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CHAPTER 3. RESULTS OF THE STUDY

3.1 Results of comprehensive magnetic resonance imaging

3.1.1 Standard MRI examination

149 volunteers underwent a standard MRI stady. In 70 of them, the pineal gland had a normal structure (Figure 8). The mean thickness of the pineal gland was 4.13 0.23 mm.

Figure 8 – MR image of patient K. (OC No. 32556, 2020), T2-PS, in the sagittal plane with normal pineal gland structure (indicated by arrow)

Cystic transformation of varying nature was detected in 79 (Figure 9). In the group with cysts less than 10 mm, the pineal gland thickness was 4.71 0.33 mm and in the group with large cysts it was 8.19±2.07 mm.

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А

B

Figure 9 – MR images of patient D., (OC № 34557, 2021), SSFP-PS, in the sagittal plane with a cyst less than 10mm (A) and patient Sh., (OC № 34876, 2021), SSFPPS, in the sagittal plane with a cyst over 10mm (B) (indicated by arrows)

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All patients were divided into 5 groups based on the structural changes of the pineal gland according to standard MR imaging based on a previously presented classification (Sirin S, 2016) (Table 4).

Table 4 — Distribution of patients according to structural changes in the pineal

gland

		Structural changes																										a (≤5														b (6-9												c (≥10										Number of									Distribution by
		of the pineal gland																											m)														mm)												mm)											patients								gender, people
																																																																											м - 33
								No cysts - 0																								-													-												-								70 (47%)
																																																																											ж - 37
																														24														2																																м - 7
						Single cyst - 1																																																		0								26 (17,5%)
																										(16,1%)															(1,4%)																																		ж - 19
		Multicystic pineal
																														25														1																															м - 12
										gland (no																																														0								26 (17,5%)
																										(16,7%)														(0,68%)																																			ж - 14
		magnification)											- 2
		Multicystic pineal
					gland (enlarged																										2																									4																				м - 3
																																									3 (2%)																										9 (6%)
							without edge																				(1,3%)																										(2,68%)																							ж - 6
							displacement)-3
		Multicystic pineal
									gland (with
																																																																												м - 6
			enlargement and																												0										6 (4%)												12 (8%)												18 (12%)
																																																																											ж - 12
	edge displacement)
											- 4

Table 4 shows that all the volunteers examined were divided into 2 roughly equal groups based on MRI findings: 70 (47%) people without signs of morphological changes

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in the pineal gland structure and 79 (53%) with the presence of different variants of cystic transformation, of which 26 (17.5%) had a single cyst in the pineal gland structure, the same number had a multicystic pineal gland without signs of its enlargement. 9 (6%) had multicystic pineal gland with signs of enlargement and no edge displacement and 18 (12%) had multicystic pineal gland with signs of enlargement and edge displacement.

In a two-factor analysis of variance, there was a statistically significant difference in mean age between individuals without a cyst (0) and multicystic pineal gland with signs of enlargement and edge displacement (4) (p=0.042). Individuals in the latter group were younger, with a mean age of 33±3.4 years, compared with 45±1.7 years in the former group. In the group with multicystic pineal gland with enlargement and without edge displacement (3), the mean age was also quite young, 33±5 years, but due to the small number of individuals in the group, no statistically significant difference was found with other groups (Table 5).

There was also no effect of gender on cyst type (p=0.840) and the combination of gender and cyst variant showed no effect on mean age (p=0.838).

Table 5 — Comparison of groups by average age

Type

Mean age in the group, M±m

p-value

of cyst

0

p0,4 = 0.042

.1;

.2; total45±1.7

m - 45±13

g - 45±16

In the

remaining

1

groups

m - 33±11

.8;

g - 37±14.3; total 35±3.2

p>0,05

2

.3;

.1; total42±2.8

m - 40±13

g - 43±16

3

37±27;

.3; total33±5

m -

g - 30±10

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4

m - 32±12; g - 36±10; total33±3.4

Additionally, individuals with PGC greater than 10 mm were examined using a protocol that also included an SSFP-PS in the sagittal plane in order to clarify the nature of structural changes in the pineal gland. The imaging benefits of the SSFP-PS are shown in Figure 10.

