Approaches to the Pineal Approaches to the Pineal RegionRegion

Jan M. Eckermann, MDJan M. Eckermann, MD

Department of NeurosurgeryDepartment of Neurosurgery

Why go there?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 RegionThe Pineal Region

• Anterior: Quadrigeminal plate, pineal body, habenular complex

• Lateral: Mesial temporal and occipital lobes, pulvinar

• Roof: Splenium• Floor: Vermis

The Quadrigeminal CisternThe 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 CisternThe 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

ApproachesApproaches

• Supracerebellar – Infratentorial

• Occiptial – Transtentorial

• Combined Supratentorial – Infratentorial Transsinus

Supracerebellar – Infratentorial Supracerebellar – Infratentorial

• Sitting or concord position

• Midline or inverted U-shaped incision

Supracerebellar – InfratentorialSupracerebellar – Infratentorial

Supracerebellar – InfratentorialSupracerebellar – Infratentorial

Supracerebellar – InfratentorialSupracerebellar – Infratentorial

Occipital - TranstentorialOccipital - Transtentorial

• Three – quarters prone position

• Operative side in dependent position

• Inverted J

Occipital - TranstentorialOccipital - Transtentorial

Occipital - TranstentorialOccipital - Transtentorial

Combined Supratentorial – Combined Supratentorial – Infratentorial TranssinusInfratentorial Transsinus

• Semiprone position• Operative side in

dependent position• Inverted J• Craniotomy made in

three pieces

Combined Supratentorial – Combined Supratentorial – Infratentorial TranssinusInfratentorial Transsinus

Complications and ConsiderationsComplications and Considerations

• Supracerebellar – Infratentorial:

• Air embolism

• Ventricluar collapse SDH, pneumocephalus

• Not suitable for superior extending lesions

• Gravity retracting cerebellum

Complications and ConsiderationsComplications 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 ConsiderationsComplications and Considerations

• Combined Supratentorial – Infratentorial Transsinus:

• Brain edema

• Venous infarcts

• Very wide exposure

• Consider primary re-anastomosis or patch graft

ReferencesReferences

• Fossett TF and Caputy JC. Operative Neurosurgical Anatomy. Thieme: New York 2002

• Haye AH and Laws ER. Brain Tumors. Churchill Livingstone: Edinburgh 1995