Suboccipital Transtentorial Approach Research Articles

The sub-occipital transtentorial approach for pineal region tumors: how I do it.

Two major approaches exist for the surgical removal of pineal region tumors: the supracebellar infratentorial and the sub-occipital transtentorial. We present the Lyon's technique of the sub-occipital transtentorial approach for pineal region tumors and our tricks to avoid complications. The principle is to expose the pineal region under the occipital lobe and not through the interhemispheric fissure. The sub-occipital transtentorial approach is a direct, extra cerebral, safe, and effective way to access tumors of the pineal region.

A Rare Case of Atypical Pleomorphic Neoplasm of Pineal Region in a Child: A Case Report

A 10-year-old boy with no past medical history presented with complaints of nausea and vomiting associated with morning headache for the last month. Ophthalmic nerve and eye exam showed diplopia and strabismus with no other significant findings on physical and neurological examination. Magnetic resonance imaging (MRI) of the brain revealed a homogenous hyperdense and enhancing mass in the pineal region. The endoscopic biopsy of the pineal region demonstrated the cells with highly pleomorphic and hyperchromatic nuclei with an increase in mitotic activity. There were many vessels but no area of vascular proliferation and necrosis. Granular bodies with eosinophilia were identified. Immunohistochemistry was positive for class III b-tubulin with epidermal growth factor receptor (EGFR) staining and glial fibrillary acidic protein (GFAP). Immunostaining was positive for p53, Phosphatase and Tensin homolog (PTEN), and oligodendrocyte transcription factor (OLIG2), while staining for cluster of differentiation (CD)34, cytokeratin (CK), human melanoma black (HMB)45, and isocitrate dehydrogenase (IDH)-R132H mutation was negative, consistent with atypical pleomorphic neoplasm of the pineal region. The patient underwent tumor resection via a sub-occipital trans-tentorial approach, followed by one dose of chemotherapy. The patient experienced a resolution of the symptom and was doing well on his bi-monthly follow up.

Surgical Approaches to the Thalamus in Relation to the White Matter Tracts of the Cerebrum

Approaching the thalamus from any angle remains a challenge because of its deep-seated location and intimate relations with adjacent important neurovascular structures and functions such as relaying sensory and motor signals and cognition. Our aim was to explore the relationship of the white matter tracts of the cerebrum to the thalamus using a fiber dissection technique, to delineate anatomic principles of approaches to the thalamus, and to discuss the tracts at risk in relation to each approach. The thalamus was subdivided into 6 different regions and 13 approaches were examined in an attempt to describe a surgical road map. To reach the anteroinferior, medial, and lateral parts of the thalamus, the anterior and middle group approaches were used, and to reach the posterosuperior and posteroinferior thalamus, posterior and middle group approaches were used. The anteroinferior zone was the most difficult site to be accessed and the posterosuperior thalamus had the maximum number of alternative approaches. The distal transsylvian approach to the posterosuperior thalamus and the supracarotid infrafrontal approach to the anteroinferior thalamus had the highest number of neural structures severed within the surgical corridor. The infratentorial approaches and the suboccipital transtentorial approach preserve most of the white matter tracts en route to the posterosuperior and medial posteroinferior parts of the thalamus. When the surgical approaches for thalamic lesions are defined, white matter tracts along the surgical route should be taken into consideration.

