Pineal region approach [Neurosurgery Wiki]

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====== Pineal region approach ======

//J.Sales-Llopis//

//Neurosurgery Service, Alicante University General Hospital, Alicante Institute for Health and
Biomedical Research (ISABIAL - FISABIO Foundation), Alicante, Spain.//

----

[[Victor Horsley]]
((Horsley V: Discussion. Proc R Soc Med 3:2, 1910 Unverified))
was the first to attempt the direct removal of a [[pineal region tumor]] in [[1910]]. Since then, various surgical approaches to the [[pineal region]] have been reported.

[[Walter Edward Dandy]] reached the pineal region down the right side of the falx and through the [[splenium]]. Stein reemphasized the route used by [[Fedor Krause]] in 1926, which consisted of the infratentorial–supracerebellar approach to the pineal region 

Many neurovascular structures form a formidable obstacle to the operative [[approach]] to this [[region]]. The approaches suitable for reaching the pineal region are the infratentorial supracerebellar, occipital transtentorial, posterior transcallosal, posterior transcortical and posterior subtemporal routes. ((Yamamoto I. Pineal region tumor: surgical anatomy and approach. J Neurooncol. 
2001 Sep;54(3):263-75. Review. PubMed PMID: 11767292.
)).

When approaching the pathology hosted by the region, [[pineal tumor]]s and [[pineal cyst]]s being the most common, a calculated preoperative assessment of anatomical relationships is warranted in order to preserve the veins draining vital structures of the [[diencephalon]]
((Hernesniemi J, Romani R, Albayrak BS, Lehto H, Dashti R, Ramsey C 3rd, Karatas
A, Cardia A, Navratil O, Piippo A, Fujiki M, Toninelli S, Niemelä M.
Microsurgical management of pineal region lesions: personal experience with 119
patients. Surg Neurol. 2008 Dec;70(6):576-83. doi: 10.1016/j.surneu.2008.07.019. 
PubMed PMID: 19055952.
))
((Nevins EJ, Das K, Bhojak M, Pinto RS, Hoque MN, Jenkinson MD, Chavredakis E.
Incidental Pineal Cysts: Is Surveillance Necessary? World Neurosurg. 2016
Jun;90:96-102. doi: 10.1016/j.wneu.2016.02.092. Epub 2016 Mar 2. PubMed PMID:
26944882.
))
((Oliveira J, Cerejo A, Silva PS, Polónia P, Pereira J, Vaz R. The
infratentorial supracerebellar approach in surgery of lesions of the pineal
region. Surg Neurol Int. 2013 Nov 30;4:154. doi: 10.4103/2152-7806.122504.
eCollection 2013. PubMed PMID: 24381797; PubMed Central PMCID: PMC3872645.
))
((Rhoton AL Jr. Tentorial incisura. Neurosurgery. 2000 Sep;47(3 Suppl):S131-53. 
PubMed PMID: 10983307.
)).


The extension of the lesion, its size, expected consistency, vascularity, and position relative
to the deep venous system, as well as the surgeon’s own training and experience, dictate the choice of the approach
((Hernesniemi J, Romani R, Albayrak BS, Lehto H, Dashti R, Ramsey C 3rd, Karatas
A, Cardia A, Navratil O, Piippo A, Fujiki M, Toninelli S, Niemelä M.
Microsurgical management of pineal region lesions: personal experience with 119
patients. Surg Neurol. 2008 Dec;70(6):576-83. doi: 10.1016/j.surneu.2008.07.019. 
PubMed PMID: 19055952.
))
((Nevins EJ, Das K, Bhojak M, Pinto RS, Hoque MN, Jenkinson MD, Chavredakis E.
Incidental Pineal Cysts: Is Surveillance Necessary? World Neurosurg. 2016
Jun;90:96-102. doi: 10.1016/j.wneu.2016.02.092. Epub 2016 Mar 2. PubMed PMID:
26944882.
))
((Abecassis IJ, Hanak B, Barber J, Mortazavi M, Ellenbogen RG. A
Single-Institution Experience with Pineal Region Tumors: 50 Tumors Over 1 Decade.
Oper Neurosurg (Hagerstown). 2017 Oct 1;13(5):566-575. doi: 10.1093/ons/opx038.
PubMed PMID: 28922884.
))
((Hart MG, Santarius T, Kirollos RW. How I do it--pineal surgery:
supracerebellar infratentorial versus occipital transtentorial. Acta Neurochir
(Wien). 2013 Mar;155(3):463-7. doi: 10.1007/s00701-012-1589-5. Epub 2012 Dec 27. 
PubMed PMID: 23269352.))
((Matula C. Tumors of the pineal region. In: Ellenbogen RG, Sekhar LN (eds). Principles of
Neurological Surgery (3rd ed). Elsevier, Philadelphia pp:565-578; 2012.))
((Patel PG, Cohen-Gadol AA, Mercier P, Boop FA, Klimo P Jr. The Posterior
Transcallosal Approach to the Pineal Region and Posterior Third Ventricle:
Intervenous and Paravenous Variants. Oper Neurosurg (Hagerstown). 2017 Feb
1;13(1):77-88. doi: 10.1227/NEU.0000000000001268. PubMed PMID: 28931256.
))
((Simon E, Afif A, M'Baye M, Mertens P. Anatomy of the pineal region applied to 
its surgical approach. Neurochirurgie. 2015 Apr-Jun;61(2-3):70-6. doi:
10.1016/j.neuchi.2013.11.008. Epub 2014 May 20. PubMed PMID: 24856313.
))
((Yağmurlu K, Zaidi HA, Kalani MYS, Rhoton AL Jr, Preul MC, Spetzler RF.
Anterior interhemispheric transsplenial approach to pineal region tumors:
anatomical study and illustrative case. J Neurosurg. 2018 Jan;128(1):182-192.
doi: 10.3171/2016.9.JNS16279. Epub 2017 Jan 13. PubMed PMID: 28084911.
))
((Youssef AS, Downes AE, Agazzi S, Van Loveren HR. Life without the vein of
Galen: Clinical and radiographic sequelae. Clin Anat. 2011 Sep;24(6):776-85. doi:
10.1002/ca.21176. Epub 2011 Mar 24. Review. PubMed PMID: 21438020.
)).

