Elsevier

Sleep Medicine

Volume 48, August 2018, Pages 127-130
Sleep Medicine

Brief Communication
Sleep disorders in children with incidental pineal cyst on MRI: a pilot study,☆☆

https://doi.org/10.1016/j.sleep.2018.05.003Get rights and content

Highlights

  • Pineal cysts can contribute to sleep disturbances in school-age children.

  • Substitute the second one for Children with pineal cyst may present with excessive sleepiness and disorder of sleep initiation and maintenance.

  • Sleep disturbance is correlated with the size of the cyst.

Abstract

Introduction

For several years, pineal cysts have been considered an incidental finding on brain MRI’s even though research and case reports have shown a possible association of pineal cysts with headaches and sleep disturbances. This pilot study aims to evaluate sleep disorders in school-age children with an incidental pineal cyst in an otherwise normal brain MRI.

Method

Children aged 6–12 years, who were referred for evaluation of headaches, tics, or syncope, and had an incidental pineal cyst on an otherwise normal brain MRI were included and compared to a control group of children with the same referral reasons but with a normal MRI and to a cohort of normal controls. The Sleep Disturbance Scale for Children (SDSC) was administered to the parents. Exclusion criteria included use of medications that affect sleep, seizures, brain abnormalities, tumors, or comorbid medical conditions that affect sleep.

Results

Eighteen children (11 females) with pineal cysts, 19 children with normal MRI, and 100 age- and sex-matched controls were included in our study. There were statistically significant differences in the total SDSC score (with a difference of 10 between the median scores) and in two of the six domains of this scale. Children with pineal cysts scored significantly higher in the domains of disorders of excessive sleepiness and disorders of initiating and maintaining sleep than the two control groups. The scores in these two domains correlated significantly with the size of the cyst.

Conclusion

School-age children with pineal cysts have significantly increased levels of sleepiness and difficulty with sleep initiation and maintenance.

Introduction

The pineal gland is a neuroendocrine structure located between both hemispheres in the epithalamus. Its main function is to participate in circadian regulation by producing melatonin from serotonin. The normal pineal gland is ovoid and with a length of less than one cm. Pineal cysts are fluid filled, well-defined, smooth edge structures within the gland [1]. Pineal cysts are considered to be an incidental finding in the brain magnetic resonance imaging (MRI) of both adults and children, with an incidence in children of up to 57% [2]. Studies in adults and children have found a higher prevalence in females than in males [3] and that the majority of pineal cysts do not change much in size with age; repeated MRI studies are rarely ordered [3].

Although pineal cysts are mostly considered to be asymptomatic, there are medical literature reports associating pineal cysts with headaches [4]. The pathophysiology of headaches in patients with pineal cysts has been postulated to be secondary to aqueductal compression in large cysts, obstruction of the vein of Galen, or disturbances in melatonin production [5].

Headaches are a common complaint in school-age children with an incidence of up to 50% [6]. Headaches can have a bidirectional relationship with sleep: ie, lack of sleep can worsen headaches and lower the headache threshold and conversely, headaches can disrupt sleep. For example, children with migraine, have an increased disruption in sleep, and children with sleep disorders have an increased prevalence of headaches [7]. The International Classification of Sleep Disorders third edition (ICSD-3) has included a category called “sleep-related headaches”; under this category, headaches occur during sleep or upon awakening. This type of headache is rare in children [8].

The Sleep Disturbances Scale for Children (SDSC) is a questionnaire validated for children and adolescents, which uses 26 questions with a Likert-type answer scale to categorize sleep disturbances under six domains: disorders of initiating and maintaining sleep (DIMS); sleep breathing disorders (SBD); disorders of arousal (DOA); sleep–wake transition disorders (SWTD); disorders of excessive somnolence (DOES); and sleep hyperhidrosis (SHY) [9].

Based on previous clinical observations [10], [11], in this study we aim to identify the sleep patterns of children with incidental pineal cyst found in brain MRI and compare them to a group of children referred for brain MRI for similar clinical reasons, as well as compare to a group of normal controls. We hypothesize that children with pineal cysts will have more sleep problems, particularly circadian disruption and daytime sleepiness, than the other two groups.

Section snippets

Subjects

Our study consisted of two parts. The first consisted of a retrospective chart review of children who had undergone brain MRI. Inclusion criteria were as follows: MRI performed between July 2016 and December 2016 in children of age 6–12 years who were referred for brain MRI for evaluation of headaches, tics, syncope, toe walking, or hearing loss and who had an incidental pineal cyst on an otherwise normal brain MRI. The size of the cysts was evaluated by measuring their longer axis. Exclusion

Results

Eighteen children (11 females) with pineal cysts (median age 10 years), 19 children (12 females) with normal brain MRI (median age 10 years), and 100 normal controls (median age 9.5 years, 52 females) were included in the study. Among children with pineal cysts, 10 were Caucasian, four were Hispanic, three were black, and one was Asian. Among children with normal brain MRI, eight were Caucasian, seven were Hispanic, three were black, and one was Asian. The normal reference controls were mainly

Discussion

Our study shows that school-age children with pineal cysts are sleepier than normal age-matched controls and children referred for MRI for similar reasons. We selected a group of school-age children to avoid the natural circadian delay changes associated with adolescence [12] and the confounding combination of sleep disturbances seen in toddlers and preschool children [13]. Our clinical control group was comparable in age, sex, race distribution, and presenting diagnosis. The association

References (17)

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    Tumor size at initial diagnosis has prognostic implications [14]. Tumors with less than 10 mm in size are considered asymptomatic, whereas tumors larger than 10 mm in size are considered symptomatic, therefore providing risk for neurological problems [3]. Head MRI is the gold standard for assessing pineal masses.

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    Prior studies have demonstrated that pineal volume alterations might be associated with a variety of clinical conditions including primary insomnia (Bumb et al., 2014), psychiatric disorders (e.g., schizophrenia, attention deficit hyperactivity disorder) (Bersani et al., 2002; Bumb et al., 2016; Findikli et al., 2015), and neurological diseases (e.g., Alzheimer disease) (Matsuoka et al., 2018). Moreover, there is evidence that school-age children in pineal cysts have significantly increased levels of sleepiness and difficulty in sleep initiation and maintenance (DelRosso et al., 2018). Evans et al. have suggested that pineal cysts may be related to migraine (Evans and Peres, 2010).

  • Correlation between Hydrocephalus and Sleep Rhythm Disturbance Post Pineal Lesion Surgery

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The work was performed at the UCSF Children's Hospital Oakland.

☆☆

The manuscript does not report on a clinical trial.

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