4. Beware the Incidentaloma
• Defined as a result that arises that is outside the original
purpose for which the diagnostic test or procedure was
conducted.
• Rise in advanced imaging has led to rise in number of
incidental findings.
5. “On the cover: Image of
a biopsy of an adenoma,
or benign tumor, in the
pituitary gland of the
brain as seen through a
microscope. Such a
finding can originate
incidentally via a number
of diagnostic imaging
tools. High resolution
imaging can reveal an
incidental pituitary tumor
10% of the time; these
tumors are usually small
and asymptomatic.”
6. Incidental oh no!
• Fear
• Stress
• Time
• Expense
? Contrast
? Sedation
? Radiation
=RISK!
10. Findings:
• 15 mm simple, pineal cyst.
• Otherwise normal study.
• What do you recommend?
11. Options:
A. Do nothing
B. Follow-up in 3 months
C. Follow-up in 6 months
D. Follow-up in 12 months
E. Fenestration
12. Pineal Cysts
• Common! 23% of normal volunteers
in imaging studies
• 25-40% of cadavers in autopsy series
• Female predominance
• Result from degenerative changes in
the gland?
• Typically asymptomatic
• Usually 2-15mm in size
• Typically remain stable over time
13. Pineal Cyst – MRI Characteristics
• Round or oval, thin-walled,
circumscribed
• Fine internal septa/cysts can be
seen with high resolution.
• Typically CSF signal
• May be bright on FLAIR
(proteinaceous)
• C+ of cyst wall common
• Uniform C+ can be seen on
delayed imaging
14. Do not fear that you’ll miss a pineal tumor
• RARE! Less than 0.2% of all intracranial neoplasms.
• Pediatric
• Pineoblastoma
• Germ Cell Tumors
• Both have restricted diffusion
• Adulthood
• Pineocytomas
• Pineal Parenchymal Tumor of Intermediate Differentiation (PPTID)
• Papillary Tumor of the Pineal Region (rare)
• All have enhancing, SOLID components
15. Pineal Cyst - Management
“No evidence to support the recommendation that follow-up
studies should be performed for pineal cysts measuring more
than 1cm… typical pineal cysts found incidentally on MR
imaging may be best followed up on a clinical basis
alone.” (AJR 2001, 50% of subjects are children)
“Routine MRI follow-up of pineal cysts is not necessary in the
absence of unusual radiological characteristics or related
clinical symptoms.” (Neuroradiology 2017, all subjects are
children)
16. Answer:
A. Do nothing
B. Follow-up in 3 months
C. Follow-up in 6 months
D. Follow-up in 12 months
E. Fenestration
No follow-up is necessary
unless the patient becomes
symptomatic
20. Pediatric Pituitary Incidentalomas
• Usually small pars intermedia or Rathke’s
cleft cysts
• Rarely grow, so follow up is not indicated.
• Hyperplastic-appearing gland in teenage
girl also normal.
21. ORIGINAL ARTICLE CLINICAL PRACTICE MANAGEMENT
Management of Incidental Pituitary Findings
on CT, MRI, and 18
F-Fluorodeoxyglucose
PET: A White Paper of the ACR Incidental
Findings Committee
Jenny K. Hoang, MBBS, MHSa
, Andrew R. Hoffman, MDb
, R. Gilberto González, MD, PhDc
,
Max Wintermark, MDd
, Bradley J. Glenn, MDe
, Pari V. Pandharipande, MD, MPH f
,
Lincoln L. Berland, MDg
, David J. Seidenwurm, MDh
Creditsawarded forthisenduringactivityaredesignated“SA-CME”bytheAmericanBoardofRadiology(ABR)andqualify
toward fulfilling requirements for Maintenance of Certification (MOC) Part II: Lifelong Learning and Self-assessment.
To access the SA-CME activity visit https://cortex.acr.org/Presenters/CaseScript/CaseView?CDId¼IA/oVctsmcc%3d.
