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

Approaches to the Pineal Approaches to the Pineal RegionRegion

Jan M. Eckermann, MDJan M. Eckermann, MD

Department of NeurosurgeryDepartment of Neurosurgery

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

The Pineal RegionThe Pineal Region

• Anterior: Quadrigeminal plate, pineal body, habenular complex

• Lateral: Mesial temporal and occipital lobes, pulvinar

• Roof: Splenium• Floor: Vermis

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

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

ApproachesApproaches

• Supracerebellar – Infratentorial

• Occiptial – Transtentorial

• Combined Supratentorial – Infratentorial Transsinus

Supracerebellar – Infratentorial Supracerebellar – Infratentorial

• Sitting or concord position

• Midline or inverted U-shaped incision

Supracerebellar – InfratentorialSupracerebellar – Infratentorial

Occipital - TranstentorialOccipital - Transtentorial

• Three – quarters prone position

• Operative side in dependent position

• Inverted J

Occipital - TranstentorialOccipital - Transtentorial

Combined Supratentorial – Combined Supratentorial – Infratentorial TranssinusInfratentorial Transsinus

• Semiprone position• Operative side in

dependent position• Inverted J• Craniotomy made in

three pieces

Combined Supratentorial – Combined Supratentorial – Infratentorial TranssinusInfratentorial Transsinus

Complications and ConsiderationsComplications and Considerations

• Supracerebellar – Infratentorial:

• Air embolism

• Ventricluar collapse SDH, pneumocephalus

• Not suitable for superior extending lesions

• Gravity retracting cerebellum


• Occiptial – Transtentorial:

• Retraction of occipital lobes visual field defects

• Disconnection syndrome

• Limited exposure of contralateral side

• Good view of quadrigeminal plate


• Combined Supratentorial – Infratentorial Transsinus:

• Brain edema

• Venous infarcts

• Very wide exposure

• Consider primary re-anastomosis or patch graft

ReferencesReferences

• Fossett TF and Caputy JC. Operative Neurosurgical Anatomy. Thieme: New York 2002

• Haye AH and Laws ER. Brain Tumors. Churchill Livingstone: Edinburgh 1995

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

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