Laura L. Hayes, MD, FAAP Nemours Children's Healthcare System Orlando, Florida May 2019

1. INCIDENTALOMAS
IN PEDIATRIC NEUROIMAGING
Laura L. Hayes, MD, FAAP

2. No Disclosures
Tips welcome via PayPal or Venmo

3. Brainless
Application of
Radiological
Findings (makes your patient) a
Victim
Of
Modern
Imaging
Technology Image by ithasnosoul

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!

7. Case 1: 16 year-old girl with headaches

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

17. Case 2: 12 year-old boy with seizures

19. Pars Intermedia/Rathke’s Cleft Cyst

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.

22. For patients 18 years of age or older:

23. Case 3: 4 year-old boy with head trauma

24. Arachnoid Cyst

25. Has remained stable in size over 7 years.

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.

28. Case 4: 7 year-old boy with GHD

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.

32. Case 6: 9 year-old boy with headaches

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

34. Bilateral arachnoid granulations
Worth mentioning if signs
of increased intracranial
pressure
Images courtesy of Dr. T. Chapman

35. Encephalocele in sigmoid venous sinus

36. Case 7: Baby with sacral dimple
• Incidental filar cyst
• Normal variant
• No follow-up
needed

37. Normal ventriculus terminalis and filar cyst
Image courtesy of Dr. T. Chapman

38. Case 8: Toddler with hypotonia

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.