Surgical Management of Brainstem Cavernous Malformation: Report of 67 Patients

Brainstem cavernous malformations (CMs) are benign lesions, often show an acute onset, and result in a high rate of morbidity. Surgical resection could inhibit the progressive deterioration of neurologic function caused by repetitive hemorrhage. This study aimed to summarize timing, approaches, and techniques of surgery and to evaluate outcomes of treatment. Between March 2011 and May 2013, 67 patients (32 male, 35 female; average age 40 years; range, 14-68 years) with brainstem CMs received surgical treatment. Clinical presentation, surgical approaches, and results of follow-up were retrospectively analyzed. Seven surgical approaches were used: orbitozygomatic approach (1 case), suboccipital transtentorial approach (Poppen approach; 3 cases), subtemporal transtentorial approach (32 cases), subtemporal transtentorial/anterior petrosectomy approach (9 cases), suboccipital retrosigmoid approach (3 cases), midline suboccipital approach (16 cases), and far lateral approach (3 cases). Total resection of the brainstem CM was achieved in all cases (100%). No operative mortality was encountered. Nine patients had new symptoms after surgery: 3 had diplopia, 3 had facial numbness, 1 had numbness of contralateral limbs, 1 had transient aphasia, and 1 had reduced muscle strength of contralateral limbs. Symptoms significantly improved in 23 patients (34.3%), symptoms were unchanged in 36 patients (53.7%), and new postoperative symptoms occurred in 9 patients (13.4%). Choosing a proper surgical approach and using appropriate techniques are fundamental for favorable outcomes of patients with brainstem CMs.

Tectal plate tumours. Our experience with a paediatric surgical series

IntroductionExophytic tectal plate tumours are a particular kind of brain stem tumour that can be treated with microsurgical resection. This paper reports our surgical experience with a paediatric series stressing and underlines the fact that this surgery can be possible because the rate of surgical mortality is low in experienced hands with acceptable morbidity. Material and methodsFrom 1997 to 2010, 27 patients were treated for exophytic tectal plate tumours. The clinical symptomatology was characterized by an intracranial hypertensive syndrome in 77% of cases, visual disorders in 36% of cases and a Parinaud's syndrome in 12% of cases. All patients were studied using a pre-operative cranio-spinal MRI with and without gadolinium. Hydrocephalus was present in 20 cases treated with a VP shunt in 6 cases and an ETV in the other cases. The surgical removal was total in 60% of cases, partial in 28% of cases and only a large biopsy in 12% of cases. From an histological point of view benign gliomas were diagnosed in 84% of cases and in 16% of cases were classified as WHO grade II and III. Eight patients needed complementary treatment, four with chemotherapy and four with chemotherapy associated to radiotherapy. As a surgical complication two patients had hydrocephalus, one patient had a sub-dural acute haematoma, two patients had an infectious complication requiring surgical treatment and antibiotic therapy, and 5 patients a mechanical shunt dysfunction. No post-surgical mortality was observed. ResultsThe most recent results after a median survival of 4.3years show that 22 patients are still alive while 5 patients died of a progressive disease. Twenty patients in school age continue to follow a normal school programme but 10 patients need assistance. ConclusionExophytic tectal plate tumours can be treated based on a microsurgical approach in paediatric patients. In experienced hands surgery can be performed with an acceptable morbidity and with zero percent mortality. In our experience, the sub-occipital transtentorial approach permits a wide view of the region and safe surgical removal.

Update on the management of pineal cysts: Case series and a review of the literature

ObjectiveThe natural history of pineal cysts still remains unclear. Incidental pineal cysts have become more common which raises the question of their management. Symptomatic pineal cysts may require a surgical solution but therapeutic indications have not yet been clearly established. MethodFrom 1986 to 2012, 26 patients with pineal cysts were identified. Their medical records were retrospectively assessed focusing on the initial symptoms, imaging characteristics of the cyst, management strategy, operative technique and their complications, as well as the latest follow-up. A systematic review of the literature is also presented. ResultsTwenty-six patients with pineal cysts were identified. The mean age was 23.5 years ranging from 7 to 49 years. Symptoms included intracranial hypertension with obstructive hydrocephalus in 18 cases and oculomotor anomalies in 12 cases. Two adult cases presented with non-specific headaches and did not require surgery. Twenty patients were operated via a suboccipital transtentorial approach with total removal of the cyst in 70% of the cases, while the remaining 4 cases were treated with an intraventricular endoscopic marsupialization associating a third ventriculostomy. Four patients required a preoperative ventriculo-peritoneal shunt due to life-threatening obstructive hydrocephalus. Overall, peri-operative mortality was nil. In the two non-operated patients, the cyst remained stable and no recurrences were observed in all operated patients with a mean follow-up of 144 months. ConclusionIn the majority of incidental pineal cysts, a clinical and imaging follow-up is sufficient but occasionally not required especially in adults as very rare cases of increase in size have been reported.

