Occipital transtentorial approach for pineal region lesions: Addressing the controversies in conventional teaching

Background: The occipital transtentorial (OT) approach is well-established approach for pineal region tumors and can be of choice for the lesions located around the suboccipital part of tentorium such as the quadrigeminal plate, posterior part of thalamus, tentorial surface of cerebellum, splenial region, posterior falx, and lesions around the tentorial incisura. However, it is not very much extensively used in the above-mentioned locations other than the pineal region. Methods: Thirty-one patients of pineal region lesions were operated by OT approach, the role of conventional preoperative evaluation of the anatomy of the venous sinuses, deep venous system, and tentorial angle was investigated. Results: A variety of lesions were operated using this approach achieving gross and near total resection in majority of the cases (76.6%), with acceptable postoperative mean modified Rankin scales (1.8). Conclusion: The OT is a preferable approach for pineal region lesions for patients of all ages and can be tailored for achieving high resectability rates irrespective of the status of the deep venous system and tentorial angle, with reasonable postoperative surgical outcome.

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Anterior interhemispheric transsplenial approach to pineal region tumors: anatomical study and illustrative case

Journal of Neurosurgery ◽

10.3171/2016.9.jns16279 ◽

2018 ◽

Vol 128 (1) ◽

pp. 182-192 ◽

Cited By ~ 6

Author(s):

Kaan Yağmurlu ◽

Hasan A. Zaidi ◽

M. Yashar S. Kalani ◽

Albert L. Rhoton ◽

Mark C. Preul ◽

...

Keyword(s):

Corpus Callosum ◽

Anatomical Study ◽

Pineal Region ◽

Venous System ◽

Illustrative Case ◽

Cerebral Veins ◽

Pineal Region Tumors ◽

Deep Venous System ◽

Surgical Corridor ◽

Occipital Lobes

Pineal region tumors are challenging to access because they are centrally located within the calvaria and surrounded by critical neurovascular structures. The goal of this work is to describe a new surgical trajectory, the anterior interhemispheric transsplenial approach, to the pineal region and falcotentorial junction area. To demonstrate this approach, the authors examined 7 adult formalin-fixed silicone-injected cadaveric heads and 2 fresh human brain specimens. One representative case of falcotentorial meningioma treated through an anterior interhemispheric transsplenial approach is also described. Among the interhemispheric approaches to the pineal region, the anterior interhemispheric transsplenial approach has several advantages. 1) There are few or no bridging veins at the level of the pericoronal suture. 2) The parietal and occipital lobes are not retracted, which reduces the chances of approach-related morbidity, especially in the dominant hemisphere. 3) The risk of damage to the deep venous structures is low because the tumor surface reached first is relatively vein free. 4) The internal cerebral veins can be manipulated and dissected away laterally through the anterior interhemispheric route but not via the posterior interhemispheric route. 5) Early control of medial posterior choroidal arteries is obtained. The anterior interhemispheric transsplenial approach provides a safe and effective surgical corridor for patients with supratentorial pineal region tumors that 1) extend superiorly, involve the splenium of the corpus callosum, and push the deep venous system in a posterosuperior or an anteroinferior direction; 2) are tentorial and displace the deep venous system inferiorly; or 3) originate from the splenium of the corpus callosum.

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The infratentorial supracerebellar approach to pineal lesions

Journal of Neurosurgery ◽

10.3171/jns.1971.35.2.0197 ◽

1971 ◽

Vol 35 (2) ◽

pp. 197-202 ◽

Cited By ~ 248

Author(s):

Bennett M. Stein

Keyword(s):

Posterior Fossa ◽

Pineal Region ◽

Venous System ◽

Pineal Tumors ◽

Content Type ◽

Minimal Morbidity ◽

Deep Venous System ◽

Infratentorial Supracerebellar Approach ◽

Fine Print

✓ In six patients with pineal tumors, a posterior fossa approach was used to explore the pineal region. This approach avoided the deep venous system and led to no mortality and minimal morbidity. Because a certain percentage of pineal lesions are benign and amenable to resection, it is recommended that all pineal tumors be explored prior to a decision regarding radiotherapy.

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Precision of preoperative diagnosis in patients with brain tumor – A prospective study based on “top three list” of differential diagnosis for 1061 patients

Surgical Neurology International ◽

10.25259/sni_5_2020 ◽

2020 ◽

Vol 11 ◽

pp. 55 ◽

Cited By ~ 1

Author(s):

Kazunori Arita ◽

Makiko Miwa ◽

Manoj Bohara ◽

FM Moinuddin ◽

Kiyohisa Kamimura ◽

...

Keyword(s):

Differential Diagnosis ◽

Brain Tumor ◽

Preoperative Diagnosis ◽

Preoperative Evaluation ◽

Correct Diagnosis ◽

Rate Sensitivity ◽

Pineal Region ◽

Surgical Strategy ◽

Pineal Region Tumors ◽

First Diagnosis

Background: Accurate diagnosis of brain tumor is crucial for adequate surgical strategy. Our institution follows a comprehensive preoperative evaluation based on clinical and imaging information. Methods: To assess the precision of preoperative diagnosis, we compared the “top three list” of differential diagnosis (the first, second, and third diagnoses according to the WHO 2007 classification including grading) of 1061 brain tumors, prospectively and consecutively registered in preoperative case conferences from 2010 to the end of 2017, with postoperative pathology reports. Results: The correct diagnosis rate (sensitivity) of the first diagnosis was 75.8% in total. The sensitivity of the first diagnosis was high (84–94%) in hypothalamic-pituitary and extra-axial tumors, 67–75% in intra-axial tumors, and relatively low (29–42%) in intraventricular and pineal region tumors. Among major three intra-axial tumors, the sensitivity was highest in brain metastasis: 83.8% followed by malignant lymphoma: 81.4% and glioblastoma multiforme: 73.1%. Sensitivity was generally low (≦60%) in other gliomas. These sensitivities generally improved when the second and third diagnoses were included; 86.3% in total. Positive predictive value (PPV) was 76.9% in total. All the three preoperative diagnoses were incorrect in 3.4% (36/1061) of cases even when broader brain tumor classification was applied. Conclusion: Our institutional experience on precision of preoperative diagnosis appeared around 75% of sensitivity and PPV for brain tumor. Sensitivity improved by 10% when the second and third diagnoses were included. Neurosurgeons should be aware of these features of precision in preoperative differential diagnosis of a brain tumor for better surgical strategy and to adequately inform the patients.

