Surgical Approaches to the Pineal Region
Department of Neurological Surgery, Columbia University, 710 West 168th Street, New York, NY 10032, USA.Neurosurgery clinics of North America (Impact Factor: 1.44). 07/2011; 22(3):367-80, viii. DOI: 10.1016/j.nec.2011.05.007
The pineal region can harbor highly diverse histologic tumor subtypes. Because optimal therapeutic strategies vary with tumor type, an accurate diagnosis is the foundation of enlightened management decisions. Either stereotactic biopsy or open surgery is essential for securing tissue for pathologic examination. Biopsy has the advantage of ease and minimal invasiveness but is associated with more sampling errors than open surgery. The emergence of endoscopic techniques and stereotactic radiosurgery provide complementary options to improve pineal tumor management, and will assume greater importance in the neurosurgeon's armamentarium.
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- "The supracerebellar-infratentorial (SCIT) approach is a common strategy used to access midline and paramedian lesions located beneath the deep venous system in the pineal-tectal region. Traditionally, a large craniotomy has been used with the SCIT approach due to the limited anatomical pathway afforded while operating in the pineal region, and it is commonly accepted that the craniotomy should be extended inferiorly to at least the rim of the foramen magnum to allow the cerebellum to sag      . However, we hypothesized that the size of the standard craniotomy could be reduced with the keyhole principle, by which the smallest opening necessary is used to access the requisite anatomy  . "
ABSTRACT: The supracerebellar-infratentorial approach to the pineal region is typically accomplished with a craniotomy that extends to at least the rim of the foramen magnum. Minimally invasive techniques that limit the inferior extent of the craniotomy have been described for this approach but, to our knowledge, no operative results have been published demonstrating the feasibility and safety of such techniques. We present a series of patients who underwent surgical resection of pineal region lesions using the minimally invasive method at our institution. Clinical, radiologic, and operative data were prospectively collected on patients treated for lesions of the pineal region by the senior author from January 2012 to July 2014. Seven patients were identified. The sitting position was employed in each patient. Keyhole craniotomies were limited to a maximum diameter of 2.5cm. Adequate working corridors were attained, and in no patient was resection limited by the exposure. No neurological or systemic complications were seen in the perioperative and early follow-up periods. In this feasibility study, we demonstrate that it is not necessary to extend a craniotomy inferiorly to the rim of the foramen magnum in order to gain access to the pineal region via relaxation of the cerebellum. The same surgical goals can be safely accomplished with a smaller craniotomy. Copyright © 2015. Published by Elsevier Ltd.
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- "This is facilitated by the position of the patient and effect of gravity. Great care is needed at this point to avoid lesions of the veins, since the basal veins of Rosenthal and the vein of Galen must always be preserved. In case of a small laceration, local hemostatics are applied, and the stop of bleeding is always confirmed with repeated jugular compression. "
ABSTRACT: Surgery of pineal region lesions is considered a challenging task, due to the particular relationship of lesions in this location with neural and vascular structures. Few series with a significant experience of dealing with these patients have been reported. We review our experience using infratentorial supracerebellar approach in the surgery of pineal region, regarding the extension of the removal, postoperative morbidity, and discussing details of the surgical technique. In all cases, a supracerebellar infratentorial approach was used in the semi sitting position. A total of 32 patients were operated in the past 20 years (3 germinomas, 3 teratoma, 3 pineocitoma, 2 pineal tumor of intermediate differentiation, 6 pineoblastomas, 6 low grade astrocytoma, 2 glioblastoma, 2 metastasis, 1 ependymoma, 1 epidermoid tumor, 1 cavernoma, and 2 arachnoid cyst). Total removal was achieved in 15 cases and subtotal extensive removal in 7 patients. In the remaining cases, only partial removal was possible, due to the involved pathological types. There was no surgical mortality and no cases of cerebellar venous infarction. Morbidity consisted of transient ocular movement disturbance in 14 patients, transient ataxia in 3 patients, and 1 case of local cerebrospinal fluid (CSF) fistula with meningitis that required surgical treatment. Supracerebellar infratentorial is a safe approach to lesions in the pineal region, and total or extensive subtotal removal is possible in most cases, with acceptable morbidity.
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ABSTRACT: Background: Hydrocephalus is often secondary to pineal region tumors. Hydrocephalus can lead to high intracranial pressure, which in turn results in disturbance of consciousness, cerebral hernia, and even death. Hydrocephalus management is important in the treatment of pineal region tumors. It is still controversial regarding to when and how to treat hydrocephalus secondary to pineal region tumors. The objective of this study is to investigate the management of hydrocephalus secondary to pineal region tumors. Methods: We retrospectively analyzed records for 51 patients admitted to the department of Neurosurgery, Jinling Hospital from April 1997 to September 2010 with hydrocephalus secondary to pineal region tumors treated through occipital transtentorial approach. Results: Preoperative ventricular drainage was performed on one patient, and ventriculoperitoneal shunts were performed on two patients. Intraoperative ventriculocisternal shunts were performed on 35 patients (the remission rate was 88.6%), no treatments on 15 patients (the remission rate was 46.7%), and ventricular drainages on three patients. VP shunts were performed on 12 patients with no remission after the operation. Conclusion: Pineal region tumors resection usually should be performed before shunting, unless there is an acute obstructive hydrocephalus. The posterior third ventricle should be opened after tumor resection. Intraoperative third ventriculostomy and ventriculocisternal shunt are reliable ways to manage hydrocephalus secondary to pineal region tumors.