Supracerebellar infratentorial approach for pineal region tumors: Our surgical and technical considerations

The infratentorial supracerebellar approach is most widely used for pineal tumors. We report our own experience and technical considerations using this approach. MaterialFrom 1982 to 2010, we operated on 232 patients with pineal region tumors. Of these, 201 patients were operated on using a suboccipital transtentorial approach while 31 patients were operated on using a supracerebellar infratentorial approach. The median age of the patients ranged between 8months and 74years. There were 19 children and 12 adults. All patients presented with elevated intracranial pressure. There were 6 pinealocytomas, 3 papillary tumors, 7 germinomas, 2 benign teratomas, 4 pineal cysts and 9 gliomas. Adjuvant post-surgical therapy consisted of chemo-radiotherapy in 4 patients, 2 with germinomas and 2 with a grade II/III gliomas. Radiotherapy was performed in the other twelve patients (5 germinomas and 7 gliomas). Results and complicationsAll patients are still alive at a median follow-up of eight years. Twelve of the 19 children are attending normal school classes for their age, 5 are attending classes for special needs children and 2 are not yet of school age at the last follow-up. Seven of the 12 adults are working normally, three are working part-time at the same job and two have retired but are able to lead a normal life. Postoperative complications included symptomatic diffuse cerebellar edema (one patient) completely resolved with a mild residual cerebellar syndrome; double vision secondary to IV nerve palsy (one patient); transitory Parinaud's syndrome (2 patients) and cerebellar gait (2 patients) nearly completely recovered at respectively six and twelve months. ConclusionThe supracerebellar infratentorial approach seems to be a safe and effective choice in the treatment of pineal region tumors. In our experience, it permits complete tumor resections with acceptable morbidity and all neurosurgeons should master this approach in order to adapt their surgical choice according to size, extent and the relationship of the lesion with the surrounding anatomical structures.

The sub-occipital transtentorial approach revisited base on our own experience

The surgical experience of the sub-occipital approach for treatment of pineal gland and pineal region tumors is reported. This approach was originally proposed by Jamieson and modified by Lapras who by changing the shape of the bone flap obtained the elevation of the occipital lobe which consequently resulted in a better exposition of this deep region. The reason why this approach became the basis for their treatment is particularly related to the personal experience of Lapras who reported his fantastic experience of surgery in this deep area and demonstrated the advantages of the sub-occipital transtentorial approach. MaterialOut of 277 patients operated from 1982 to 2012 in Lyon for a pineal tumor, 233 were treated by a sub-occipital approach: 153 males, 125 females, 75 patients of pediatric age. The majority of patients were operated on in a sitting position which represents a surgical specialty of the anesthesiological school of Lyon. ResultsComplete tumor removal was possible in 135 patients (58%) and partial in 60 patients (26%). For 38 patients, it was not possible to establish the quality of surgical resection. The incidence of hemianopsia decreased to less that 2% of cases while the incidence of severe pneumocephaly which requires a prolonged intensive care hospitalization was less than 4% of cases. Mortality related to this surgical approach in the Lyonnais school series was 0% during this period. ConclusionIn our experience the sub-occipital transtentorial approach seems to us the best approach for pineal tumors because it permits a large exposition of the pineal region favoring the removal of the tumor with a lateral extension and also for tumors extending low into the posterior cranial fossa. In fact, this is our preferred approach because it has been used in a large majority of cases. However, surgeons have to be familiar with other possible approaches to obtain the best result in terms of removal and also to decrease the rate of sequelae to improve the quality of life of these patients.

The Suboccipital Transtentorial Approach: Indications, Technique, and Outcomes in Five Illustrative Cases

Introduction: The suboccipital retrosigmoid approach is an effective alternative to transpetrosal approaches to petroclival meningiomas. Samii modified this with a retrosigmoid intradural suprameatal approach to increase access to the middle fossa and Meckel's cave. More recently, Watanabe et al modified this by preferentially dividing the tentorium with limited drilling of the suprameatal bone, which they termed the “lateral supracerebellar transtentorial approach.” Poppen introduced sectioning of the tentorium via an occipital approach for pineal region pathology. We present our experience with a suboccipital transtentorial approach.

