Manajemen Anestesi pada Pasien dengan Tumor Regio Pineal yang Menjalani Kraniotomi Pengangkatan Tumor dengan Posisi Duduk

Incidence of pineal regio tumor is 0.4-1% of intracranial tumors. Its location which is buried between two cerebral hemispheres, close to brainstem and hypothalamus become a difficult challenge for the neurosurgeon. Surgery with supracerebellar approach in sitting position is the best method to access the lesion. Sitting position also facilitates the optimal visual field with minimal retractions. However, for anesthesiologist, sitting position is challenging since it has its own complexities during positioning the patient and the risk of complications. Venous air embolism is one of the main concern and if not detected early and treated appropriately would leads to cardiovascular collapse instantly. This is a case of a 38-year-old male with chief complaint of severe headache and blurred vision started 4 months before admission. The Magnetic Resonance Imaging showed a pineal region tumor with perifocal edema, without midline deviation. The patient underwent craniotomy tumor removal with sitting position. The procedure lasted for 10 hours and uneventful. The principle of ABCDE neuroanesthesia, sitting position and its implications, and difficult tumor location are some anesthesia considerations for this patient. A thorough preoperative evaluation, good communication and coordination between surgery and anesthesia team are needed for a smooth uneventful procedure performed in sitting position.

Interhemispheric transcallosal intervenous approach to a pineal region tumor

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.

Resection of a pineal region papillary tumor using robotic exoscope: improved visualization and ergonomics for deep seeded tumor

Surgery for pineal region tumors is technically challenging due to their deep location and close proximity to critical deep venous structures, midbrain, and thalamus. A high-definition video exoscope was recently proposed as an alternative to the operating microscope. The authors illustrate a case of the midline supracerebellar infratentorial approach to resect a pineal region tumor using the Modus V exoscope and demonstrate the improved visualization of critical structures in this deep location. Additionally, the marked improvement in surgeon comfort suggests that this system may have significant advantages over traditional microscope-based surgery for tumors of the pineal region. The video can be found here: https://stream.cadmore.media/r10.3171/2021.4.FOCVID2127.

Hydrocephalus Associated with Brain Tumor: Characteristics, Management & Outcomes in a Regional Neurosurgical Centre in Nigeria

Introduction: Brain tumor is a common neurosurgical condition encountered by neurosurgeons in clinical practice. Hydrocephalus could be associated with brain tumor thereby increasing the burden of the disease to the affected patients. Characteristics and outcome of hydrocephalus resulting from brain tumors are almost unknown in our setting. The objectives of this study were to describe the characteristics and outcome of hydrocephalus caused by brain tumor in our center. Methods: A retrospective analysis of all cases of hydrocephalus resulting from brain tumor managed in our center between January 2015 to December 2019. Relevant data extracted from patient’s case files and operation register was analysed. Results: Out of the total sixty-eight cases of brain tumors, thirty (44.1%) cases of hydrocephalus caused by brain tumor were managed over the study period. The mean age of presentation was 14 years ± 2 SD with a slight male preponderance (M: F = 1.07:1). The most common clinical presentations were headache, progressive visual impairment, altered conscious level and ataxia. Posterior fossa tumors were the commonest (21/30), followed by craniopharyngioma (6/30) and one case each for pituitary macroadenoma, pineal region tumor and choroid plexus papilloma respectively. Pediatric age group was the most affected (19/30). All patients had ventriculoperitoneal shunting before definitive surgery. Postoperative outcome was good in the majority of cases (27/30), mortality was recorded in one patient (1/30). Conclusion: Hydrocephalus is a common association in patients with brain tumor in our center. Most cases of brain tumor associated hydrocephalus occur in children and posterior fossa tumor is the commonest aetiology. The outcome of ventriculoperitoneal shunting is relatively good in our setting.

Co-Occurrence of Pineal-Region and Pituitary-Stalk Hemangioblastomas in a Patient Presenting with Von Hippel-Lindau Disease – A Case Report

Introduction Hemangioblastomas of the pineal region or pituitary stalk are extremely rare. Only two cases of hemangioblastomas involving the pineal region have been reported, and four involving the pituitary stalk. The purpose of the present manuscript is to describe an unusual case of supposed hemangioblastoma found concomitantly in the pineal region and pituitary stalk of a patient diagnosed with Von Hippel-Lindau (VHL) disease. Case Report A 35-year-old female patient with a previous diagnosis of VHL complaining of occipital headaches and balance disturbances for three weeks, who previously had a cerebellar hemangioblastoma resected. The visual characteristics of the tumor suggested a friable vascular lesion with a reddish-brown surface, and an incisional biopsy was performed. The tumor consisted of a dense vascular network surrounded by fibrous stroma abundant in reticulin and composed by both fusiform and dispersed xanthomatous cells; the immunohistochemistry was immunopositive for neuron-specific enolase and immunonegative for epithelial membranous antigen. The patient has been monitored closely for 2 years, and the supratentorial masses have not presented any volume alteration. Conclusion This rare association must be taken into account in patients with VHL disease, or at least be suspected in patients who present a thickening of the pituitary stalk and a pineal-region mass. We believe a biopsy of our asymptomatic patient could have been dangerous due to inherent complications like intraoperative bleeding. We recommend close observation of asymptomatic lesions with MRIs every six months or until the lesions become symptomatic. If the pineal-region tumor does become symptomatic, gross resection via a transcallosal approach would be ideal.

Human Midbrain Auditory Evoked Potentials Do Not Differ Between Bursts and Suppressions of Cortex Activity in Propofol Anesthesia: Case Report

Propofol, the most widely administered anesthetic agent, is used for sedation and general anesthesia. During general anesthesia it can induce bursts and suppressions of cortex activity, which exact mechanism of generation has not been identified yet. The aim of study was to investigate the difference between midbrain auditory evoked potentials recorded during bursts and suppressions of cortex activity. These potentials were registered from the drainage-electrode implanted in the cerebral aqueduct of an adult patient with an obstructive hydrocephalus who had undergone pineal region tumor removal through anterior interhemispheric transcallosal approach. The cortex activity was divided into rare bursts of alpha activity (total length of 9 seconds) and prolonged suppressions (total length of 104 seconds). Midbrain auditory evoked potentials included long latency peaks with no statistically significant difference in their amplitudes and latencies between bursts and suppressions of cortex activity. The results suggest that human midbrain auditory evoked potentials do not differ between bursts and suppressions of cortex activity in propofol anesthesia. Therefore, for clear midbrain auditory evoked potentials cognitive but not the total electrical activity of the cortex should be suppressed.

Pineal Tumor

A diagnosis of pineal region tumor requires a thorough history, physical exam, neuroimaging, and tumor markers. A computed tomography (CT) scan may demonstrate pineal calcification engulfed by the tumor or displaced peripherally. Magnetic resonance imaging (MRI) should be carefully evaluated for contrast enhancement patterns and multifocal disease. Hydrocephalus is common and may be the primary cause of the symptoms at presentation. Cerebrospinal tumor markers need to be performed if the physician suspects germ cell tumor. In children, germ cell tumors are a more common tumor pathology than pineal parenchymal tumors. If tumor markers are nondiagnostic, a histologic biopsy is indicated in order to determine appropriate therapeutic modalities. If surgical resection is indicated, an occipital transtentorial or an infratentorial supracerebellar approach may be used, depending on the tumor anatomy and surgeon preference.