Two cases of pineal-region meningiomas derived from arachnoid membrane over the vein of Galen without dural attachment

Abstract BACKGROUND: The distribution of the arachnoid membrane and its relationship with the neurovascular structures in the pineal region are still not fully understood. OBJECTIVE: Because the arachnoid membrane has an intimate relationship with the neurovascular structures in the pineal region and it will always be encountered surgically, we attempted to clarify the formation and distribution of the arachnoid envelope over the pineal region (AEPG). METHODS: The formation and distribution of the AEPG and its relationship with the neurovascular structures in the pineal region were examined by anatomic dissection in 20 adult cadaveric formalin-fixed heads. RESULTS: The supratentorial and infratentorial outer arachnoid membranes converged at the tentorial apex and then embraced and ran forward along the vein of Galen to form the AEPG. The AEPG could be divided into 2 parts. Typically, the posterior part of the AEPG enveloped the vein of Galen and the terminal segments of its tributaries, and the anterior part of the AEPG enveloped the suprapineal recess, the pineal gland, and the distal segment of the internal cerebral veins. The compartment demarcated by the AEPG did not communicate with the adjacent subarachnoid cisterns or space. CONCLUSION: Previous knowledge about the AEPG, as well as the superior boundary and the contents of the quadrigeminal cistern, needs to be revised. The arrangement and individual variation of AEPG are important for a better understanding of the various growth patterns of the pineal tumors and the relationship between the tumor and the neurovascular structures in the pineal region.

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Atypical Growth Pattern of an Intraparenchymal Meningioma

Case Reports in Radiology ◽

10.1155/2016/7985402 ◽

2016 ◽

Vol 2016 ◽

pp. 1-5

Author(s):

Zhen Zeng ◽

Tijiang Zhang ◽

Yihua Zhou ◽

Xiaoxi Chen

Keyword(s):

Growth Pattern ◽

Pineal Region ◽

Pathological Examination ◽

Intracranial Meningioma ◽

Temporal Region ◽

Right Cerebral Hemisphere ◽

Dural Attachment ◽

The Right ◽

Chinese Male ◽

Irregular Mass

Meningiomas are the most common primary nonneuroglial extra-axial neoplasms, which commonly present as spherical or oval masses with a dural attachment. Meningiomas without dural attachment are rare and, according to their locations, are classified into 5 varieties, including intraventricular, deep Sylvain fissure, pineal region, intraparenchymal, or subcortical meningiomas. To the best of our knowledge, intraparenchymal meningioma with cerebriform pattern has never been reported. In this paper, we report a 34-year-old Chinese male patient who presented with paroxysmal headaches and progressive loss of vision for 10 months and blindness for 2 weeks. A thorough physical examination revealed loss of bilateral direct and indirect light reflex. No other relevant medical history and neurologic deficits were noted. Computed tomography and magnetic resonance imaging scans showed an irregular mass with a unique cerebriform pattern and extensive peritumoral edema in the parietal-occipital-temporal region of the right cerebral hemisphere. The initial diagnosis was lymphoma. Intraoperatively, the tumor was completely buried in a sulcus in the parietal-occipital-temporal region without connecting to the dura. The histological diagnosis was intracranial meningioma based on pathological examination. Therefore, when an unusual cerebriform growth pattern of a tumor is encountered, an intraparenchymal meningioma should be considered as a differential diagnosis.

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Parieto-Occipital Interhemispheric Transfalcine, Trans-Bitentorial Approach for Radical Resection of Falcotentorial Meningiomas

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0039-1685181 ◽

2020 ◽

Vol 81 (04) ◽

pp. 355-361

Author(s):

Tomu Okada ◽

Kousuke Miyahara ◽

Shin Tanino ◽

Kouji Suzuki ◽

Nobuyuki Watanabe ◽

...

