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

2018 ◽  
Vol 128 (1) ◽  
pp. 182-192 ◽  
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.

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

2021 ◽  
Vol 12 ◽  
pp. 503
Author(s):  
Abhishek Katyal ◽  
Anil Jadhav ◽  
Aparna Katyal ◽  
Anita Jagetia ◽  
Shaam Bodeliwala ◽  
...  
Keyword(s):  
Preoperative Evaluation ◽  
Posterior Part ◽  
Pineal Region ◽  
Venous System ◽  
Pineal Region Tumors ◽  
Deep Venous System ◽  
Conventional Teaching ◽  
The Status ◽  
Quadrigeminal Plate ◽  
Tentorial Incisura

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.

scholarly journals Interhemispheric transcallosal intervenous approach to a pineal region tumor

2021 ◽  
Vol 5 (1) ◽  
pp. V11
Author(s):  
Daniel A. Donoho ◽  
Guillermo Aldave
Keyword(s):  
Extent Of Resection ◽  
Pineal Region ◽  
Cerebral Veins ◽  
Surgical Morbidity ◽  
Pineal Tumors ◽  
Pineal Region Tumor ◽  
Pineal Region Tumors ◽  
Transcallosal Approach ◽  
Formidable Challenge ◽  
The Right

Pineal region tumors represent a formidable challenge to the neurosurgeon. Choosing the right approach is key to optimizing the extent of resection and minimizing surgical morbidity. In this video, the authors show an interhemispheric transcallosal approach to a pineal region tumor in a 15-year-old boy. The advantage of this corridor over posterior approaches is that it provides a nice view of the tumor plane with the venous complex, especially while dissecting tumor from the anterior aspect of the internal cerebral veins on their vertical path. Thus, this approach represents a safe and effective alternative for selected pineal tumors. The video can be found here: https://stream.cadmore.media/r10.3171/2021.4.FOCVID2120.

The infratentorial supracerebellar approach to pineal lesions

1971 ◽  
Vol 35 (2) ◽  
pp. 197-202 ◽  
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.

Anatomical Study of the Arachnoid Envelope Over the Pineal Region

2011 ◽  
Vol 68 (suppl_1) ◽  
pp. ons7-ons15 ◽  
Author(s):  
Qi Song-tao ◽  
Zhang Xi-an ◽  
Fan Jun ◽  
Huang Guang-long ◽  
Pan Jun ◽  
...  
Keyword(s):  
Anterior Part ◽  
Posterior Part ◽  
Anatomical Study ◽  
Pineal Region ◽  
Growth Patterns ◽  
Cerebral Veins ◽  
Vein Of Galen ◽  
Arachnoid Membrane ◽  
Pineal Tumors ◽  
Neurovascular Structures

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.

Anatomy of the deep venous system in vein of Galen malformation and its changes after endovascular treatment depicted by magnetic resonance venography

2018 ◽  
Vol 11 (1) ◽  
pp. 84-89 ◽  
Author(s):  
Olivia Winkler ◽  
Waleed Brinjikji ◽  
Heinrich Lanfermann ◽  
Friedhelm Brassel ◽  
Dan Meila
Keyword(s):  
Endovascular Treatment ◽  
Venous Drainage ◽  
Venous System ◽  
Cerebral Veins ◽  
Common Phenomenon ◽  
Vein Of Galen ◽  
Vein Of Galen Malformation ◽  
Deep Venous System ◽  
Internal Cerebral Veins ◽  
Lateral Mesencephalic Vein

Background and purposeIt is classically thought that the internal cerebral veins (ICV) do not communicate with the venous pouch of vein of Galen malformations (VGM). We report on the anatomy of the deep venous system in VGM with special emphasis on the drainage of the ICV and possible changes after endovascular treatment.Materials and methodsWe retrospectively analyzed DSA and 2D time-of-flight MR venograms of 55 children with VGM. We evaluated all pre- and post-operative images for the presence of the ICVs and determined their route of venous drainage.ResultsOf 55 children, pre-operative 2D MRV detected the ICVs in 19 cases (35%) compared with one case (2%) for pre-embolization DSA (2%) (P<0.0001). Of the cases in which the ICVs were seen preoperatively, in 15 cases (78.9%) the ICV drained directly into the VGM while in the other four cases, the ICV used alternative venous drainage routes. On post-operative MRV, the ICVs were seen in 17 cases (31%) on MRV and 10 cases (18.2%) on DSA with drainage into an adult-like vein of Galen in 13 cases (76%), respectively (P=0.08). In four cases normal ICV drainage into the vein of Galen was seen even when the venous sac was closed. In two cases there was a change in ICV drainage from the vein of Galen to the lateral mesencephalic vein.ConclusionThe communication of the ICV with the VGM is a common phenomenon. Different changes of venous drainage routes do occur after treatment and are best seen on MRV.

