Highlights
- •The crucial point of pineal region surgery is picking the ideal approach for the extend of the lesion maximizing removal while minimizing surgical morbidity.
- •Better anatomical knowledge is necessary for surgical excision of pineal lesions.
- •In this study, we aimed to combine our clinical experiences and anatomic trick points of parietooccipital interhemispheric transtentorial approach.
Abstract
Access to the pineal region has always been a challenge for neurosurgeons. The parietooccipital
interhemispheric transtentorial approach is a slight variation of the traditional
occipital transtentorial approach that provides adequate exposure to the lesions of
the pineal region without introducing additional risks. In this study, the modified
parietooccipital interhemispheric transtentorial approach is discussed including step-by-step
anatomical cadaveric dissections and operative images. 27 adult patients (age > 18)
who were operated over a 30-year period (1992–2022) by the senior author (M.N.P.)
at two clinics, Marmara University, Department of Neurosurgery, Istanbul, Turkey and
Acibadem Mehmet Ali Aydinlar University, Department of Neurosurgery, Istanbul, Turkey
were analyzed. Only pineal region tumors were included in the analysis. Falcotentorial
meningiomas and vascular lesions including cavernomas were excluded. 5 cadaveric specimens
were dissected step by step following the surgical approach. Each step was documented
using a Canon EOS 5D Mark II camera with Canon 100 mm Macro Lens. Step by step images
of the dissections were presented including comparison with surgical images. Additional
illustrations were used to describe the surgical corridor. The surgical corridor is
maintained anterior to the parietooccipital sulcus along the medial of the precuneus.
No retraction to the calcarine sulcus resulted in no postoperative hemianopsia. The
neurovascular structures along the surgical corridor along with the nuances of the
tentorium incision and splenium resection are discussed. The parietooccipital interhemispheric
transtentorial approach provides a wide and safe corridor for surgical resection of
pineal tumors.
Keywords
Abbreviations:
CSF (Cerebrospinal Fluid), PPTID (Pineal parenchymal tumor of intermediate differentiation), PTPR (Papillary tumor of the pineal region), WHO (World Health Organization), SCIT (Supracerebellar infratentorial), MRI (Magnetic resonance imaging), VP (Ventriculoperitoneal)To read this article in full you will need to make a payment
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References
- Tumours of the Pineal Body.Proc R Soc Med. 1910; 3: 65-78
- The Krause operations.J Neurosurg. 1992; 76: 1032-1036
- Operative experience in cases of pineal tumor.Arch Surg. 1936; 33: 19-46
- DIAGNOSIS AND TREATMENT OF PINEAL TUMOURS.: WITH REPORT OF A CASE.Lancet. 1932; 219: 3-9
- Extirpation of a huge pinealoma from a patient with pubertas praecox: a new operative approach.Arch Neurol Psychiatry. 1937; 37: 385-397
- Tumors of the posterior portion of the third ventricle.J Neurosurg. 1953; 10: 1-18
- Tumors of the pineal region.J Neuropathol Exp Neurol. 1954; 13: 540-561
- Should Extirpation be Attempted in Cases of Neoplasm in or Near the Third Ventricle of the Brain?: Experiences with a Palliative Method.J Neurosurg. 1948; 5: 249-275
- Arne Torkildsen and the ventriculocisternal shunt: the first clinically successful shunt for hydrocephalus.J Neurosurg. 2016; 124: 1421-1428
- Surgical removal of pineal tumors (pinealomas and teratomas): Experience in a series of 19 cases.J Neurosurg. 1965; 23: 565-571
- The infratentorial supracerebellar approach to pineal lesions.J Neurosurg. 1971; 35: 197-202
- Comparison of the infratentorial and transtentorial approaches to the pineal region.Neurosurgery. 1978; 3: 1-8
- On the surgery of the seat of the soul: the pineal gland and the history of its surgical approaches.Neurosurgery Clinics. 2011; 22: 321-333
- The right occipital approach to a pinealoma.J Neurosurg. 1966; 25: 706-710
- Incidence of pineal tumours. A review of the literature.Neurochirurgie. 2015; 61: 65-69
Louis DN, Perry A, Wesseling P, Brat DJ, Cree IA, Figarella-Branger D, Hawkins C, Ng HK, Pfister SM, Reifenberger G, Soffietti R. The 2021 WHO classification of tumors of the central nervous system: a summary. Neuro-oncology. 2;23(8) (2021):1231-51.
- Biomarkers of pineal region tumors: A review.Ochsner J. 2019; 19: 26-31
Tamrazi, B.; Nelson, M.; Blüml, S. Pineal region masses in pediatric patients. Neuroimaging Clin. N. Am. 2017, 27, 85–97. [.
Louis, D.N.; Ohgaki, H.; Wiestler, O.D.; Cavenee, W.K.; Burger, P.C.; Jouvet, A.; Scheithauer, B.W.; Kleihues, P. The 2007 WHOclassification of tumours of the central nervous system. Acta Neuropathol. 2007, 114, 97–109, Erratum in Acta Neuropathol. 2007,114, 547.