In this region, the [[Infratentorial supracerebellar approach]] and [[Occipital transtentorial approach]] are the two most commonly used approaches, using microsurgical, endoscopic, or combined techniques 
((Yamamoto I. Pineal region tumor: surgical anatomy and approach. J Neurooncol. 
2001 Sep;54(3):263-75. Review. PubMed PMID: 11767292.
))
((Hart MG, Santarius T, Kirollos RW. How I do it--pineal surgery:
supracerebellar infratentorial versus occipital transtentorial. Acta Neurochir
(Wien). 2013 Mar;155(3):463-7. doi: 10.1007/s00701-012-1589-5. Epub 2012 Dec 27. 
PubMed PMID: 23269352.))
((Cardia A, Caroli M, Pluderi M, Arienta C, Gaini SM, Lanzino G, Tschabitscher
M. Endoscope-assisted infratentorial-supracerebellar approach to the third
ventricle: an anatomical study. J Neurosurg. 2006 Jun;104(6 Suppl):409-14. PubMed
PMID: 16776376.))
((Gore PA, Gonzalez LF, Rekate HL, Nakaji P. Endoscopic supracerebellar
infratentorial approach for pineal cyst resection: technical case report.
Neurosurgery. 2008 Mar;62(3 Suppl 1):108-9; discussion 109. doi:
10.1227/01.neu.0000317380.60938.79. PubMed PMID: 18424974.
))
((Liu JK. Endoscopic-assisted interhemispheric parieto-occipital transtentorial 
approach for microsurgical resection of a pineal region tumor: operative video
and technical nuances. Neurosurg Focus. 2016 Jan;40 Video Suppl
1:2016.1.FocusVid.15450. doi: 10.3171/2016.1.FocusVid.15450. PubMed PMID:
26722692.
))
((Tanikawa M, Yamada H, Kitamura T, Sakata T, Mase M. Endoscopic Occipital
Transtentorial Approach for Pineal Region Tumor. Oper Neurosurg (Hagerstown).
2018 Feb 1;14(2):206-207. doi: 10.1093/ons/opx089. PubMed PMID: 29351684.
)).

When planning a pineal region approach, among the pivotal anatomic guidelines is the tentorial alignment, since a “steep” [[tentorium]] demands a switch from a [[Supracerebellar Infratentorial approach]] to [[Occipital transtentorial approach]]
((Syed HR, Jean WC. A Novel Method to Measure the Tentorial Angle and the
Implications on Surgeries of the Pineal Region. World Neurosurg. 2018
Mar;111:e213-e220. doi: 10.1016/j.wneu.2017.12.037. Epub 2017 Dec 16. PubMed
PMID: 29258947.
)).
----



Neurovascular, particularly venous, relationships of the pineal region are the most complex in the cranium because the ICVs, BVs, and their tributaries converge at the vein of Galen. 

Contains the [[Pineal gland]].
Tumors in this region can be of a wide variety of types; the most common are germ cell tumors, which arise from developmental abnormalities, and pineal cell tumors, which come from the cells of the [[pineal gland]] itself. 

Deeply located beneath the corpus callosum and surrounding by crucial veins, the pineal and tectal structures still challenge the surgeon. Either anterior or posterior, many surgical approaches have been developed to reach the pineal region. Most popular are likely the posterior suboccipital or occipito-parietal transtentorial routes. Others, primarily transcallosal or supracerebellar, may be indicated depending of the extension of the tumors while the transcortical routes (frontal, parietal or atrial) have been almost given up
(({{pubmed>long:24629622}}))


Pineal region tumors pose certain challenges in regard to their resection: a deep surgical field, associated critical surrounding neurovascular structures, and narrow operative working corridor due to obstruction by the apex of the [[culmen]]. 

{{::pineal_region.png?400|}}


[[Anterior interhemispheric transsplenial approach]].

[[Supracerebellar infratentorial approach]]
((Stein BM. The infratentorial supracerebellar approach to pineal lesions. J
Neurosurg. 1971 Aug;35(2):197-202. PubMed PMID: 5315191.
)).

[[Lateral supracerebellar infratentorial approach]].

[[Occipital transtentorial approach]].

[[Posterior interhemispheric transcallosal approach]].

[[Suboccipital transtentorial approach]].

[[Transcallosal interforniceal approach]].

A common approach to lesions of the pineal region is along the midline below the [[torcula]]. However, reports of how shifting the approach off midline affects the surgical exposure and relationships between the tributaries of the [[vein of Galen]] are limited.

Understanding the characteristics of different infratentorial routes to the [[pineal gland]] will aid in gaining a better view of the pineal gland and cerebellomesencephalic fissure and may reduce the need for venous sacrifice at the level of the tentorial sinuses draining the upper cerebellar surface and the tributaries of the vein of Galen
((Matsuo S, Baydin S, Güngör A, Miki K, Komune N, Kurogi R, Iihara K, Rhoton AL 
Jr. Midline and off-midline infratentorial supracerebellar approaches to the
pineal gland. J Neurosurg. 2017 Jun;126(6):1984-1994. doi:
10.3171/2016.7.JNS16277. Epub 2016 Oct 7. PubMed PMID: 27715436.
)).