Endoscopic surgery for tumors of the pineal region via a paramedian infratentorial supracerebellar keyhole approach (PISKA)

Abstract

The tumors of the pineal region represent a significant challenge in terms of patient selection and surgical approach. Traditional surgical options were commonly used to approach this area causing considerable surgical morbidity and mortality. We report for the first time on a series of endoscopic procedures for lesions of the pineal region performed via an infratentorial supracerebellar keyhole approach (PISKA) in the prone position using endoscope-assisted and endoscope-controlled technique. A single-institution series of 11 consecutive patients (five male and six female patients [11 total cases]; mean age 21 years, range 1-75 years) treated via the endoscope-assisted and endoscope-controlled PISKA for a pathological entity in the pineal region was retrospectively reviewed. The mean follow-up time was 24 months. The endoscopic PISKA was successfully used to approach a variety of pineal lesions, including pineocytoma (three patients), pineal cysts (four patients), germinoma, lipoma, medulloblastoma, and glioblastoma (one patient each). Gross total resection was achieved in ten cases and subtotal resection in one case. The mean preoperative tumor volumes were approximately 2 × 2 cm. Five patients developed postoperatively transient Parinaud's syndrome. One patient underwent surgical revision for cerebrospinal fluid leak. There was no mortality. Ten patients had an uneventful postoperative course with restitutio ad integrum after a mean follow-up duration of 13.5 months. The endoscopically PISKA is a safe and effective minimally invasive approach that enables endoscopic treatment of different lesions of the pineal region with comparable results to standard microsurgical technique but less morbidity.

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“…Patients with benign Fig. 1 Representative case with a pineal lesion resected endoscopically [33]. A 14-year-old girl presented with headache and double vision.…”

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“…32 Most studies of endoscopic surgeries for thalamic lesions are limited to the anterior part of the thalamus 36 or endoscopic biopsy, 1,33 but none have focused on the pulvinar. Tseng et al 41 performed an endoscopic supracerebellar infratentorial retropineal approach, and Thaher et al 40 performed a paramedian infratemporal supracerebellar key approach to pineal gland tumors close to the pulvinar. These approaches are likely suitable for lesions in the pulvinar as well.…”

Recent advances in molecular biology and treatment strategies for intracranial germ cell tumors

“…[71] Multiple studies [65,66,72,73] have demonstrated ETV's safety, diagnostic efficacy, and lower morbidity and mortality compared with conventional approaches. Recently, Thaher et al [74] also reported 11 cases of endoscopic surgery via a paramedian infratentorial supracerebellar keyhole approach (PISKA) for tumors of the pineal region. They believed that the endoscopically PISKA is a safe and effective minimally invasive approach that enables endoscopic treatment of different lesions in the pineal region, accompanied with comparable results to standard microsurgical technique but with less morbidity.…”