26. Arachnoid Cysts
• Circumscribed CSF signal collections
• Very common (2% of scans)
• Boys>Girls
• Primary or secondary
• Anterior middle cranial fossa most common
(L>R)
• Large size range
• Usually asymptomatic & incidental
• Most don’t change substantially over time
(especially in children >4 years of age.)
27. Arachnoid cysts
• Treatment indicated if causing clear & specific
neurologic symptoms.
• Mass effect alone not indication for sx.
• Spontaneous rupture of cysts causing subdural
hygroma is uncommon.
• Contact sports may be restricted w/ large cysts.
• Intracystic hemorrhage s/p trauma rare.
• Tx options include endoscopic fenestration, but
depend on location.
29. Cavum Velum Interpositum Cyst
• Incidental finding
• Follow up imaging only if
becomes symptomatic
• Does not need contrast
30. Case 5: 13 year old girl with metastatic work-up
31. Developmental Venous Anomaly
• Usually incidental finding
unless associated w/
cavernous malformation
(seizures).
• Usually no clinical
significance.
• Look for gliosis or
hemosiderin to suggest steal
phenomenon or bleeding.
33. Arachnoid Granulations
• Common filling defects in the transverse and sigmoid venous sinuses
• Also called pacchionian bodies, they are aggregates of fibroelastic
tissue continuous with the subarachnoid spaces where CSF enters
the venous systems.
• Rare venous outlet obstruction
• Occasionally cause bony remodeling/erosion
• Need to differentiate from thrombus
39. Filar Lipoma
• If filum terminale is thickened more than 2mm and fatty, pay attention
to the position of the conus.
• Position of the conus below L2 is suspicious.
• Fatty infiltration of the filum terminale not uncommon & often
discovered incidentally but can be associated w/ cord tethering.
• Look for secondary signs on the scan (scoliosis, syrinx, fecal and
urinary retention.)
• Tethered cord is typically a clinical diagnosis.
40. • We have perspective about the prevalence of the findings, and we know
what is suspicious.
• If it has no bearing on the patient’s symptoms and no clinical significance,
consider confining it to the report’s body or omit.
• If you include it in impression, please give a recommendation.
• Our referring doctors and patients appreciate the guidance.
41. Selected References
• Fakhran S, Escott EJ. Pineocytoma mimicking a pineal cyst on
imaging: true diagnostic dilemma or a case of incomplete imaging?
AJNR January 2008; 29(1):159-163.
• Pastel DA, Mamourian AC, and Duhaime AC. Internal structure in
pineal cysts on high-resolution MRI: not a sign of malignancy. JNS
July 2009; 4(1):81-84.
• Barboriak DP, Lee L, Provenzale JM. Serial MRI of pineal cysts .
Implications for Natural History and Follow-up. AJR 2001;176:737-743.
• Smith AB, Rushing EJ, Smirniotopoulos JG. From the Archives of the
AFIP: Lesions of the pineal region: Rad-Path Correlation.
Radiographics 2010;30(7).
• Maher CO, Piatt JH (Section on Neurologic Surgery). Incidental
findings on brain and spine imaging in children. Pediatrics April
2015;135(4).
42. Selected References
• Al-Holou WN, et al. Prevalence and natural history of arachnoid
cysts in children. J Neurosurg Pediatr 2010 Jun;5(6):578-85.
• Mustansir F, Bashir S, Darbar A. Management of Arachnoid
Cysts: A comprehensive review. Cureus 2018 Apr;10(4):e2458.
• Jafrani R, et al. Intracranial arachnoid cysts: Pediatric
neurosurgery update. Surg Neurol Int 2019;10:15.
• Hoang JK. Incidental findings on imaging: Omit or provide
recommendations. JACR October 2016;13(1):1170.
• Hayward R. VOMIT (victims of modern imaging technology)- an
acronym for our times. BMJ 2003 Jun7;326(7401):1273.