A B C

Figure 10 — MR images of the brain. Comparison of two-dimensional T2-PS in the sagittal plane (A) and three-dimensional SSFP-PS in the sagittal and axial planes

(B, C) in the same patient G., (OC №34748, 2021). In the image (A), the cyst appears to be unicameral, but in the 3D sequence (B, C), the PGC appears to be multicameral and large in size. The content of one chamber has a slightly reduced MR signal, suggesting increased protein content. This multicameral cyst can be considered atypical. The changes described are indicated by arrows

In 8 subjects, the original interpretation of 'solitary pineal gland cyst' changes was changed to multicystic changes. An additional was also assessed criterion for edge displacement in the case of a large cyst (Figure 11).

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А

B

Figure 11 — MR images of the brain, SSFP-PS, axial plane. Variants of cystic transformation without edge displacement in patient L. (OC №32234, 2020) (A) and with edge displacement in patient A. (OC №32256, 2020) (B) (indicated by arrows)

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Subsequently, based on the changes identified by the SSFP-PS, DWI-PS from the second phase of the dataset were taken data of 48 people to assess whether they had MR patterns of central venous hypertension and to assess the impact of the pineal gland structure on the surrounding structures.

Volunteers were conventionally divided into 3 groups of equal numbers based on cyst size: the first group without cysts, the second with small cysts (less than 10 mm) or small cystic degeneration and the third with a large cyst over 10 mm (Table 6).

In the group with large cysts, out of 16 people, 11 had category 4c, where 4 is a multicystic pineal gland with an increase in size and edge displacement.

5 people were assigned category 3c, where 3 is a multicystic pineal gland with an increase in size and no edge displacement.

In the group with small cysts, out of 16 people — 9 people were given category 1a, 6 people were given category 2a, 1 person was given category 4b.

Analysis of variance between the three groups revealed that the group of individuals with large cysts was significantly (p1,3 = 0.025) younger than the group without evidence of cysts, but not significantly different from those with small cysts. The mean age of patients with large cysts was the youngest at 30.81±10.8 years.

In addition, the mean thickness of the pineal gland in the group of individuals with a large cyst was 8.19±2.07, compared with individuals with a small cyst (4.55±1.03) and without a cyst (4.14±0.78), which was statistically significantly greater (p1,3 = 0.0004, p2,3 = 0.0004).

The same ratios were obtained when assessing the significance of the difference in the mean distance from the corpus callosum to the tectal plate in each group.

The mean value in the group with large cysts was 10.39±1.6, which was significantly greater (p1,3 =0.002, p2,3 =0.0004) compared with the other groups.

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Table 6 - MRI-detected changes in patients with different PGC variants

Indicators	Without	With small	With large	F-	p-value
	PGC	PGC (less	PGC (over	criterion
		than	10mm)
		10mm)
Number of	16	16	16	-		-
patients,
people
Average age,	42,5±14,2	35,88±11,	30,81±10,8	3,703	p1,3	= 0.025
years		3
Average	4,14±0,78	4,55±1,03	8,19±2,07	40,008	p1,3 = 0.0004
pineal gland					p2,3	= 0.0004
thickness,
mm
Average	8,4±1,4	7,96±1,7	10,39±1,6	11,130	p1,3 = 0.002
distance					p2,3	= 0.0004
from the
splenium of
the corpus
callosum to
the tectal
plate, mm
Signs of	0	0	8		p1,3	≤ 0.05;
aqueduct					p2,3 ≤ 0.05
stenosis,
man
Signs of	0	0	1		p> 0,05
tectal plate
compression,
man

None of the patients showed evidence of occlusive hydrocephalus, but 8 had noncritical aqueduct stenosis (1.5 mm or less). In addition, patients with category 4 had the narrowest aqueduct lumen (1.1-1.2 mm) (Figure 12). One person showed signs of tectal plate compression (Figure 13).

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А

B

Figure 12 - MR images of the brain, SSFP-PS, sagittal plane. Signs of aqueduct stenosis in the presence of a large cyst in patient A. (OC №32256, 2020) (A). Its width in the sagittal plane at its narrowest point is 1.1mm. For comparison, here is an image of patient B. (OC №33598, 2020) with PGC, who has a 2.2-mm wide ductus (B)

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Figure 13 — MR images of the brain, SSFP-PS, sagittal plane. Signs of compression of the quadrigeminal plate in patient C. (OC №33768, 2020) (A). The lamina is thinned, flattened, and its upper contour is smoothed due to volumetric exposure. For comparison, there is an image of the PGC of patient L (OC №33786, 2020) without any signs of impact on the quadrigeminal plate. It has convex contours in the sagittal plane (B) (indicated by arrows)