Transverse Sinus-Tentorium Splitting Approuch for Pineal Region Tumors. Case Report.

Abstract

Fig. 1 Preoperative T 1 -weighted magnetic resonance images with gadolinium revealing a pineal region mass with multiple components. left: Axial view, right: sagittal view. AbstractA 15-year-old boy with a large pineal region mass was admitted to our institute. The tentative diagnosis was mixed germ cell tumor. Tumor resection was carried out via a transverse sinus-tentorium splitting approach. The tumor tissue was completely resected, and no operative complication other than transient vertical gaze paresis was noted. The histological diagnosis was mixed germ cell tumor composed of mature and immature teratoma, germinoma, and embryonal carcinoma. After three courses of chemotherapy, the patient underwent external irradiation. He remained asymptomatic with no signs of recurrence 42 months after the surgery. The combination of the infratentorial supracerebellar approach and the occipital transtentorial approach provides excellent views and work space above and below the tentorial notch. Transverse sinus section is not mandatory for this approach, but sectioning of the unilateral transverse sinus and the tentorium along the rectal sinus allows retraction of the falx and the underlying brain to the opposite side. Thus, a much wider horizontal and vertical projection is obtained. This approach enables safer and more extensive tumor removal for large pineal region tumors.

An overview of the current surgical options for pineal region tumors

“…[45] Subsequently, a variety of approaches to access lesions of the pineal region were devised and modified over the years. These approaches include the supracerebellar infratentorial,[28] occipital transtentorial,[49] combined supra-infratentorial transsinus,[45972] posterior transcallosal interhemispheric,[13] and transcortical transventricular[66] approaches. The infratentorial supracerebellar and the occipital transtentorial approaches [Figure 1] are currently the most frequently used access ways to excise lesions of the pineal region.…”

Three-dimensional Computed Tomography Angiography of the Galenic System for the Occipital Transtentorial Approach

“…2,4,7,18,29,37,43,50) The greatest advantage of the occipital transtentorial approach over Stein's approach is the excellent operative view both above and below the tentorial notch, especially for removal of large tumors with extension in the superior, lateral (to the thalamus), and posterior-inferior (to the midbrain) directions or tumors that involve the deep venous system. 3,7,16,17,20,31,44,50) However, the vein of Galen, the basal vein ipsilateral to the approach, and the internal cerebral vein (ICV) may obstruct tumor removal 24,31,33,36) ; the superior sagittal sinus and the falx obstruct any approach from the midline trajectory, so tumors extending to the opposite side or anterior third ventricle cannot be easily reached 24,31,33,36,44) ; and visualization of the contralateral quadrigeminal region and ipsilateral lateral wall of the third ventricle is poor.…”