====== Pineal Region Meningioma Surgery ======

[[Pineal region meningioma]]s are rare, deep-seated tumors that present significant surgical challenges due to the surrounding critical neurovascular anatomy.

===== 🧠 Anatomical Considerations =====

The pineal region is bordered by vital structures:
  * Deep venous system:
    * Internal cerebral veins
    * Vein of Galen
    * Basal veins of Rosenthal
  * Brainstem (especially the tectal plate - superior colliculi)
  * Thalami and splenium of corpus callosum
  * Aqueduct of Sylvius (obstructive hydrocephalus risk)
  * Tentorial incisura and straight sinus

===== 🩺 Indications for Surgery =====

Surgical intervention is indicated when:
  * The tumor causes symptoms (e.g. hydrocephalus, Parinaud’s syndrome, headaches, ataxia)
  * There is progressive growth or mass effect
  * Histological diagnosis is required
  * The lesion is deemed operable with acceptable risk

===== 🛠️ Surgical Approaches =====

Main approaches depending on tumor location and venous anatomy:

====Approaches===
Unilateral [[occipital transtentorial approach]] (Poppen's approach). 

  * **Occipital transtentorial approach (OTA)**
    * Suitable for tumors above the vein of Galen
    * Wide surgical corridor
    * Risk: occipital lobe retraction → visual field deficits

  * **Supracerebellar infratentorial approach (SCITA)**
    * Ideal for lesions below the vein of Galen
    * Less cortical manipulation
    * Patient usually in sitting or park-bench position

  * **Interhemispheric transcallosal or parietal transventricular**
    * Less common
    * Used for tumors extending into lateral ventricles

===== ⚠️ Surgical Risks =====

  * Injury to deep veins (especially vein of Galen or internal cerebral veins) → potentially fatal
  * Persistent or worsened hydrocephalus
  * Visual impairment from retraction or ischemia
  * Brainstem injury → ataxia, gaze palsy

===== 🧪 Postoperative Management =====

  * Monitor neurological status and signs of hydrocephalus
  * Early postoperative MRI for resection control
  * Temporary or permanent CSF diversion (EVD or VP shunt) if needed
  * Histological diagnosis (typically WHO Grade I meningioma)

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**Tip:** Detailed preoperative planning with venous imaging (MRV or DSA) is essential to avoid injuring the deep venous system.