Supracerebellar infratentorial endoscopically controlled resection of pineal lesions: case series and operative technique

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The heterogeneous clinical manifestations and operative characteristics of pathological entities in the pineal region represent a significant challenge in terms of patient selection and surgical approach. Traditional surgical options have included endoscopic transventricular resection; open supratentorial microsurgical approaches through the midline, choroidal fissure, lateral ventricle, and tentorium; and supracerebellar infratentorial (SCIT) approaches through the posterior fossa. The object of the current study was to review the preoperative characteristics and outcomes for a cohort of patients treated purely via the novel endoscopically controlled SCIT approach.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A single-institution series of 9 consecutive patients (4 male and 5 female patients [10 total cases]; mean age 21 years, range 6–37 years) treated via the endoscopically controlled SCIT approach for a pathological entity in the pineal region was retrospectively reviewed. The mean follow-up time was 13.2 months.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>The endoscopically controlled SCIT approach was successfully used to approach a variety of pineal lesions, including pineal cysts (6 patients), epidermoid tumor, WHO Grade II astrocytoma (initial biopsy and recurrence), and malignant mixed germ cell tumor (1 patient each). Gross-total resection and/or adequate cyst fenestration was achieved in 8 cases. Biopsy with conservative debulking was performed for the single case of low-grade astrocytoma and again at the time of recurrence.</jats:p> <jats:p>The mean preoperative tumor and cyst volumes were 9.9 ± 4.4 and 3.7 ± 3.2 cm<jats:sup>3</jats:sup>, respectively. The mean operating times were 212 ± 71 minutes for tumor cases and 177 ± 72 minutes for cysts. Estimated blood loss was less than 150 ml for all cases. A single case (pineal cyst) was converted to an open microsurgical approach to enhance visualization. There were no operative complications, as well as no documented CSF leaks, additional CSF diversion procedures, or air emboli. Seven patients underwent concomitant third ventriculostomy into the quadrigeminal cistern. At the time of the last follow-up evaluation, all patients had a stable or improved modified Rankin Scale score.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The endoscopically controlled SCIT approach may be used for the biopsy and resection of appropriately selected solid tumors of the pineal region, in addition to the fenestration and/or resection of pineal cysts. Preoperative considerations include patient presentation, anticipated disease and vascularity, degree of local venous anatomical distortion, and selection of optimal paramedian trajectory.</jats:p></jats:sec>

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

“…Endoscopic supracerebellar infratentorial approaches to this region have also been recently developed. [611272931]…”

“…The cistern magna was then opened in all cases, allowing for the exit of a large amount of CSF, making possible the access to the superior surface of both cerebellar hemispheres without retraction. Although significant improvements with the use of smaller craniotomies and endoscopic approaches have been described,[61126272931] a large craniotomy makes possible to take full advantage of the effect of gravity.…”

Modified Pure Endoscopic Approach to Pineal Region: Proof of Concept of Efficient and Inexpensive Surgical Model Based on Laboratory Dissections

“…Choque-Velasquez 5 routinely passed through the endoscope ports, but they are used independently of the endoscope over the cerebellar surface in order to reduce the risks of potential complications. 3,20 Differently from the previous reports, in our model we used an inexpensive borescope, which was connected to a 16 inches personal computer monitor. The borescope offered a satisfactory view of the main neurovascular structures of the pineal region.…”

“…However, a small craniotomy of about [3][4] cm is enough to access to the pineal region through the MAPEnd we describe. 1,3,20 The introduction of the endoscope under microscopic control is recommended in order to decrease the risk of accidental mechanical injury. 21 However, we did not experience any inadvertent damage of neurovascular structures even if a microscope was not available, thanks to a careful insertion of the borescope.…”

An overview of the current surgical options for pineal region tumors

“…[6065] Uschold et al . reported using the endoscope for excision of pineal cysts and selected solid tumors of the pineal region.…”