Supracerebellar Infratentorial Approach Research Articles

Anatomic, qualitative, and quantitative evaluation of the variants of the infratentorial supracerebellar approach to the posteroinferior thalamus.

The posteroinferior region of the thalamus is formed by the pulvinar, and it is surgically accessed through the infratentorial supracerebellar approach, between the midline and the retromastoid region. This study aimed to compare the paramedian, lateral, extreme lateral, and contralateral paramedian corridors with the posteroinferior thalamus through a suboccipital craniotomy and an infratentorial supracerebellar access. Ten cadavers were studied, and the microsurgical dissections were accompanied by the measurement of the variables using a neuronavigation system. Statistical analysis was performed using analysis of variance (ANOVA). The distance between the access midpoint at the cranial surface and pulvinar varied between 53.3 and 53.9mm, the contralateral access being an exception (59.9mm). The vertical angle ranged from 20.6° in the contralateral access to 23.5° in the lateral access. There was a gradual increase in the horizontal angle between the paramedian (17.4°), lateral (31.3°), and extreme lateral (43.7°) accesses. But, this angle in the contralateral access was 14.6°, similar to that of the paramedian access. The exposed area of the thalamus was 125.1mm2 in the paramedian access, 141.8mm2 in the lateral access, and 165.9mm2 in the extreme lateral access, which was similar to that of the contralateral access (164.9mm2). The horizontal view angle increased with lateralization of the access, which facilitated microscopic visualization. With regard to the exposure of the microsurgical anatomy, the extreme lateral and contralateral accesses circumvent the neural and vascular obstacles at the midline, allowing a larger area of anatomical exposure.

RESECCIÓN MICROQUIRURGICA DE UN CAVERNOMA PONTINO MEDIANTE UN ABORDAJE SUPRACEREBELOSO INFRATENTORIAL EXTREMO LATERAL

Introduction: Cavernomas on the posterolateral pontomesencephalic surface can be approached from an extreme lateral supracerebellar infratentorial corridor, although the theory is scarce. The brainstem has a dense concentration of nuclei and fibers that are responsible for a high rate of morbidity when treating brainstem lesions. The objective of this work is to demonstrate the safe microsurgical resection technique for the complete removal of a pontine cavernoma. Clinical Case: 27-year-old woman with a 5-month history of disease; characterized by headache, left facial paresis and right half body paresis. Magnetic resonance imaging (MRI) showed a hemorrhage in the middle cerebellar peduncle compatible with a ruptured cavernoma, initially receiving medical treatment. Subsequently, due to an increase in the motor deficit and the presence of keratopathy in the left eye, surgery was decided. A retromastoid craniotomy and an extreme lateral supracerebellar infratentorial approach were performed. A safe entry zone was identified and the cavernoma was completely excised. In the postoperative period, she did not present additional neurological deficit, being extubated at 24 hours, with a score on the Glasgow scale of 15 points. Postoperative brain tomography (CT) showed the absence of the cavernoma. Conclusion: The far lateral supracerebellar infratentorial approach is safe for the excision of cavernomas with a middle cerebellar peduncle. When combined with the significant reverse Trendelenburg position it results in minimal cerebellar retraction as the cerebellum descends with gravity. Keywords: Hemangioma, Cavernous, Pons, Middle Cerebellar Peduncle, Craniotomy (source: MeSH NLM)

Hydrocephalus in children – A rare case of pineal cavernoma and literature review

Background: Cavernous malformations prevalence ranges from 0.4 to 0.6% and accounts for 5–15% of all central nervous system vascular malformations. Pineal cavernomas constitute <1% of all locations published in the literature, with a total of 26 cases reported, only 5 regarding the pediatric population until 2020. Overall annual hemorrhage rate is 2.4%. Symptoms are often due to hydrocephalus and intracranial hypertension.Case Description: We report a case of a 5-year-old child with visual disturbances, headache, and progressive neurologic deterioration. MR showed a lesion in the pineal region and triventricular hydrocephalus. She was submitted to endoscopic third ventriculostomy and total excision of the lesion by the infratentorial supracerebellar approach a few days later. Histopathological examination confirmed a pineal cavernous malformation. The patient returned to her normal life without any neurologic deficit and a normal development.Conclusion: The ideal treatment is primary lesion removal; however, due to the infrequency and because it is a curable lesion, studies seeking to deepen the knowledge of this disease are considered relevant.

How I do it: lateral supra-cerebellar infra-tentorial approach for P2-P3 junction cerebral aneurysms.