scholarly journals Combined bi-occipital suboccipital transsinus transtentorial approach for resection of a pineal region falcotentorial meningioma: operative video and technical nuances

2016 ◽  
Vol 40 (videosuppl1) ◽  
pp. 1
Author(s):  
James K. Liu
Keyword(s):  
Venous Pressure ◽  
Patient Positioning ◽  
Occipital Lobe ◽  
Transverse Sinus ◽  
Pineal Region ◽  
Neurophysiologic Monitoring ◽  
Pineal Region Tumors ◽  
Before And After ◽  
Surgical Corridor ◽  
Transtentorial Approach

Large deep-seated meningiomas of the falcotentorial region present a formidable surgical challenge. In this operative video, the author demonstrates the combined bi-occipital suboccipital transsinus transtentorial approach for microsurgical resection of a large falcotentorial meningioma. This approach involves division of the less dominant transverse sinus after assessment of the venous pressure before and after clipping of the sinus with continuous neurophysiologic monitoring. Mild retraction of the occipital lobe and cerebellum results in a wide supra- and infratentorial exposure of extensive pineal region tumors. This video atlas demonstrates the operative technique and surgical nuances, including patient positioning, supra- and infratentorial craniotomy, transsinus transtentorial incision, and tumor removal with preservation of the vein of Galen complex. In summary, the combined bi-occipital suboccipital transsinus transtentorial approach provides a wide supra- and infratentorial surgical corridor for removal of select falcotentorial meningiomas.The video can be found here: https://youtu.be/3aD8h2uwBAo.

Virtual Reality Surgical Rehearsal and 2-Dimensional Operative Video of a Paramedian Supracerebellar Infratentorial Approach Endoscopic Resection of Pineocytoma: 2-Dimensional Operative Video

2020 ◽  
Vol 20 (1) ◽  
pp. E51-E52
Author(s):  
Walter C Jean
Keyword(s):  
Virtual Reality ◽  
Solid Tumors ◽  
Endoscopic Resection ◽  
Pineal Region ◽  
Histopathological Diagnosis ◽  
Pineal Tumor ◽  
Cerebral Veins ◽  
Patient Consent ◽  
Surgical Corridor ◽  
Keyhole Approach

Abstract An endoscopic “keyhole” approach to a deep-lying skull base lesion can be a daunting challenge. For the pineal region, the techniques for endoscopic resection of solid tumors in this location are also new.1,2 In such a situation, surgical rehearsal in virtual reality (VR) can significantly improve the surgeon's confidence.3 In this operative video, we demonstrate the use of VR in surgical planning and rehearsal to determine the best approach to a large, solid pineal tumor in a 46-yr-old patient. Using the patient's computed tomography angiography and magnetic resonance imaging, a VR model of his anatomy was created (SNAP VR360 version 3.8.0, Surgical Theater Inc, Cleveland, Ohio). VR rehearsal showed that, with the tumor tucked under the corpus callosum and cradled by the internal cerebral veins and veins of Rosenthal, a supratentorial approach would be suboptimal. Because of the steep angle of the patient's tentorium in the midline, a classic supracerebellar infratentorial (SCIT) approach would be challenging, and thus a paramedian variant of SCIT was chosen.4 For a right-handed surgeon, the left side was used, and the endoscope was docked at the extreme left, out of the main surgical corridor. Shown in the video, the endoscopic resection achieved a complete resection. The histopathological diagnosis was a pineocytoma. No adjuvant treatment is recommended. Given the rarity of pineocytoma,5 the novelty of endoscopic resection of solid tumors in the region, and the challenge of “keyhole” approaches to deep-lying targets, VR rehearsal facilitated the achievement of the surgical goal and avoided the morbidity of a more extensive exposure. Patient consent was obtained prior to the creation of the video and available on request. RHOTON images in the video are from The Rhoton Collection®.

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

2016 ◽  
Vol 40 (videosuppl1) ◽  
pp. 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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