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Endoscopic-assisted interhemispheric parieto-occipital transtentorial approach for microsurgical resection of a pineal region tumor: operative video and technical nuances

Neurosurgical FOCUS ◽

10.3171/2016.1.focusvid.15450 ◽

2016 ◽

Vol 40 (videosuppl1) ◽

pp. 1 ◽

Cited By ~ 1

Author(s):

James K. Liu

Keyword(s):

Occipital Lobe ◽

Pineal Region ◽

Cerebral Veins ◽

Pineal Region Tumor ◽

Pineal Region Tumors ◽

Straight Sinus ◽

Occipital Transtentorial Approach ◽

Microsurgical Resection ◽

Tentorial Incisura ◽

Transtentorial Approach

The angle of the straight sinus and tentorium cerebelli can often influence the choice of surgical approach to the pineal region. The supracerebellar infratentorial approach can be technically challenging and a relative contraindication in cases where the angle of the straight sinus and tentorium is very steep. Similarly, an occipital transtentorial approach, which uses a low occipital craniotomy at the junction of the superior sagittal sinus and transverse sinus, may not provide the best trajectory to the pineal region in patients with a steep tentorium. In addition, this approach often necessitates retraction on the occipital lobe to access the tentorial incisura and pineal region, which can increase the risk of visual compromise. In this operative video, the author demonstrates an alternative route using an endoscopic-assisted interhemispheric parieto-occipital transtentorial approach to a pineal region tumor in a patient with a steep straight sinus and tentorium. The approach provided a shorter route and more direct trajectory to the tumor at the tentorial incisura, and avoided direct fixed retraction on the occipital lobe when performed using the lateral position, thereby minimizing visual complications. This video atlas demonstrates the operative technique and surgical nuances, including the application of endoscopic-assisted microsurgical resection and operative pearls for preservation of the deep cerebral veins. In summary, the parieto-occipital transtentorial approach with endoscopic assistance is an important approach in the armamentarium for surgical management of pineal region tumors.The video can be found here: https://youtu.be/Ph4veG14aTk.

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Stereotactic Radiosurgery for Pineal Region Tumors

Neurosurgery Clinics of North America ◽

10.1016/s1042-3680(18)30692-2 ◽

1992 ◽

Vol 3 (1) ◽

pp. 245-253 ◽

Cited By ~ 17

Author(s):

Peter K. Dempsey ◽

L. Dade Lunsford

Keyword(s):

Stereotactic Radiosurgery ◽

Pineal Region ◽

Pineal Region Tumors

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Role of Neuroendoscopic Procedures in “Minimally-Invasive” Preferential Management of Pineal Region Tumors

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0034-1382198 ◽

2014 ◽

Vol 75 (S 01) ◽

Author(s):

S. Oi ◽

Y. Enchev

Keyword(s):

Minimally Invasive ◽

Pineal Region ◽

Pineal Region Tumors

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CT and MR of pineal region tumors

Magnetic Resonance Imaging ◽

10.1016/0730-725x(94)92348-5 ◽

1994 ◽

Vol 12 (1) ◽

pp. 17-24 ◽

Cited By ~ 3

Author(s):

Athanasios D. Gouliamos ◽

Angelos E. Kalovidouris ◽

Grigoris K. Kotoulas ◽

Alexandra K. Athanasopoulou ◽

John R. Kouvaris ◽

...

Keyword(s):

Pineal Region ◽

Pineal Region Tumors

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Posterior interhemispheric transtentorial approach for resection of a meningioma at the posteromedial tentorial incisura

Neurosurgical FOCUS ◽

10.3171/2016.1.focusvid.15428 ◽

2016 ◽

Vol 40 (videosuppl1) ◽

pp. 1 ◽

Cited By ~ 1

Author(s):

Sun Liyong ◽

Yuhai Bao ◽

Jiantao Liang ◽

Mingchu Li ◽

Jian Ren

Keyword(s):

Third Ventricle ◽

Symptomatic Improvement ◽

Pineal Region ◽

Increased Intracranial Pressure ◽

Total Removal ◽

Adjacent Structures ◽

Patient Reported ◽

Surgical Corridor ◽

Tentorial Incisura ◽

Transtentorial Approach

The posterior interhemispheric approach is a versatile approach to access lesions of the pineal region, posterior incisural space, posterior region of third ventricle, and adjacent structures. We demonstrate the case of a 26-year-old woman with symptoms of increased intracranial pressure and hydrocephalus caused by a meningioma at the posteromedial tentorial incisura. Gross-total removal of the tumor was successfully achieved via a posterior interhemispheric transtentorial approach. The patient reported an immediate and significant symptomatic improvement after surgery. The detailed operative technique and surgical nuances, including the surgical corridor, tentorium incision, tumor dissection and removal are illustrated in this video atlas.The video can be found here: https://youtu.be/nSNyjQKl7aE.

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