P2-P3 junction aneurysms are challenging to treat surgically because of their frequent complex morphology and their location deep in close proximity to the midbrain. The sub-temporal route requires significant retraction of the temporal lobe in addition to potential injury to the vein of Labbe. We describe the technique for treating such aneurysms via a lateral supra-cerebellar infra-tentorial (LSCIT) approach, which eliminates manipulation of the temporal lobe. Cadaveric dissection provided comprehensive understanding of relevant anatomy. Intraoperative video shows clipping of the aneurysm using a LSCIT approach. LSCIT approach allows safe clipping of P2-P3 aneurysms with minimal brain manipulation.

Endoscopic supracerebellar infratentorial approach to pineal and posterior third ventricle lesions in prone position with head extension: a technical note

ABSTRACT Objective The supracerebellar infratentorial (SCIT) approach is frequently used for the treatment of lesions in the pineal and posterior third ventricle region and can be performed in a sitting or prone position. We describe our experience with the purely endoscopic SCIT approach, using a prone position, with neck extension and head rotation. Methods We analysed all paediatric and adult patients operated on between July 2013 and January 2018 using the purely endoscopic SCIT approach. The surgical procedure was conducted through a paramedian subtorcular key-hole suboccipital craniotomy. The assistant held the endoscope and the surgeon used fine, long shaft instruments for bimanual tumour dissection. The prone position with head retroflexion allowed a gravity-aided enlargement of the anatomical surgical corridor between tentorium and cerebellum and enhanced venous blood drainage, similarly to the sitting or semi-sitting position, but with a decreased risk of air embolism. Results The approach allowed a complete removal of lesions located in the pineal region and in the posterior part of the third ventricle. Seven patients have been operated with this approach. All of them had the tumour completely removed. No permanent neurological deficits have been observed. Conclusions The endoscopic SCIT approach enables effective and safe removal of pineal and posterior third ventricle lesions, even of moderate dimensions (up to 3 cm). The endoscope guarantees a detailed view and illumination of the deep-seated structures. The tumour resection can be performed with bimanual use of microsurgical instruments.

In Reply to the Letter to the Editor Regarding “Pure Endoscopic Supracerebellar Infratentorial Approach to the Pineal Region: A Case Series”

In Reply to the Letter to the Editor Regarding “Pure Endoscopic Supracerebellar Infratentorial Approach to the Pineal Region: A Case Series”

Cavernous Malformations in and Around the Third Ventricle: Indications, Approaches, and Outcomes.

Cavernous malformations in structures in and around the third ventricle are a challenging conceptual and surgical problem. No consensus exists on the ideal approach to such lesions. To perform a retrospective review of our institutional database to identify and evaluate approaches used to treat cavernous malformations located in and around the third ventricle. Information was extracted regarding lesion size and location, extent of resection, time to last follow-up, surgical approach, presenting symptoms, preoperative and postoperative neurological status, and specific approach-related morbidity. All 39 neurosurgical operations (in 36 patients) were either an anterior interhemispheric (AIH) (44%, 17/39) or a supracerebellar infratentorial (SCIT) (56%, 22/39) approach. Gross-total resection was achieved in 23 of 39 procedures (59%), a near-total resection in 1 (3%), and subtotal resection in 15 (38%). For the 31 patients with at least 3 mo of follow-up, the mean modified Rankin Scale (mRS) score was 1.5. Of the 31 patients, 25 (81%) had an mRS score of 0 to 2, 4 had a mRS score of 3 (13%), and 1 each had a mRS score of 4 (3%) or 5 (3%). Most approaches to cavernous malformations in and around the third ventricle treated at our institution have been either an AIH or a SCIT approach. The AIH approach was used for lesions involving the lateral wall of the third ventricle or the midline third ventricular floor, whereas the SCIT approach was used for lesions extending from the third ventricle into the dorsolateral midbrain, with acceptable clinical results.

