that met inclusion and exclusion criteria. RESULTS: All 26 input studies were either case reports or single-centre retrospective cohorts. The majority of outcome data were derived from routine physician-recorded notes. A total of 294 patients with surgically managed nhSPC were identified. Demographics: Mean age was 29 (range: 4-63) with 77% females. Mean cyst size was 15 mm (5-35). Supracerebellar-infratentorial approach was adopted in 90% of cases, occipital-transtentorial in 9%, and was not reported in 1%. Most patients were managed by cyst resection (96%), and the remainder by fenestration. Mean post-operative follow-up was 35 months (0-228). PRESENTATION: Headache was the commonest symptom (87%), followed by visual (54%), nausea/vomit (34%) and vertigo/dizziness (31%). Other symptoms included focal neurology (25%), sleep disturbance (17%), cognitive impairment (16%), loss of consciousness (11%), gait disturbance (11%), fatigue (10%), 'psychiatric' (2%) and seizures (1%). Mean number of symptoms reported at presentation was 3 (0-9). OUTCOMES: Improvement rate was 93% (to minimise reporting bias only consecutive cases from cohort studies were considered, N = 280) and was independent of presentation. Predictors of better outcomes were large cyst size (OR = 5.76; 95% CI: 1.74-19.02) and resection over fenestration (OR = 12.64; 3.07-52.01). Age predicted worse outcomes (OR = 0.95; 0.91-0.99). Overall complication rate was 17% and this was independent of any patient characteristics. Complications with long-term consequences occurred in 10 cases (3.6%): visual disturbance (3), chronic incisional pain (2), sensory disturbance (1), fatigue (1), cervicalgia (1), cerebellar stroke (1) and mortality due to myocardial infarction (1). CONCLUSIONS: Although the results support the role of surgery in the management of nhSPCs, they have to be interpreted with a great deal of caution as the current evidence is limited, consisting only of case reports and retrospective surgical series. Inherent to such studies are inhomogeneity and incompleteness of data, selection bias and bias related to assessment of outcome carried out by the treating surgeon in the majority of cases. Prospective studies with patient-reported and objective outcome assessment are needed to provide higher level of evidence.

Centre for Minimally Invasive Neurosurgery Prince of Wales Hospital Sydney NSW Australia

Department of Clinical Neurosciences University of Cambridge Cambridge UK

Department of Neurosurgery Addenbrooke's Hospital University of Cambridge Cambridge UK

Department of Neurosurgery and Neurooncology 1St Faculty of Medicine Charles University Military University Hospital U Vojenske Nemocnice 1200 Prague 6 Czech Republic

Department of Neurosurgery B Pierre Wertheimer Neurological and Neurosurgical Hospital Hospices Civils de Lyon 59 Boulevard Pinel 69394 Lyon Cedex 03 France

Department of Neurosurgery Cairo University Cairo Egypt

Department of Neurosurgery Greifswald University Medicine Greifswald Germany

Department of Neurosurgery Helsinki University Hospital University of Helsinki Helsinki Finland

Department of Neurosurgery Military Institute of Medicine Warsaw Poland

Department of Neurosurgery Oslo University Hospital Rikshospitalet Nydalen Postboks 4950 0424 Oslo Norway

Department of Neurosurgery University of Heidelberg Heidelberg Germany

Department of Physiology Development and Neuroscience University of Cambridge Cambridge UK

Faculty of Medicine University of Oslo Oslo Norway

Institute of Clinical Medicine Faculty of Medicine University of Oslo Oslo Norway

Juha Hernesniemi International Center for Neurosurgery Henan Provincial People's Hospital Zhengzhou China

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