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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,

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Approaches to the Pineal Region

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  1. Approaches to the Pineal Region Jan M. Eckermann, MD Department of Neurosurgery

  2. 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

  3. The Pineal Region • Anterior: Quadrigeminal plate, pineal body, habenular complex • Lateral: Mesial temporal and occipital lobes, pulvinar • Roof: Splenium • Floor: Vermis

  4. 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

  5. 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

  6. Approaches • Supracerebellar – Infratentorial • Occiptial – Transtentorial • Combined Supratentorial – Infratentorial Transsinus

  7. Supracerebellar – Infratentorial • Sitting or concord position • Midline or inverted U-shaped incision

  8. Supracerebellar – Infratentorial

  9. Supracerebellar – Infratentorial

  10. Supracerebellar – Infratentorial

  11. Occipital - Transtentorial • Three – quarters prone position • Operative side in dependent position • Inverted J

  12. Occipital - Transtentorial

  13. Occipital - Transtentorial

  14. Combined Supratentorial – Infratentorial Transsinus • Semiprone position • Operative side in dependent position • Inverted J • Craniotomy made in three pieces

  15. Combined Supratentorial – Infratentorial Transsinus

  16. Complications and Considerations • Supracerebellar – Infratentorial: • Air embolism • Ventricluar collapse  SDH, pneumocephalus • Not suitable for superior extending lesions • Gravity retracting cerebellum

  17. Complications and Considerations • Occiptial – Transtentorial: • Retraction of occipital lobes  visual field defects • Disconnection syndrome • Limited exposure of contralateral side • Good view of quadrigeminal plate

  18. Complications and Considerations • Combined Supratentorial – Infratentorial Transsinus: • Brain edema • Venous infarcts • Very wide exposure • Consider primary re-anastomosis or patch graft

  19. References • Fossett TF and Caputy JC. Operative Neurosurgical Anatomy. Thieme: New York 2002 • Haye AH and Laws ER. Brain Tumors. Churchill Livingstone: Edinburgh 1995

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