The hanging technique using the superior petrosal vein in surgical transposition for trigeminal neuralgia

BackgroundRecently, transposition of the offending vessel has become the gold standard technique in microvascular decompression for trigeminal neuralgia. Teflon felt is the main material used, and the effectiveness of transposing the offending vessel to the cerebellar tentorium using Teflon felt has been widely demonstrated. However, foreign body reaction occurs in some cases causing granulation tissue formation and recurrence of trigeminal neuralgia. We investigated an alternative technique where the offending vessel (superior cerebellar artery) is transposed to the superior petrosal vein without use of Teflon felt for treating trigeminal neuralgia. MethodsThis study involved 12 patients who underwent surgery using the hanging technique for trigeminal neuralgia in which the superior cerebellar artery was the offending vessel. Surgery was performed using the retrosigmoid approach. The horizontal fissure of the cerebellum was opened, the root entry zone of the trigeminal nerve was accessed via the infratentorial supracerebellar approach, and the superior cerebellar artery was detached and released. The artery was then moved to the tentorium, formed into a loop, hung on the superior petrosal vein, and affixed with fibrin glue. ResultsFacial pain improved in all cases and sufficient decompression of the trigeminal nerve was confirmed on imaging postoperatively. ConclusionThis hanging technique is expected to have low risk of recurrence of trigeminal neuralgia because it does not use foreign materials potentially causing granulation tissue formation and adhesion around the trigeminal nerve. This simple practical technique using existing anatomical structures and no foreign materials appears promising, although long-term follow-up is required.

Interpeduncular Sulcus Approach to the Posterolateral Pons

In this article, we describe a new safe entry point for the posterolateral pons. To show the adjacent anatomy and measure the part of the interpeduncular sulcus that can be safely accessed, we first performed a review of the literature regarding the pons anatomy and its surgical approaches. Thereafter, 1 human cadaveric head and 15 (30 sides) human brainstems with attached cerebellums were bilaterally dissected with the fiber microdissection technique. A clinical correlation was made with an illustrative case of a dorsolateral pontine World Health Organization grade I astrocytoma. The safe distance for accessing the interpeduncular sulcus was found to extend from the caudal end of the lateral mesencephalic sulcus to the point at which the intrapontine segment of the trigeminal nerve crosses the interpeduncular sulcus. The mean distance was 8.2 mm (range, 7.15-8.85 mm). Our interpeduncular sulcus safe entry zone can be exposed through a paramedian infratentorial supracerebellar approach. When additional exposure is required, the superior portion of the quadrangular lobule of the cerebellar hemispheric tentorial surface can be removed. In the presented case, surgical resection of the tumor was performed achieving a gross total resection, and the patient was discharged without neurologic deficit. The interpeduncular sulcus safe entry zone provides an alternative direct route for treating intrinsic pathologic entities situated in the posterolateral tegmen of the pons between the superior and middle cerebellar peduncles. The surgical corridor provided by this entry point avoids most eloquent neural structures, thereby preventing surgical complications.

What is the risk of venous cerebellar infarction in the supracerebellar infratentorial approach?

The supracerebellar infratentorial approach (SCITA) is a standard approach used in a neurosurgical practice. It carries some risk of associated complications including cerebellar venous infarction with possible serious sequelae. The objective of this study is to address the incidence of cerebellar venous infarction in SCITA. A search through the currently available literature was performed in September 2019 from the year 2000 until September 2019 dealing with 'supracerebellar infratentorial approach'. Out of the 578 patients found in thirteen case series, two venous infarctions were present; the remaining four patients were published as case reports. By analysing the case series, we calculated the risk of such a complication to be 0.345% (95% CI [0.061%, 1.248%]). Case reports were not included. The real risk is estimated to be higher. The risk of cerebellar venous infarction is an unpredictable, infrequent but real complication with potentially dreadful sequelae. Each neurosurgeon using this approach should be aware of this event when employing this approach. The avoidance of cerebellar venous infarction can be lowered by leaving as many bridging veins intact as possible.

Pure Endoscopic Supracerebellar Infratentorial Approach to the Pineal Region: A Case Series

Surgical approaches to pineal lesions present a challenge because of limited visibility and maneuverability within the posterior fossa. The supracerebellar infratentorial (SCIT) technique has emerged as an approach to pineal lesions. We aim to demonstrate the efficacy of the endoscopic SCIT technique through a case series conducted at our institution and highlight the advantages of the endoscopic technique over the microscopic alternative. To evaluate the effectiveness and safety of the endoscopic SCIT approach. We conducted a retrospective review of pure endoscopic SCIT cases conducted at our institution. Demographic information, preoperative and postoperative imaging, neurological status, surgical data, and complications were recorded. Six patients who underwent pure endoscopic SCIT surgery were identified for analysis. The average lesion volume was 14.12 ± 7.24 cm3. The median postoperative length of stay was 5.0 days. The average surgical duration was 3.54 ± 0.71 hours. All operations were performed inprone position with zero- and 30-degree endoscopes. Pathology included one each of the following lesions: Pineoctyoma, metastatic melanoma, atypical teratoma rhabdoid tumor, ependymoma, epidermoid, abscess. Gross total resection (GTR) was achieved in 5/6 patients, and near-total resection was achieved in 1/6 patients. Surgical complications included one case of postoperative infection. The purely endoscopic SCIT approach is a safe and effective approach for deep-seated pineal lesions. This approach allows for visibility and maneuverability around the lesion and facilitates high rates of GTR.

