Abstract: Pineal region space-occupying lesions (PR-SOL) are a group of rare and heterogeneous intracranial lesions. Their clinical manifestations include not only typical neurological symptoms resulting from obstructive hydrocephalus caused by tumor compression of the cerebral aqueduct, but also a range of complex neuropsychiatric symptoms such as cognitive impairment, emotional, behavioral disturbances, headache and sleep disorders. These neuropsychiatric symptoms are diverse and nonspecific, often masking the underlying intracranial pathology and leading to delays in diagnosis and treatment. They represent a significant clinical issue affecting patients’ functional recovery and long-term prognosis. This review describes the clinical presentations of these neuropsychiatric symptoms, and the multiple pathological mechanisms involving increased intracranial pressure, compression of neural structures, endocrine disorders, and neuroinflammation, and summarizes comprehensive management strategies based on etiological treatment combined with multidisciplinary collaboration, in order to provide a reference for clinical identification and intervention.