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Kondo A, Suzuki M, Shimizu Y, Akiyama O. The surgical intervention for pineal region tumors. Childs Nerv Syst 2023; 39:2341-2348. [PMID: 37436474 DOI: 10.1007/s00381-023-06071-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/05/2023] [Indexed: 07/13/2023]
Abstract
Histological and molecular characterization is essential for the diagnosis of pediatric brain tumors. In the pineal region tumors, it is necessary to remove a sufficient tumor volume to make a diagnosis. However, surgery in this region is challenging due to its deep anatomical location and surrounded by critical structures and complex venous system. Knowledge of the anatomy and function of the pineal region and tumor histological types is imperative for the successful management of pineal region tumors. This article describes surgical approaches to pineal tumors, focusing on the occipital transtentorial approach and adding the author's experience to what has been known in the literature. Recent innovations have made this approach more popular and can be applied to occipital fossa lesions.
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Affiliation(s)
- Akihide Kondo
- The Department of Neurosurgery, Juntendo University Faculty of Medicine, 2-1-1 Bunkyo, Tokyo 1138321, Japan.
| | - Mario Suzuki
- The Department of Neurosurgery, Juntendo University Faculty of Medicine, 2-1-1 Bunkyo, Tokyo 1138321, Japan
| | - Yuzaburo Shimizu
- The Department of Neurosurgery, Juntendo University Faculty of Medicine, 2-1-1 Bunkyo, Tokyo 1138321, Japan
| | - Osamu Akiyama
- The Department of Neurosurgery, Juntendo University Faculty of Medicine, 2-1-1 Bunkyo, Tokyo 1138321, Japan
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Cinalli G, Marini A, Russo C, Spennato P, Mirone G, Ruggiero C, Quaglietta L, De' Santi MS, Covelli E. Herophilus-Galen line as a predictor of extent of resection in the occipital interhemispheric transtentorial approach to pineal tumors in children. J Neurosurg Pediatr 2022; 30:119-127. [PMID: 35453105 DOI: 10.3171/2022.3.peds2231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/08/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goals of this study were to evaluate the extent of resection (EOR) obtained with an occipital interhemispheric transtentorial approach (OITA) in a series of pediatric patients with pineal region tumors and to define preoperative radiological factors predictive of the EOR. METHODS This is a retrospective cohort study of a series of pediatric patients with pineal tumors who underwent surgery through a microsurgical OITA performed by the senior author during the period from January 2006 to January 2020. The tumor volume was measured preoperatively, and then on sagittal midline cuts the authors identified the most cranial point of the torcular Herophili (defined as the "Herophilus point") and the lowest point of the inferior profile of the vein of Galen (defined as the "Galen point"). The line joining these two points (defined as the "Herophilus-Galen line" [H-G line]) was used to identify the "Herophilus-Galen plane" (H-G plane) perpendicular to the sagittal plane. Tumor volumes located below and above this plane were measured. EOR was evaluated by measuring residual tumor volume visible on T1 volumetric injected sequences of immediate postoperative MRI. RESULTS Thirty patients were selected for study inclusion. The preoperative mean tumor volume was 15.120 cm3 (range 0.129-104.3 cm3). The mean volumes were 2.717 cm3 (range 0-31 cm3) above the H-G plane and 12.40 cm3 (median 5.27 cm3, range 0.12-72.87 cm3) below the H-G plane. Three patients underwent only biopsy. Of the remaining 27 patients, gross-total resection (GTR; 100% tumor volume) was achieved in 20 patients (74%). In the remaining 7 patients, the mean residual tumor volume was 7.3 cm3 (range 0.26-17.88 cm3). In 3 of these patients, GTR was accomplished after further surgical procedures (1 in 2 patients, 3 in 1 patient) for an overall GTR rate of 85.18%. Larger tumor volume was significantly associated with incomplete resection (p < 0.001). A tumor volume ≤ 2 cm3 above the H-G plane (p = 0.003), linear extension ≤ 1 mm above the H-G line, and pineal histology were predictive of GTR at first OITA procedure (p = 0.001). CONCLUSIONS The H-G line is an intuitive, easy-to-use, and reliable indicator of the superior anatomical limit of visibility during the microsurgical OITA. This anatomical landmark may be useful as a predictor of EOR for pineal tumors performed through this approach. The main limitations of this study are the small number of patients and the exclusively pediatric age of the patient population.
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Affiliation(s)
| | | | | | | | | | | | - Lucia Quaglietta
- 3Unit of Pediatric Neuro-Oncology, Santobono-Pausilipon Children's Hospital, Naples, Italy
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Papadimitriou K, Belouaer A, Starnoni D, Daniel RT. Extreme lateral supracerebellar infratentorial approach for tentorial arteriovenous fistula associated with a giant venous ectasia: how I do it. Acta Neurochir (Wien) 2022; 164:1663-1667. [PMID: 34386853 PMCID: PMC9160099 DOI: 10.1007/s00701-021-04945-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/14/2021] [Indexed: 11/16/2022]
Abstract
Background Surgery of tentorial dural arteriovenous fistulas (DAVF) associated with large ectatic vein remains challenging due to the intimate neurovascular relationships in the incisural space. Interruption of the arterialized vein requires a good knowledge of the regional anatomy and a precise preoperative evaluation. Methods We describe the key steps extreme lateral supracerebellar infratentorial (ELSI) approach for tentorial DAVF with a video illustration. The surgical anatomy is described along with the advantages and limitations of this approach. Conclusions In cases of tentorial DAVF where the foot of the arterialized vein is located in the infratentorial compartment, ELSI offers good surgical exposure and outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-021-04945-6.