Midline and Paramedian Supracerebellar Infratentorial Approach to The Pineal Region: A Comparative Clinical Study in 112 Patients

The midline supracerebellar infratentorial (SCIT) approach and its paramedian development are commonly used for dealing with pineal lesions. Comparative clinical studies are lacking, however. We aim to establish the better performance of the paramedian SCIT approach in terms of clinical safety in surgically treated pineal cysts and pineal region tumors. Procedural functionality and effectiveness have been also analyzed. A comparative analysis of clinical, radiologic, pathologic, and surgical features, and outcome was performed between 55 midline and 57 paramedian SCIT approaches that were exclusively performed in 112 patients (57 pineal cysts and 55 tumors of the pineal region) operated in sitting position by a single surgeon. Information was retrieved from hospital records and microsurgical videos. The paramedian SCIT approach linked with fewer postoperative complications (odds ratio [OR]: 0.40) and fewer approach-related complications (OR: 0.28) than the midline SCIT approach. The SCIT paramedian approach was achieved in a shorter time, by a smaller bone flap, and with fewer complex procedural steps than the midline approach. The SCIT paramedian approach did not require the opening of the falx cerebelli, midline cerebellar retraction, section of the midline cerebellar draining veins, nor wide opening of the dura. Gross total resection, size of the lesion, microsurgical time for removal, histopathological diagnosis and postoperative outcome were statistically similar in both groups. The SCIT approach represents a safer and more functional approach for the removal of cysts and tumors of the pineal region than the classic midline approach, while maintaining the same effectiveness.

Supracerebellar Infratentorial Endoscopy for Quadrigeminal Cistern Epidermoid

The standard microscopic supracerebellar infratentorial approach for the pineal region is limited by tunnel vision. Herein, we describe endoscopic supracerebellar infratentorial surgery in a patient with quadrigeminal cistern epidermoid presenting with hydrocephalus. In the sitting position, following a 6 cm longitudinal incision and small suboccipital craniotomy, the dura was cut in V shape and kept reflected. The bridging veins were coagulated and cut, taking the 0° endoscope inside. A sharp incision is given over the thickened arachnoid over the inferior paramedian area. The precentral cerebellar vein is exposed at the lower part, coagulated and divided. Gentle bimanual intracapsular removal of the epidermoid flakes is performed with intermittent saline irrigation and suction. Assisted by rotating the angled endoscope, curved coaxial instruments help remove the cerebello-mesencephalic and lateral extensions of the epidermoid. Endoscopic supracerebellar infratentorial approach provides a panoramic and angled view of the pineal region, through a narrow corridor, avoiding cerebellar retraction.

The lateral supracerebellar infratentorial, translateral mesencephalic sulcus approach to the mesencephalopontine junction.

The lateral supracerebellar infratentorial (SCIT) approach provides advantageous access to lesions located in the lateral mesencephalon and mesencephalopontine junction. For lesions that abut the pial surface, a direct approach is ideal and well tolerated. For deep-seated lesions, the lateral mesencephalic sulcus (LMS) can be used to access lesions with minimal morbidity to the patient. This video demonstrates the use of the SCIT approach via the LMS to remove a cavernous malformation at the level of the mesencephalopontine junction. The use of somatosensory and motor evoked potential monitoring and intraoperative neuronavigation is essential for optimizing patient outcomes. Meticulous, multilayered closure is critical for optimal results in the posterior fossa. For optimal patient outcomes, approach selection for deep-seated lesions should combine the two-point method with safe entry zones. At follow-up, the patient had persistent sensory changes but was otherwise neurologically intact.The video can be found here: https://youtu.be/bHFEZhG8dHw.

Supracerebellar Infratentorial Approach for Complex Thalamic Cavernous Malformation: 2-Dimensional Operative Video.