Keyword(s):

Radical Resection ◽

Blind Spot ◽

Pineal Region ◽

Anterolateral Approach ◽

Vein Of Galen ◽

Operating Field ◽

Sagittal Sinus ◽

Window Method ◽

A Site ◽

Turn Over

Abstract Objective Falcotentorial meningioma occurs close to the falcotentorial edges and the confluence of the vein of Galen. The posterosuperior approach conventionally used to reach this site does not allow direct visualization of the tumor matrix, making detachment difficult. Meningiomas at this location are therefore among those that are not well amenable to radical resection. We devised an alternative anterolateral approach that, when used in addition to the posterosuperior approach, provides an operating field which allows to overview large, bilaterally extending tumors. We report this parieto-occipital interhemispheric transfalcine, trans-bitentorial approach, together with associated procedural modifications. Methods We used the approach in four patients with falcotentorial meningioma between February 2008 and July 2017. We began by extending a parieto-occipital craniotomy slightly beyond the midline, to pass across the most caudal bridging vein on the rostral side. We then created a fan-shaped fenestration as large as possible in the falx, between the superior sagittal sinus and the inferior sagittal and straight sinuses (window 1). We further performed wedge-shaped resections of both tentorial edges to the left and right of window 1 (windows 2 and 3). Tumor debulking was then carried out via these three windows (the triple-window method). Finally, we detached the tumor in the area of the falcotentorial edges and the confluence of the vein of Galen. To obtain a superorostral operating field as wide as possible from laterally, thereby exposing the potential blind spots, the operating surgeon used both hands while retracting the precuneus, and the assistant surgeon used both hands to turn over the falcotentorial edges (twosome four-hand retractorless microsurgery). Results The wide operating field provided by this parieto-occipital interhemispheric transfalcine, trans-bitentorial approach and twosome four-hand retractorless microsurgery provides a direct view of delicate structures at the falcotentorial edges and the confluence of the vein of Galen, a site that is most likely to be a blind spot in conventional approaches. Retraction of the precuneus on the nondominant side enabled radical resection with no neurologic deficit in any of the patients. Conclusions The parieto-occipital interhemispheric transfalcine, trans-bitentorial approach with the triple-window method opens an anterolateral operating field in addition to a posterosuperior operating field in large tumors located in the falcotentorial and pineal region, extending anteroposteriorly and bilaterally. The twosome four-hand retractorless technique via this approach enables visualization of the tumor matrix at sites, which are barely visible with the conventional approach. Thus, the tumor can be removed more radically and safely.

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DEPICTION OF SMALL VEINS DRAINING INTO THE VEIN OF GALEN USING PREOPERATIVE 3‐DIMENSIONAL NAVIGATION IN LIVING PATIENTS

Operative Neurosurgery ◽

10.1227/01.neu.0000340782.46602.64 ◽

2009 ◽

Vol 64 (suppl_5) ◽

pp. ons247-ons252 ◽

Cited By ~ 3

Author(s):

Mario Giordano ◽

Karsten H. Wrede ◽

Lennart H. Stieglitz ◽

Laura Columbano ◽

Madjid Samii ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Digital Subtraction Angiography ◽

Pineal Region ◽

Digital Subtraction ◽

Vein Of Galen ◽

Resonance Imaging ◽

3 Dimensional ◽

Small Vessels ◽

Computed Tomographic

Abstract OBJECTIVE The purpose of this study was to delineate the anatomy of the precentral cerebellar vein, superior vermian vein, and internal occipital vein using reconstructions of computed tomographic and magnetic resonance imaging scans with navigation software. These data were compared with previous anatomic and angiographic findings to show the resolution and accuracy of the system. METHODS We retrospectively reviewed 100 patients with intracranial pathologies (50 computed tomographic scans with contrast and 50 magnetic resonance imaging scans with gadolinium) using a neuronavigation workstation for 3-dimensional reconstruction. Particular attention was paid to depiction of the precentral cerebellar vein, superior vermian vein, and internal occipital vein. The data were reviewed and analyzed. RESULTS The precentral cerebellar vein, superior vermian vein, and its tributary, the supraculminate vein, were depicted in 52 (52%) patients. The internal occipital vein was delineated on 99 (49.5%) sides and joined the basal vein and vein of Galen in 39 (39.4%) and 60 (60.6%) hemispheres, respectively. Comparing these results with previous angiographic studies, the ability of the neuronavigation system for depicting these vessels is similar to that of digital subtraction angiography. CONCLUSION This study illustrates the possibility of depicting the small vessels draining into the pineal region venous complex using 3-dimensional neuronavigation with an accuracy comparable to that of digital subtraction angiography. This tool provides important information for both surgical planning and intraoperative orientation.

