Transcript Approaches to the Pineal Region

Approaches to the Pineal
Region
Jan M. Eckermann, MD
Department of Neurosurgery
Why go there?
• Pineal cell tumors: pineocytomas,
pineoblastomas
• Germ cell tumors: teratomas, dermoid,
epidermoid, endodermal sinus, embryonal
cell, choriocarcinoma, germinoma,
• Astrocytomas, meningioma, ependymoma,
metastatic tumors
The Pineal Region
• Anterior:
Quadrigeminal plate,
pineal body,
habenular complex
• Lateral: Mesial
temporal and occipital
lobes, pulvinar
• Roof: Splenium
• Floor: Vermis
The Quadrigeminal Cistern
• Both supra- and infratentorial
• Anterior: Superior medullary velum,
quadrigeminal plate, pineal gland
• Posterior: Thick arachnoid to tentorium
• Lateral: Loose arachnoid separates from
ambient cisterns
The Quadrigeminal Cistern
• Structures within:
• Great vein of Galen
• Terminal internal cerebral
veins
• Basal vein of Rosenthal
• Pericallosal veins
• Internal occipital veins
• PCA (P4)
• Posterior choroidal a. 
cisterna velum
interpositum
Approaches
• Supracerebellar – Infratentorial
• Occiptial – Transtentorial
• Combined Supratentorial – Infratentorial
Transsinus
Supracerebellar – Infratentorial
• Sitting or concord
position
• Midline or inverted Ushaped incision
Supracerebellar – Infratentorial
Supracerebellar – Infratentorial
Supracerebellar – Infratentorial
Occipital - Transtentorial
• Three – quarters
prone position
• Operative side in
dependent position
• Inverted J
Occipital - Transtentorial
Occipital - Transtentorial
Combined Supratentorial –
Infratentorial Transsinus
• Semiprone position
• Operative side in
dependent position
• Inverted J
• Craniotomy made in
three pieces
Combined Supratentorial –
Infratentorial Transsinus
Complications and Considerations
• Supracerebellar – Infratentorial:
• Air embolism
• Ventricluar collapse  SDH,
pneumocephalus
• Not suitable for superior extending lesions
• Gravity retracting cerebellum
Complications and Considerations
• Occiptial – Transtentorial:
• Retraction of occipital lobes  visual field
defects
• Disconnection syndrome
• Limited exposure of contralateral side
• Good view of quadrigeminal plate
Complications and Considerations
• Combined Supratentorial –
Infratentorial Transsinus:
• Brain edema
• Venous infarcts
• Very wide exposure
• Consider primary re-anastomosis or patch
graft
References
• Fossett TF and Caputy JC. Operative
Neurosurgical Anatomy. Thieme: New York
2002
• Haye AH and Laws ER. Brain Tumors.
Churchill Livingstone: Edinburgh 1995