Key points for the approach include the use of a supracerebellar infratentorial craniotomy, dynamic and gravity retraction, lighted bipolar forceps and suction, and stereotactic navigation. This patient has a large cavernous malformation extending from the midbrain to the thalamus in craniocaudal extent. The cavernous malformation extends to the midbrain surface along the interface with the ambient cistern, making it appropriate for the supracerebellar infratentorial approach. By cutting the tentorium access to the superior extension becomes feasible. The cavernous malformation is excised in a piecemeal manner utilizing a CO2 laser. Because removal of the large mass allowed the partial collapse of the cavity, a small segment of the cavernous malformation obscured by the collapse is retained cranially along the foramen of Monro. This situation required a return to the operating room for complete excision. The patient tolerated both procedures well and remained at her neurological baseline postoperatively. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. The surgical video has been used with permission from the Barrow Neurological Institute.

Surgical treatment of falcotentorial meningiomas: a retrospective review of a single-institution experience.

Meningiomas at the falcotentorial junction represent a rare subgroup of complex meningiomas. Debate remains regarding the appropriate treatment strategy for and optimal surgical approach to these tumors, and surgical outcomes have not been well described in the literature. The authors reviewed their single-institution experience in the management, approach selection, and outcomes for patients with falcotentorial meningiomas. From the medical records, the authors identified all patients with falcotentorial meningiomas treated with resection at the Barrow Neurological Institute between January 2007 and October 2017. Perioperative clinical, surgical, and radiographic data were retrospectively collected. For patients who underwent the supracerebellar infratentorial approach, the tentorial angle was defined as the angle between the line joining the nasion with the tuberculum sellae and the tentorium in the midsagittal plane. Falcotentorial meningiomas occurred in 0.97% (14/1441) of the patients with meningiomas. Most of the patients (13/14) were female, and the mean patient age was 59.8 ± 11.3 years. Of 17 total surgeries (20 procedures), 11 were single-stage primary surgeries, 3 were two-stage primary surgeries (6 procedures), 2 were reoperations for recurrence, and 1 was a reoperation after surgery had been aborted because of brain edema. Hydrocephalus was present in 5 of 17 cases, 4 of which required additional treatment. Various approaches were used, including the supracerebellar infratentorial (4/17), occipital transtentorial/transfalcine (4/17), anterior interhemispheric transsplenial (3/17), parietal transventricular (1/17), torcular (2/17), and staged supracerebellar infratentorial and occipital transtentorial/transfalcine (3/17) approaches. Of the 17 surgeries, 9 resulted in Simpson grade IV resection, and 3, 1, and 4 surgeries resulted in Simpson grades III, II, and I resection, respectively. The tentorial angle in cases with Simpson grade I resection was significantly smaller than in those with an unfavorable resection grade (43.3° ± 4.67° vs 54.0° ± 3.67°, p = 0.04). Complications occurred in 10 of 22 approaches (17 surgeries) and included visual field defects (6 cases, 2 permanent and 4 transient), hemiparesis (2 cases), hemidysesthesia (1 case), and cerebellar hematoma (1 case). Falcotentorial meningiomas are challenging lesions. A steep tentorial angle is an unfavorable preoperative radiographic factor for achieving maximal resection with the supracerebellar infratentorial approach. Collectively, the study findings show that versatility is required to treat patients with falcotentorial meningiomas and that treatment goals and surgical approach must be individualized to obtain optimal surgical results.

Lateral supracerebellar infratentorial approach for pontomesencephalic cavernous malformations.

Cavernomas at the posterolateral pontomesencephalic surface can be approached from a lateral infratentorial supracerebellar corridor. In this surgical video, we demonstrate two cases of brainstem cavernomas resected through a lateral supracerebellar infratentorial approach. A supine position with lateral turn of the head was used along with significant reverse Trendelenburg to allow the cerebellum to fall away with gravity from the tentorium. After exposure of the posterior surface of the brainstem between the tentorium and the superior cerebellar surface with aid of neuronavigation, the cavernomas were safely resected.The video can be found here: https://youtu.be/fUDdaprg26Y.

Paramedian contralateral supracerebellar infratentorial approach to thalamic cavernous malformation.

Cavernous malformations (CVMs) located in the thalamus are uncommon. However, they pose difficulties for resection because of their close proximity to eloquent areas of the brain and vascular structures, and all surgical corridors to access them are narrow. In this video, we report the case of a 19-year-old woman who presented with a long-standing history of right hemiparesis with recent deterioration. MRI revealed a large CVM located in the left thalamus, with signs of recent hemorrhage extending to the left cerebral peduncle. Resection was achieved with a paramedian contralateral supracerebellar infratentorial approach in a semisitting position, with an uneventful postoperative course.The video can be found here: https://youtu.be/Arvu52FkHOE.

