approaches to the pineal region jan m. eckermann, md department of neurosurgery
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Approaches to the Pineal Approaches to the Pineal RegionRegion
Jan M. Eckermann, MDJan M. Eckermann, MD
Department of NeurosurgeryDepartment of Neurosurgery
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Why go there?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
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The Pineal RegionThe Pineal Region
• Anterior: Quadrigeminal plate, pineal body, habenular complex
• Lateral: Mesial temporal and occipital lobes, pulvinar
• Roof: Splenium• Floor: Vermis
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The Quadrigeminal CisternThe 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
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The Quadrigeminal CisternThe 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
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ApproachesApproaches
• Supracerebellar – Infratentorial
• Occiptial – Transtentorial
• Combined Supratentorial – Infratentorial Transsinus
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Supracerebellar – Infratentorial Supracerebellar – Infratentorial
• Sitting or concord position
• Midline or inverted U-shaped incision
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Supracerebellar – InfratentorialSupracerebellar – Infratentorial
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Supracerebellar – InfratentorialSupracerebellar – Infratentorial
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Supracerebellar – InfratentorialSupracerebellar – Infratentorial
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Occipital - TranstentorialOccipital - Transtentorial
• Three – quarters prone position
• Operative side in dependent position
• Inverted J
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Occipital - TranstentorialOccipital - Transtentorial
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Occipital - TranstentorialOccipital - Transtentorial
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Combined Supratentorial – Combined Supratentorial – Infratentorial TranssinusInfratentorial Transsinus
• Semiprone position• Operative side in
dependent position• Inverted J• Craniotomy made in
three pieces
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Combined Supratentorial – Combined Supratentorial – Infratentorial TranssinusInfratentorial Transsinus
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Complications and ConsiderationsComplications and Considerations
• Supracerebellar – Infratentorial:
• Air embolism
• Ventricluar collapse SDH, pneumocephalus
• Not suitable for superior extending lesions
• Gravity retracting cerebellum
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Complications and ConsiderationsComplications and Considerations
• Occiptial – Transtentorial:
• Retraction of occipital lobes visual field defects
• Disconnection syndrome
• Limited exposure of contralateral side
• Good view of quadrigeminal plate
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Complications and ConsiderationsComplications and Considerations
• Combined Supratentorial – Infratentorial Transsinus:
• Brain edema
• Venous infarcts
• Very wide exposure
• Consider primary re-anastomosis or patch graft
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ReferencesReferences
• Fossett TF and Caputy JC. Operative Neurosurgical Anatomy. Thieme: New York 2002
• Haye AH and Laws ER. Brain Tumors. Churchill Livingstone: Edinburgh 1995