Background: Hydrocephalus is a common complication associated with pineal lesions, including tumors and cysts. This structured abstract aims to provide a comprehensive overview of the pathophysiology, diagnostic evaluation, and management strategies for hydrocephalus in the context of pineal lesions. Methods: A review of relevant literature was conducted to gather current insights into hydrocephalus secondary to pineal lesions. PubMed, Google Scholar, and academic databases were searched for articles published between 2014 and 2024. Keywords included “hydrocephalus,” “pineal lesion,” “pineal tumor,” “cyst,” “diagnosis,” “treatment,” and “management.” Results: Pineal lesions, by obstructing CSF pathways, often lead to hydrocephalus due to impaired CSF flow dynamics. Neuroimaging, particularly MRI and CT scans, plays a pivotal role in diagnosing both the pineal lesion and associated hydrocephalus. Treatment strategies for hydrocephalus in pineal lesions include surgical interventions such as endoscopic third ventriculostomy (ETV), ventriculoperitoneal shunt (VPS) placement, and tumor resection. Nonsurgical options, including medical therapy and observation, may also be considered depending on the patient’s clinical status and lesion characteristics. Conclusion: Hydrocephalus in pineal lesions presents a complex clinical scenario requiring a multidisciplinary approach for optimal management. Early diagnosis, accurate characterization of the lesion and associated hydrocephalus, and timely intervention are crucial for improving patient outcomes. Further research is needed to refine treatment algorithms and enhance our understanding of the underlying mechanisms of hydrocephalus in pineal lesions.