Vein of Galen arteriovenous malformation: Unedited microneurosurgery

Background:Vein of Galen arteriovenous malformations (VGAVMs) are vascular malformations of the pineal region between a persistent embryological median prosencephalic vein of Markowski and the arterial choroidal system by a direct (mural type) or indirect (choroidal type) communication. Angiographic evaluation of VGAVMs usually describes a limbic arch between the anterior and posterior cerebral arteries throughout a pericallosal artery, and the classic “ε” shape configuration of the thalamostriate veins drainage into a subtemporal or a lateral mesencephalic vein due to the underdevelopment of the straight sinus, sigmoid sinus, and jugular bulbs. Moreover, falcine dural channels join the pouch of the malformation with the posterior third of the superior sagittal sinus and less frequently with the cavernous sinus, inferior petrosal sinus, and facial veins. At present, endovascular therapy is the standard management for these lesions. However, under failure of endovascular procedures such in this case, microsurgical management of VGAVMs under an experienced neurosurgical team might be paramount.Case Description:The patient with a choroidal type VGAVM and multiple failed endovascular procedures underwent sitting praying position and midline supracerebellar infratentorial approach. Strong retraction with stitches and proper hemostasis of a highly vascular dura was achieved after transverse sinus-based opening. Accurate microsurgical dissection between the superior cerebellar surface and the tentorium allowed a supracerebellar approach over the vermis and along the midline recognizing the venous pouch of the VGAVM instead of the absent straight sinus. Water dissection allowed us to differentiate the cleavage plane between the VGAVM and surrounding structures maintaining an impeccable surgical field as well. Under high microscopic magnification, arterial feeders of the malformation coming from the posterior cerebral artery were recognized. Intraoperative angiography and reevaluation of the preoperative imaging helped us to confirm a safety approach before coagulation and cut those vascular feeders. Throughout an open-close and short bursts bipolar coagulation techniques preventing attachment of conventional bipolar tips within the vascular structure and without permanent use of water irrigation, the vessels were carefully dissected, coagulated, and sectioned. Along with our experience, we believe that this standard coagulation technique applied in all vascular malformation surgeries is safe and effective. A remaining small plexiform malformation associated with the vein of Galen malformation was coagulated and isolated. A new intraoperative angiography determined complete microsurgical occlusion of the VGAVM. Careful homeostasis based on electrocoagulation and surgical was achieved. Finally, we performed a microsurgical wound closure as a conventional technique in Helsinki neurosurgery.Conclusion:This unedited video offers all detailed aspects that a neurosurgeon as the senior author JH considers essential when performing an efficient and safe surgery for a VGAVM.Videolink:http://surgicalneurologyint.com/videogallery/vein-of-galen-avm.

Purely endoscopic supracerebellar infratentorial approach for epidermoid cyst in third ventricle

Introducción: El Quiste Epidermoide como tumor de la región pineal es una patología infrecuente y poco descripta. Su prevalencia en el 3er ventrículo es de 0,0042% de los tumores primarios intracraneales. Para lograr la exeresis macroscópica total se utilizó el abordaje Supracerebeloso Infratentorial con Endoscopio rígido de Base de Cráneo, técnica descripta para abordaje de lesiones de la región pineal. El Objetivo del Trabajo es la presentación de la técnica quirúrgica del abordaje, con la resolución de la patología infrecuente que se presenta.Materiales y métodos: Paciente de 16 años de edad con antecedentes de DBT insípida y cefaleas crónicas intermitentes (m-RS 1). RMN de encéfalo evidencia lesión ocupante de espacio hiperintensa T2 e hipointensa en T1 con realce periférico y restricción en la difusión. Presenta refuerzo a nivel del tallo hipofisario. Se plantea diagnóstico de tumor germinal. Marcadores en LCR negativos. Se decide realizar abordaje puramente endoscópico de la región para toma de muestra. Congelación determina quiste epidermoide y se procede a realizar exeresis macroscópica total.Resultados: Se realizó exeresis macroscópica total de quiste de epidermoide en tercer ventrículo con abordaje supracerebeloso infratentorial a través de endoscópico rígido de base de cráneo, en paciente de 16 años, cursando postoperatorio tardío sin secuelas y mejoría sintomática con persistencia de DBT insípida (m-RS 1).Conclusión: El abordaje puramente endoscópico supracerebeloso infratentorial es una opción segura para el tratamiento quirúrgico de lesiones en el tercer ventrículo, en este caso, un quiste epidermoide.