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Endoscopic-assisted posterior interhemispheric retrocallosal transfalcine approach for microsurgical resection of a pineal region falcotentorial meningioma: operative video and technical nuances

Neurosurgical FOCUS ◽

10.3171/2016.1.focusvid.15453 ◽

2016 ◽

Vol 40 (videosuppl1) ◽

pp. 1 ◽

Cited By ~ 1

Author(s):

James K. Liu ◽

Michael A. Cohen

Keyword(s):

Significant Risk ◽

Signs And Symptoms ◽

Lateral Position ◽

Surgical Anatomy ◽

Pineal Region ◽

Definitive Treatment ◽

Surgical Approaches ◽

Vein Of Galen ◽

Straight Sinus ◽

Microsurgical Resection

Falcotentorial meningiomas are rare tumors of the pineal region that arise from the dural folds where the falx and tentorium meet and are often intimately related to the vein of Galen and straight sinus. These lesions often present with signs and symptoms related to hydrocephalus and brainstem compression. Surgical resection of falcotentorial meningiomas remains the definitive treatment, with a variety of surgical approaches used to resect these lesions. The choice of approach depends on several factors, including the size and location of the tumor relative to the vein of Galen complex. Falcotentorial meningiomas can be technically challenging to remove with significant risk of morbidity because of the close proximity to and occasional invasion of the vein of Galen and straight sinus. In this operative video, the authors demonstrate an illustrative step-by-step technique for endoscopic-assisted microsurgical resection of a falcotentorial meningioma using the posterior interhemispheric retrocallosal transfalcine approach for a superiorly positioned falcotentorial meningioma. The surgical nuances are discussed, including the surgical anatomy, gravity-assisted interhemispheric approach in the lateral position, retrocallosal dissection, transfalcine exposure, tumor removal, and preservation of the vein of Galen complex. In summary, the posterior interhemispheric retrocallosal transfalcine approach is a useful surgical strategy for select superiorly positioned falcotentorial meningiomas.The video can be found here: https://youtu.be/d8mdunsRacs.

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Meningiomas of the Pineal Region and Third Ventricle

Neurosurgery ◽

10.1227/00006123-197910000-00016 ◽

1979 ◽

Vol 5 (4) ◽

pp. 489-495 ◽

Cited By ~ 36

Author(s):

Rodney Rozario ◽

Lester Adelman ◽

Robert J. Prager ◽

Bennett M. Stein

Keyword(s):

Clinical Presentation ◽

English Literature ◽

Third Ventricle ◽

Pineal Region ◽

Radiological Findings ◽

Total Removal ◽

True Nature ◽

Preoperative Diagnostic ◽

Dural Attachment ◽

Velum Interpositum

Abstract The clinical presentation, radiological findings, and surgical management of two cases of meningioma arising from the velum interpositum without dural attachment are described. The true nature of these tumors was not suspected despite extensive preoperative diagnostic evaluation. A total removal was effected in both cases with the use of the operating microscope and a posterior fossa approach to the pineal region. A review of similar cases from the English literature is presented.

