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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,

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approaches to the pineal region

Approaches to the Pineal Region

Jan M. Eckermann, MD

Department 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 region
The Pineal Region
  • Anterior: Quadrigeminal plate, pineal body, habenular complex
  • Lateral: Mesial temporal and occipital lobes, pulvinar
  • Roof: Splenium
  • Floor: Vermis
the quadrigeminal cistern
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 cistern5
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
Approaches
  • Supracerebellar – Infratentorial
  • Occiptial – Transtentorial
  • Combined Supratentorial – Infratentorial Transsinus
supracerebellar infratentorial
Supracerebellar – Infratentorial
  • Sitting or concord position
  • Midline or inverted U-shaped incision
occipital transtentorial
Occipital - Transtentorial
  • Three – quarters prone position
  • Operative side in dependent position
  • Inverted J
combined supratentorial infratentorial transsinus
Combined Supratentorial – Infratentorial Transsinus
  • Semiprone position
  • Operative side in dependent position
  • Inverted J
  • Craniotomy made in three pieces
complications and considerations
Complications and Considerations
  • Supracerebellar – Infratentorial:
  • Air embolism
  • Ventricluar collapse  SDH, pneumocephalus
  • Not suitable for superior extending lesions
  • Gravity retracting cerebellum
complications and considerations17
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 considerations18
Complications and Considerations
  • Combined Supratentorial – Infratentorial Transsinus:
  • Brain edema
  • Venous infarcts
  • Very wide exposure
  • Consider primary re-anastomosis or patch graft
references
References
  • Fossett TF and Caputy JC. Operative Neurosurgical Anatomy. Thieme: New York 2002
  • Haye AH and Laws ER. Brain Tumors. Churchill Livingstone: Edinburgh 1995