The infratentorial supracerebellar approach in surgery of lesions of the pineal region

Abstract

Background:Surgery of pineal region lesions is considered a challenging task, due to the particular relationship of lesions in this location with neural and vascular structures. Few series with a significant experience of dealing with these patients have been reported.Methods:We review our experience using infratentorial supracerebellar approach in the surgery of pineal region, regarding the extension of the removal, postoperative morbidity, and discussing details of the surgical technique. In all cases, a supracerebellar infratentorial approach was used in the semi sitting position.Results:A total of 32 patients were operated in the past 20 years (3 germinomas, 3 teratoma, 3 pineocitoma, 2 pineal tumor of intermediate differentiation, 6 pineoblastomas, 6 low grade astrocytoma, 2 glioblastoma, 2 metastasis, 1 ependymoma, 1 epidermoid tumor, 1 cavernoma, and 2 arachnoid cyst). Total removal was achieved in 15 cases and subtotal extensive removal in 7 patients. In the remaining cases, only partial removal was possible, due to the involved pathological types. There was no surgical mortality and no cases of cerebellar venous infarction. Morbidity consisted of transient ocular movement disturbance in 14 patients, transient ataxia in 3 patients, and 1 case of local cerebrospinal fluid (CSF) fistula with meningitis that required surgical treatment.Conclusion:Supracerebellar infratentorial is a safe approach to lesions in the pineal region, and total or extensive subtotal removal is possible in most cases, with acceptable morbidity.

Our Experience with Infratentorial Supracerebellar (ITSC) Approach for Pineal Region Tumor Excision

“…22 There was total resection of tumors in 14 patients (82.3%), subtotals in 2 patients(11.8%) and only one biopsy in 1 (5.9%) in Maichzzak's series of 17 patients who harbored pineal tumors. In Konovalov's Series of 225 patients who underwent surgical excision, total tumor removal was achieved in 148(58%), subtotal in 74 (29%) and partial in 33(13%).…”

“…2,4,8,13 Tissue diagnosis can be made either stereotactic or endoscopic biopsy or open surgical proce dure. 1,2,4,8,13,15,17,19,20,22,23,26,28,31,32 These days, due to advancement in neurosurgical techniques combined with neuroanesthesia and postoperative critical care methods have made aggressive surgical resection, a mainstay of management. So, complete tumor removal has been clearly established an optional treatment for pineal tumors.…”

“…Commonly used approaches for pineal region tumors are infratentorial supracerebellar (ITSC), occipital transtentorial, transcallosal interhemispheric and transcortical transventricular 2,3,4,8,11,13,16,20,22,23,31,32 The fi rst successful removal of a pineal tumor was reported by Krause and Oppenheim in 1913 and they had removed the tumor using ITSC approach. 21 Then in 1926, Krause described modest success without operative mortality in three patients.…”

“…2,3,7,16,20,22,23,32 ITSC is indicated for small and medium sized pineal region tumor located infratentorially and in midline. This approach is performed either in sitting or in prone (Concord) position.…”

“…1,2,4,9,11,14,26,28,31 There are several surgical approaches for open surgery to pineal regions tumor, however, infratentorial supracerebellar (ITSC) approach has been widely accepted and used worldwide and about 90% of pineal region tumors can be removed using this approach. 3,16,20,22,23,32 Oppenheim and Krause reported the fi rst successful pineal region tumor removal in 1913 using ITSC approach. 21 In 1926, Krause described modest success without operative morbidity in three patients using ITSC corridor.…”