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Most studies rely on cyst size or morphology as surgical criteria. This study aims to assess clinical-radiological correlations and outcomes in a consecutive single-center cohort, and to compare outcomes across microsurgical, endoscopic, and stereotactic approaches.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      A retrospective analysis was performed on 46 symptomatic PC patients treated between 2008 and 2024. Clinical data and radiological data, including cyst dimensions, third ventricle-mesencephalic angle, aqueduct diameter, and predominant expansion were analyzed. Patients were categorized into surgical (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200918) and non-surgical (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200928) cohorts. Surgical outcomes were assessed using the Chicago Chiari Outcome Scale (CCOS) at 3-month, 12-month, and long-term follow-up. Statistical comparisons were conducted to correlate radiological markers with symptoms and postoperative outcomes.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Headache was the most common symptom in both groups (80%), followed by visual disturbances in the surgical group (33%), and vertigo in the non-surgical group (32%). Compared with the non-surgical cohort, the surgical patients had larger cysts, narrower aqueducts (0.9 vs. 1.6\u00a0mm,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001) and a higher prevalence of predominant anterior expansion (67% vs. 7%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). Among all operated patients, 94% achieved good or excellent CCOS outcomes at 12-months, and 93% maintained these outcomes at long-term follow-up (mean 62\u00a0months, range 16\u2013216\u00a0months). Neither PC volume nor hydrocephalus predicted consistently postoperative outcome. Microsurgical resection (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200912) achieved favorable long-term outcome (mean CCOS 14.9), but the highest complication rate (3 patients) and the highest recurrence of headache despite total PC excision. Endoscopic fenestration with ventriculostomy (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20093) yielded the best long-term outcome (mean CCOS 15.7) with no recurrences. Stereotactic drainage with a catheter with a Rickham reservoir placement (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20093) provided stable decompression but lower CCOS scores at long-term (mean CCOS 13.0) compared with other approaches.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Surgery for symptomatic PC provides durable improvement when guided by radiological-clinical criteria. Aqueduct diameter was more closely associated with outcome than PC size. Microsurgical, endoscopic, and stereotactic approaches each have specific roles that should guide individualized treatment.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00701-026-06845-z","type":"journal-article","created":{"date-parts":[[2026,3,25]],"date-time":"2026-03-25T22:16:01Z","timestamp":1774476961000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Pineal cyst surgery beyond morphology: a critical evaluation of a consecutive surgical series"],"prefix":"10.1007","volume":"168","author":[{"given":"Filipe Wolff","family":"Fernandes","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Assel","family":"Saryyeva","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Elvis J.","family":"Hermann","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Makoto","family":"Nakamura","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Joachim K.","family":"Krauss","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2026,3,25]]},"reference":[{"issue":"11","key":"6845_CR1","first-page":"298","volume":"122","author":"M Al Mutawa","year":"2025","unstructured":"Al Mutawa M, Lange I, Kirsch M, Fl\u00f6el A, Fleck S, Schroeder HWS (2025) Symptomatic pineal cysts without ventricular enlargement: diagnosis and treament. 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