- Outcome of single-trajectory rigid endoscopic third ventriculostomy and biopsy in the management algorithm of pineal region tumors: A case series and review of the literature.Childs Nerv Syst. 2018; 34: 1335-1344
- CBTRUS Statistical Report: Primary brain and other central nervous system tumors diagnosed in the United States in 2009–2013.Neuro Oncol. 2016; 18: v1-v75
- Regression of pineal lesions: Spontaneous or iatrogenic? A case report and systematic literature review.World Neurosurg. 2017; 108: 939-947
- Venous complications in supracerebellar infratentorial approach.Acta Neurochir. 2013 Mar; 155: 477-478
- Neurosurgical venous considerations for tumors of the pineal region resected using the infratentorial supracerebellar approach.J Clin Neurosci. 2011 Nov 1; 18: 1481-1485
- Midline and off-midline infratentorial supracerebellar approaches to the pineal gland.J Neurosurg. 2016 Oct 1; 126: 1984-1994
- Midline and paramedian supracerebellar infratentorial approach to the pineal region: a comparative clinical study in 112 patients.World Neurosurg. 2020 May; 1: e194-e207
D'Amico, Randy S., Jeffrey N. Bruce. “Complications of Surgery for Pineal Region Tumors.” Complications in Neurosurgery. Elsevier, 2019. 125-131.
Rhoton A. The cerebral veins. Neurosurgery 2002;51 Suppl 1:159 205.
- An overview of the current surgical options for pineal region tumors.Surg Neurol Int. 2014; 5
- Extent of resection and long-term survival of pineal region tumors in Helsinki Neurosurgery.World Neurosurg. 2019 Nov; 1: e379-e391
- Principles of treatment of the pineal region tumors.Surg Neurol. 2003; 59: 252-270
- Pineal gland tumors: experience from the SEER database.J Neurooncol. 2009; 94: 351-358
- Radical resection of nongerminomatous pineal region tumors via the occipital transtentorial approach based on arachnoidal consideration: experience on a series of 143 patients.Acta Neurochir. 2014; 156: 2253-2262
- The posterior transcallosal approach to the pineal region and posterior third ventricle: intervenous and paravenous variants.Operat Neurosurg. 2017; 13: 77-88
- Microsurgical resection of pineal region tumors.J Neurooncol. 2016; 130: 351-366
- Management of Obstructive Hydrocephalus Associated with Pineal Region Cysts and Tumors and Its Implication in Long-Term Outcome.World Neurosurg. 2021; 149: e913-e923
- Management of hydrocephalus secondary to pineal region tumors.Clin Neurol Neurosurg. 2013; 115: 1809-1813
- Management of pineal region tumors in a pediatric case series.Neurosurg Rev. 2021; 44: 1417-1427
- The sitting position in neurosurgery: Indications, complications and results. a single institution experience of 600 cases.Acta Neurochir(Wien). 2013; 155: 1887-1893
- Effect of positive end-expiratory pressure on the incidence of venous air embolism and on the cardiovascular response to the sitting position during neurosurgery.Br J Anaesth. 1998; 80: 30-35
- The sitting position for neurosurgery in children: a review of 16 years’ experience.Br J Anaesth. 2002; 88: 12-17
- Is the sitting or the prone position best for surgery for posterior Fossa tumors in children.Paediatr Anaesth. 2001; 11: 541-547
- Praying sitting position for pineal region surgery: an efficient variant of a classic position in neurosurgery.World Neurosurg. 2018 May; 1: e604-e611
- A streamlined protocol for the use of the semi-sitting position in neurosurgery: a report on 48 consecutive procedures.J Clin Neurosci. 2013 Jan 1; 20: 32-34
Feigl GC, Decker K, Wurms M, et al. Neurosurgical Procedures in the Semisitting Position: Evaluation of the Risk of Paradoxical Venous Air Embolism in Patients with a Patent Foramen Ovale.
- A standardized protocol for the prevention of clinically relevant venous air embolism during neurosurgical interventions in the semisitting position.Neurosurgery. 2009 Mar 1; 64: 533-539
- Venous air embolisms and sitting position in Helsinki pineal region surgery.Surg Neurol Int. 2018; : 9
- Prone versus sitting position in neurosurgery—differences in patients' hemodynamic management.World Neurosurg. 2017 Jan; 1: 261-266
- Neuro-ophthalmological function of patients with pineal region tumors approached transtentorially in the semisitting position.J Neurosurg. 1992 May 1; 76: 746-751
- Malignant pineal region rumors.J Neurosurg. 1979; 51: 597-607
- Three-quarter prone approach to the pineal-tentorial region.Surg Neurol. 1988; 29: 298-306
Article info
Publication history
Accepted:
December 26,
2022
Received:
November 6,
2022
Identification
Copyright
© 2022 Published by Elsevier Ltd.