Use of 3D-computed tomography angiography for planning the surgical removal of pineal region meningiomas using Poppen's approach: a report of ten cases and a literature review

BackgroundThere are several treatment approaches for pineal region meningiomas, such as Poppen's approach, Krause's approach and combinations of the two approaches. We present our experience with the use of 3D-computed tomography angiography for planning the surgical removal of pineal region meningiomas using a suboccipital transtentorial approach (Poppen's approach) and evaluate the role of Poppen's approach.MethodsDuring the period from January 2005 to June 2010, ten patients presented to us with pineal region meningioma. MRI was routinely used to define the tumor size, position, and its relevant complications while 3D-CTA was applied to define the blood supply of the tumor and the venous complex (VC) shift before operations. Most of the meningiomas had developed at both sides of the tentorial plane and extended laterally with typical characteristics of a pineal region tumor.ResultsAll tumors were completely removed surgically without any injury to the VC. Postoperative intracranial infection occurred in one case who recovered after antibiotics were given. Postoperative intraventricular hemorrhage and pneumocephalus were found in one case, but fully recovered after conservative treatment. In the nine cases of concurrent hydrocephalus, this was gradually relieved in eight patients and the single case that became aggravated was successfully treated with ventriculoperitoneal shunt. Moreover, the follow-up MRI examinations did not indicate any recurrence of the meningiomas.ConclusionWe found that the use of Poppen's approach is strongly supported for the successful removal of pineal region meningiomas without serious complications.

Meningiomas of pineal region in children

Meningiomas are uncommon tumors in children and either more rarely encountered in the pineal region. We report two cases of meningioma of the pineal region in children. One of these cases was a five years-old girl and the other a one year-old boy. No specific clinical presentation or tomographic examinations findings was identified before treatment, suggestive of a diagnosis of meningioma. The clinical and laboratory features were very similar to the most common tumors of the pineal region. Prior to the surgery, the histology of these tumors was not suspected. Both patients underwent direct surgery and complete removal was achieved by a suboccipital transtentorial approach. The tumors originated from velum interpositum in both cases. At the follow up, one case presented with recurrence six years later, and she underwent a reoperation with total resection without morbidity. Long-term follow up presented no other recurrences.

Endodermal cyst of the quadrigeminal cistern: case report

BACKGROUND Endodermal cysts usually develop in the subdural space in the anterior spinal cord and rarely occur inside the cranium. Most intracranial endodermal cysts develop in the posterior fossa. We report the first case of an endodermal cyst in the quadrigeminal cistern. CASE DESCRIPTION The patient was a 71-year-old man who suffered from gait disturbance for 6 months. Although head computed tomography (CT) scanning 4 years previously did not show any cystic lesion, CT and magnetic resonance imaging (MRI) on admission showed a cystic lesion extending from the quadrigeminal cistern to the right ambient cistern. The cyst was subtotally removed via a suboccipital transtentorial approach. The cyst wall consisted of a layer of columnar epithelium and connective tissue. Based on the results of immunostaining, it was diagnosed as an endodermal cyst. CONCLUSIONS It is possible that the increase of secretion from the cells lining the cyst may have caused a difference in osmotic pressure between the cerebrospinal fluid and the cyst contents, leading to rapid enlargement of the cyst. An endodermal cyst should be removed as completely as possible because its cells have the ability to grow and produce secretions.

Ganglioglioma da região da pineal: relato de caso

Ganglioglioma are tumors presenting neoplastic glial cells and nerve cells, very rarely found in the pineal region. Only eight cases have been previously published in the literature. We present the case of a 14 years-old male patient with a ganglioglioma of the pineal region. The patient was treated surgically by a suboccipital transtentorial approach with complete removal. Histopathologic specimens with immunostaining revealed a ganglioglioma grade I. We conclude that these tumors are rare and should be treated surgically aiming total remove. If it is not possible or in case of reocurrence the patient should be followed and radiotherapy could be considered.