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Vein of Galen arteriovenous malformation: Unedited microneurosurgery

Surgical Neurology International ◽

10.25259/sni-110-2019 ◽

2019 ◽

Vol 10 ◽

pp. 113

Author(s):

Joham Choque-Velasquez ◽

Juha Hernesniemi

Keyword(s):

Endovascular Procedures ◽

Vascular Malformations ◽

Cerebral Arteries ◽

Transverse Sinus ◽

Senior Author ◽

Pineal Region ◽

Preoperative Imaging ◽

Vein Of Galen ◽

Intraoperative Angiography ◽

Straight Sinus

Background: Vein of Galen arteriovenous malformations (VGAVMs) are vascular malformations of the pineal region between a persistent embryological median prosencephalic vein of Markowski and the arterial choroidal system by a direct (mural type) or indirect (choroidal type) communication. Angiographic evaluation of VGAVMs usually describes a limbic arch between the anterior and posterior cerebral arteries throughout a pericallosal artery, and the classic “ε” shape configuration of the thalamostriate veins drainage into a subtemporal or a lateral mesencephalic vein due to the underdevelopment of the straight sinus, sigmoid sinus, and jugular bulbs. Moreover, falcine dural channels join the pouch of the malformation with the posterior third of the superior sagittal sinus and less frequently with the cavernous sinus, inferior petrosal sinus, and facial veins. At present, endovascular therapy is the standard management for these lesions. However, under failure of endovascular procedures such in this case, microsurgical management of VGAVMs under an experienced neurosurgical team might be paramount. Case Description: The patient with a choroidal type VGAVM and multiple failed endovascular procedures underwent sitting praying position and midline supracerebellar infratentorial approach. Strong retraction with stitches and proper hemostasis of a highly vascular dura was achieved after transverse sinus-based opening. Accurate microsurgical dissection between the superior cerebellar surface and the tentorium allowed a supracerebellar approach over the vermis and along the midline recognizing the venous pouch of the VGAVM instead of the absent straight sinus. Water dissection allowed us to differentiate the cleavage plane between the VGAVM and surrounding structures maintaining an impeccable surgical field as well. Under high microscopic magnification, arterial feeders of the malformation coming from the posterior cerebral artery were recognized. Intraoperative angiography and reevaluation of the preoperative imaging helped us to confirm a safety approach before coagulation and cut those vascular feeders. Throughout an open-close and short bursts bipolar coagulation techniques preventing attachment of conventional bipolar tips within the vascular structure and without permanent use of water irrigation, the vessels were carefully dissected, coagulated, and sectioned. Along with our experience, we believe that this standard coagulation technique applied in all vascular malformation surgeries is safe and effective. A remaining small plexiform malformation associated with the vein of Galen malformation was coagulated and isolated. A new intraoperative angiography determined complete microsurgical occlusion of the VGAVM. Careful homeostasis based on electrocoagulation and surgical was achieved. Finally, we performed a microsurgical wound closure as a conventional technique in Helsinki neurosurgery. Conclusion: This unedited video offers all detailed aspects that a neurosurgeon as the senior author JH considers essential when performing an efficient and safe surgery for a VGAVM. Videolink: http://surgicalneurologyint.com/videogallery/vein-of-galen-avm.

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Midline and off-midline infratentorial supracerebellar approaches to the pineal gland

Journal of Neurosurgery ◽

10.3171/2016.7.jns16277 ◽

2016 ◽

Vol 126 (6) ◽

pp. 1984-1994 ◽

Cited By ~ 13

Author(s):

Satoshi Matsuo ◽

Serhat Baydin ◽

Abuzer Güngör ◽

Koichi Miki ◽

Noritaka Komune ◽

...

