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Dr. Frank
Dr. Frank, Board Certified Physician
Category: Neurology
Satisfied Customers: 8999
Experience:  Board certified general Adult Neurologist, with experience in experimental neuroimaging and neurodiagnostics.
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I have been offered an endoscopic approach to removing a

Customer Question

I have been offered an endoscopic approach to removing a small pineal cyst that is causing compression of the tectal plate and superior colliculus. My symptoms are double vision blurred vision, vertigo, tinnitus, headache and fatigue. I am wondering if you can provide me with another opinon.
Submitted: 7 months ago.
Category: Neurology
Expert:  Dr. Phil, MD replied 7 months ago.
Thanks for this questionI am wondering if radiation or gamma knife was offered.This is a viable option to shrink the cyst.
Customer: replied 7 months ago.
No, it was not offered, i was told depending on the image, the cyst is 8-10mm is size. I have attached the image i was shown by the doctor. Can you verify the presence of the pineal cyst?
Customer: replied 7 months ago.
im sorry that us the wrong image
Customer: replied 7 months ago.
Attached is the correct image.
Expert:  Dr. Phil, MD replied 7 months ago.
Yes, I canask your doctor about itthey should be able to refer you for radiation or gamma knife evaluation
Expert:  Dr. Frank replied 7 months ago.
Hello Welcome to JA. I am a board certified Adult Neurologist and can answer your question. Do you want to go through this image, I can tell you where the lesion is. do you also have any additional images? Dr Frank
Expert:  Dr. Frank replied 7 months ago.
To find the cyst, you start at the triangular dark shape just in front of the cerebellum, that large area at the back of your brain that functions in balance. can you find that? Dr frank
Expert:  Dr. Frank replied 7 months ago.
You need to pull out the other images that are in the horizontal plane if you wish to see the impression upon the tectal plate, the collicular fibers, do you have those? If you want me to review your entire scan, you can upload the CD in Dropbox, and then return with your link to the upload, and I can then review the images and explain them to you. Just let me know thanks Dr frank
Expert:  Dr. Frank replied 7 months ago.
I will also put out the phone option box if you want to go through this on the phone. JA charges extra, but if you wish, just put your number into the offer box, and a time to call if not now. You can upload the entire image file and we can discuss that as well so you understand your situation. Let me know if interested Dr Frank
Customer: replied 7 months ago.
I am trying to upload the folder from that image series, but the file is large
Expert:  Dr. Frank replied 7 months ago.
HI From that one image you posted, can you see the cyst in question? I can direct you to it. you start with the fourth ventricle, that triangular area, and move up. You will see a dark channel (that is the aquaduct of Sylvius) above that is the tectal plate (superior and inferior colliculus) there should be two bumps but one is compressed slightly, the superior, by this oblong mass with a little whitish (fluid) inside it. That is the pineal cyst. Do you see it? let me know Dr frank
Customer: replied 7 months ago.
yes, i see that thank you, ***** ***** another way to upload the cd images?
Expert:  Dr. Frank replied 7 months ago.
The way we have here is to use Dropbox (many of the clients have done this with me) and then come back with the URL address. You can also go to Google Drive, and upload it, then come back with your user name and password, and I can look at it that way. We are limited here. I will try to upload the phone option box if you want to talk Dr frank
Customer: replied 7 months ago.
https://drive.google.com/folderview?id=0Bw9sIGRewhVTbC1rOGFZelFNMVU&usp=sharingI think this should work - series 12 was where the image was taken
Customer: replied 7 months ago.
please let me know if you have trouble opening or viewing
Expert:  Dr. Frank replied 7 months ago.
Hi. I can see them. Hang on and I will be back. Dr frank
Expert:  Dr. Frank replied 7 months ago.
HI. So I can see it much better now. Is this your first scan? You do know that pineal cysts are common (2.3% in the general population) and you only consider intervention when symptomatic. How can I help? Dr Frank
Customer: replied 7 months ago.
This is my second scan in a few months, the first scan was via open mri,so it was not strong enough. I have had symptoms of double vision, extremely blurred vision (with 20/25 eye sight when straining to focus) cluster headaches that do not go away, extreme bouts of vertigo, 24/7 tinnitus, fatigue, neuro opthamolgist noted i had visual field defects...etc.... one doctor has offered endoscopic removal due to what he says is compression to the quadrigemenial plate and superior colliclus.Just wanted to ask to see if you think thoses symptoms tie into this lesion as i have saw doctors for these problems for the last 15 years, only to be told that there is nothing else they can do.....
