Purpose <p>Pineal cysts (PC) are benign cysts of the pineal gland (PG). Some patients with PCs have nonspecific symptoms such as headache, sleep disturbances, dizziness, and nausea. In cases of hydrocephalus or Parinaud syndrome, surgical removal of the cyst is the gold standard. However, even without evidence of these signs and symptoms, some patients are offered to undergo surgery. Regarding the indication, the surgical methodology and the clinical outcome in case of unspecific symptoms, evidence is insufficient.</p> Methods <p>All patients undergoing microsurgical fenestration for PC from 2005 – 2021 were included in the analysis. A survey was carried out inquiring about preoperative symptoms, limitations in daily activities, medication use, and postoperative improvement. Preoperative radiological parameters were also evaluated. The primary endpoint of this study was symptom improvement at last follow-up, as assessed by our survey. Radiographic and clinical factors were evaluated for their correlation with symptom improvement. Secondary endpoints were surgical complications, such as surgical site infections (SSI), cerebrospinal fluid fistula (CSF fistula), intraoperative bleeding and mortality.</p> Results <p>Forty-seven patients were included in the analysis. The follow-up period ranged from 5 to 176&#xa0;months, with an average follow-up time of 84.13&#xa0;months (about 7&#xa0;years) post-surgery. Mean preoperative visual analogue scale (VAS) was 7 (SD 2.34), while postoperatively it was 1 (SD 1.91). The majority of patients (94%) showed a decrease in their VAS postoperatively. In a paired-sample t-test for the VAS, the postoperative improvement was statistically significant (<i>p</i> &lt; .001). No mortality or severe adverse events were reported.</p> Conclusions <p>Microsurgical cyst fenestration can yield symptom improvement in non-hydrocephalic patients with PC and unspecific symptoms. Further work is needed to validate both this surgical technique and indications therefor.</p>