Keyword(s):

Pineal Gland ◽

Pineal Region ◽

Vein Of Galen ◽

Surgical Exposure ◽

Direct Exposure ◽

Endoscopic Assistance ◽

Bridging Veins ◽

Cerebellar Retraction ◽

Far Lateral ◽

Formalin Fixed

OBJECTIVEA common approach to lesions of the pineal region is along the midline below the torcula. However, reports of how shifting the approach off midline affects the surgical exposure and relationships between the tributaries of the vein of Galen are limited. The purpose of this study is to examine the microsurgical and endoscopic anatomy of the pineal region as seen through the supracerebellar infratentorial approaches, including midline, paramedian, lateral, and far-lateral routes.METHODSThe quadrigeminal cisterns of 8 formalin-fixed adult cadaveric heads were dissected and examined with the aid of a surgical microscope and straight endoscope. Twenty CT angiograms were examined to measure the depth of the pineal gland, slope of the tentorial surface of the cerebellum, and angle of approach to the pineal gland in each approach.RESULTSThe midline supracerebellar route is the shortest and provides direct exposure of the pineal gland, although the culmen and inferior and superior vermian tributaries of the vein of Galen frequently block this exposure. The off-midline routes provide a surgical exposure that, although slightly deeper, may reduce the need for venous sacrifice at both the level of the veins from the superior cerebellar surface entering the tentorial sinuses and at the level of the tributaries of the vein of Galen in the quadrigeminal cistern, and require less cerebellar retraction. Shifting from midline to off-midline exposure also provides a better view of the cerebellomesencephalic fissure, collicular plate, and trochlear nerve than the midline approaches. Endoscopic assistance may aid exposure of the pineal gland while preserving the bridging veins.CONCLUSIONSUnderstanding the characteristics of different infratentorial routes to the pineal gland will aid in gaining a better view of the pineal gland and cerebellomesencephalic fissure and may reduce the need for venous sacrifice at the level of the tentorial sinuses draining the upper cerebellar surface and the tributaries of the vein of Galen.

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Microsurgical anatomy of the great cerebral vein of Galen and its tributaries

Journal of Neurosurgery ◽

10.3171/jns.2003.99.6.1028 ◽

2003 ◽

Vol 99 (6) ◽

pp. 1028-1038 ◽

Cited By ~ 27

Author(s):

Patrick Chaynes

Keyword(s):

Venous Drainage ◽

Pineal Region ◽

Surgical Approaches ◽

Cerebral Vein ◽

Cerebral Veins ◽

Microsurgical Anatomy ◽

Vein Of Galen ◽

Content Type ◽

Deep Cerebral Veins ◽

Fine Print

Object. The deep cerebral veins may pose a major obstacle in operative approaches to deep-seated lesions, especially in the pineal region where multiple veins converge on the great cerebral vein of Galen. Because undesirable sequelae may occur from such surgery, the number of veins and branches to be sacrificed during these approaches should kept to a minimum. The purpose of this study was to examine venous drainage into the vein of Galen with a view to surgical approaches. If a vein hampering surgical access must be sacrificed, it can therefore be selected according to the smallest draining territory. Methods. The deep cerebral veins and their surrounding neural structures were examined in 50 cerebral hemispheres from 25 adult cadavers in which the arteries and veins had been perfused with red and blue silicone, respectively. Special consideration was given to the size and location of drainage of the vein of Galen and its tributaries. Conclusions. When a surgeon approaches the pineal region, several veins may hamper the access route. From posterior to anterior, these include the following: the superior vermian and the precentral or superior cerebellar veins, which drain into the posteroinferior aspect of the vein of Galen; and the tectal and pineal veins, which drain into its anterosuperior aspect. The internal occipital vein is the main vessel draining into the lateral aspect of the vein of Galen. It may be joined by the posterior pericallosal vein, and in that case has an extensive territory. To avoid intraoperative venous infarction, it is important to use angiography to determine the venous organization before surgery and to estimate the permeability and size of the branches of the deep venous system.

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Pineal region meningiomas without dural attachment

Surgical Neurology ◽

10.1016/s0090-3019(82)80044-x ◽

1982 ◽

Vol 17 (2) ◽

pp. 147-151 ◽

Cited By ~ 20

Author(s):

José M. Roda ◽

Antonio Pérez-Higueras ◽

Bartolomé Oliver ◽

Marcelino P. Alvarez ◽

Martín G. Blázquez

Keyword(s):

Pineal Region ◽

Dural Attachment

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