Expert:  Dr. Frank replied 7 months ago.
The one doc that said you had compression is correct. this is also getting into the cerebellar vermis, the part of the cerebellum that effects your balance. I would agree that you need an endoscopic approach to getting this cyst reduced in size and the walls removed if they are greater than 2 mm (cannot measure here, but it would be in the report) Gamma Knife is not indicated to treat this type of lesion as there is no neoplastic element, it is a cyst. Endoscopic approach is advised (my opinion, I am not a neurosurgeon, so I would ask that you get at least two neurosurgical opinions, but it makes sense to me)
Expert:  Dr. Frank replied 7 months ago.
I tried to upload the phone option to you so we could talk in more depth about this, but it is broken here. If you want to discuss this by phone, there is an option button there, JA charges more for this premium service, but if you need that I am available to call you and discuss this further. If satisfied with this answer, please remember to rate this service by clicking on the rating stars, as that is how I am compensated for my work thanks dr Frank
Customer: replied 7 months ago.
Is there only 1 area of compression, or are there 2? i would just like to know prior to my next neurosurgeon visit.
Expert:  Dr. Frank replied 7 months ago.
The pineal cyst is circular and expanding, so it comes into contact with the tectal plate (the tectal plate is comprised of the superior and inferior colliculus) as it presses on the superior part of the plate (the superior colliculus more on the left, right on the scan) and also extends into the area of the cerebellar vermis that fills that space in the ambient cistern (area of CSF around the pineal gland). So there really isn't two compressions, it is filling a space like a sphere and pushing at a few points, understand? Dr Frank
Customer: replied 7 months ago.
i do thank you....The symptoms i described above...are those type of symptoms associated with the compression?
Expert:  Dr. Frank replied 7 months ago.
The superior colliculus controls vision, double vision can be a problem in this situation where there is compression, and also moving the eyes in a correct fashion (tracking). We think also what becomes important in vision (the filtering process) comes from the colliculus, so this is not an area to ignore. Feelings of dizziness, and vestibular disorder are more tied to the inferior colliculus, which does not seem involved here, but really who knows as there can be connections involved we cannot see, so I would say it is possible your dizziness/vestibular symptoms could be involved, or it could be an indirect effect related to vasospasm, even to migraine, hard to say . The neuro-ophthalmologist hopefully did test you for optokinetic nytasmus, and if he thinks your eye movements were abnormal, that is a reason in my mind to get this fixed. I hope that helps you Dr Frank
Customer: replied 7 months ago.
She did note a 4th nerve palsy with a weak superior oblique muscle but was not sure if that was due to the cyst or if it was congenital. Is it possible the the cyst is causing the 4th nerve palsy?
Expert:  Dr. Frank replied 7 months ago.
Yes, it is possible. The fibers leaving the 4th nerve nuclei wrap around the third nerve motor nucleus (edinger-westphal. They are on the other side of the aquaduct from the tectum but are not in the midline, so it is possible. That could account for double (skewed) vision if that is a problem for you. Do you have a head tilt? Dr frank
Customer: replied 7 months ago.
Yes i do have a head tilt...my double vision is vertical. one image on top and the other image below and to left....looking down causing double and looking left and right also causes double. Also when i lay down flat, my vision is constantly double.
Expert:  Dr. Frank replied 7 months ago.
I see. So that can be the 4th nerve lesion, either the fibers or the nucleus itself, or the muscle, although that is less likely given the cyst in my mind Dr Frank
Expert:  Dr. Frank replied 7 months ago.
I hope I was able to answer all of your questions. Please remember to rate my service by clicking on the rating stars, as that is how I am compensated for my work thanks Dr frank
Customer: replied 7 months ago.
Thank you, ***** ***** able to review all the images i uploaded including the horizontal plane? Just would like to know if there is any other information that i am not aware of
Customer: replied 7 months ago.
And i will absolutely rate 5 stars, i appreciate all of your feedback.
Expert:  Dr. Frank replied 7 months ago.
HI. Yes, there are some good positives, like there is no contrast enhancement that I can see in the area around the pineal cyst, to suggest a benign tumor like a pineocytoma. I do not see any changes within the aquaduct itself, which is good news as well. No enlargement of the lateral or third ventricles as to consider an obstructive hydrocephalus. All good news. Dr Frank