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Bogdanov EI, Faizutdinova AT, Heiss JD. Posterior cranial fossa and cervical spine morphometric abnormalities in symptomatic Chiari type 0 and Chiari type 1 malformation patients with and without syringomyelia. Acta Neurochir (Wien) 2021; 163:3051-3064. [PMID: 34448046 DOI: 10.1007/s00701-021-04941-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND To better understand how anatomical features of Chiari malformation type 0 (CM0) result in the manifestation of Chiari malformation type 1 (CM1) signs and symptoms, we conducted a morphometric study of the posterior cranial fossa (PCF) and cervical canal in patients with CM1 and CM0. METHODS This retrospective study had a STROBE design and included 120 adult patients with MRI evidence of a small PCF (SPCF), typical clinical symptoms of CM1, and a diagnosis of CM1, CM0, or SPCF-TH0-only (SPCF with cerebellar ectopia less than 2 mm and without syringomyelia). Patients were divided by MRI findings into 4 groups: SPCF-TH0-only, SPCF-TH0-syr (CM0 with SPCF and syringomyelia), SPCF-CM1-only (SPCF with cerebellar ectopia 5 mm or more without syringomyelia), and SPCF-CM1-syr (CM1 with syringomyelia). Neurological examination data and MRI parameters were analyzed. RESULTS All patient cohorts had morphometric evidence of a small, flattened, and overcrowded PCF. The PCF phenotype of the SPCF-TH0-only group differed from that of other CM cohorts in that the length of clivus and supraocciput and the height of the PF were longer, the upper CSF spaces of PCF were taller, and the area of the foramen magnum was smaller. The SPCF-TH0 groups had a more significant narrowing of the superior cervical canal and a smaller decrease in PCF height than the SPCF-CM1 groups. CONCLUSIONS Patients with SPCF-TH0 with and without syringomyelia developed Chiari 1 symptoms and signs. Patients with SPCF-TH0-syr (Chiari 0) had more constriction of their CSF pathways in and around the foramen magnum than patients with SPCF-TH0-only.
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Katyal A, Jadhav A, Katyal A, Jagetia A, Bodeliwala S, Singhal GD, Nazir W, Batra V, Srivastava AK, Singh D. Occipital transtentorial approach for pineal region lesions: Addressing the controversies in conventional teaching. Surg Neurol Int 2021; 12:503. [PMID: 34754553 PMCID: PMC8571259 DOI: 10.25259/sni_168_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 09/07/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The occipital transtentorial (OT) approach is well-established approach for pineal region tumors and can be of choice for the lesions located around the suboccipital part of tentorium such as the quadrigeminal plate, posterior part of thalamus, tentorial surface of cerebellum, splenial region, posterior falx, and lesions around the tentorial incisura. However, it is not very much extensively used in the above-mentioned locations other than the pineal region. METHODS Thirty-one patients of pineal region lesions were operated by OT approach, the role of conventional preoperative evaluation of the anatomy of the venous sinuses, deep venous system, and tentorial angle was investigated. RESULTS A variety of lesions were operated using this approach achieving gross and near total resection in majority of the cases (76.6%), with acceptable postoperative mean modified Rankin scales (1.8). CONCLUSION The OT is a preferable approach for pineal region lesions for patients of all ages and can be tailored for achieving high resectability rates irrespective of the status of the deep venous system and tentorial angle, with reasonable postoperative surgical outcome.
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Affiliation(s)
- Abhishek Katyal
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, Delhi, India
| | - Anil Jadhav
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, Delhi, India
| | - Aparna Katyal
- Department of Radiodiagnosis, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, Delhi, India
| | - Anita Jagetia
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, Delhi, India
| | - Shaam Bodeliwala
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, Delhi, India
| | - Ghanshyam Das Singhal
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, Delhi, India
| | - Wajid Nazir
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, Delhi, India
| | - Vineeta Batra
- Department of Pathology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, Delhi, India
| | - Arvind Kumar Srivastava
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, Delhi, India
| | - Daljit Singh
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, Delhi, India
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Giammattei L, Starnoni D, Benes V, Froelich S, Cossu G, Borsotti F, Májovsky M, Sufianov AA, Fava A, di Russo P, Elbabaa SK, González-López P, Messerer M, Daniel RT. Extreme Lateral Supracerebellar Infratentorial Approach: Surgical Anatomy and Review of the Literature. World Neurosurg 2021; 147:89-104. [PMID: 33333288 DOI: 10.1016/j.wneu.2020.12.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/05/2020] [Accepted: 12/07/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The extreme lateral supracerebellar infratentorial (ELSI) approach has the potential to access several distinct anatomical regions that are otherwise difficult to reach. We have illustrated the surgical anatomy through cadaveric dissections and provided an extensive review of the literature to highlight the versatility of this approach, its limits, and comparisons with alternative approaches. METHODS The surgical anatomy of the ELSI has been described using 1 adult-injected cadaveric head. Formalized noninjected brain specimens were also dissected to describe the brain parenchymal anatomy of the region. An extensive review of the literature was performed according to each targeted anatomical region. Illustrative cases are also presented. RESULTS The ELSI approach allows for wide exposure of the middle and posterolateral incisural spaces with direct access to centrally located intra-axial structures such as the splenium, pulvinar, brainstem, and mesial temporal lobe. In addition, for skull base extra-axial tumors such as petroclival meningiomas, the ELSI approach represents a rapid and adequate method of access without the use of extensive skull base approaches. CONCLUSIONS The ELSI approach represents one of the most versatile approaches with respect to its ability to address several anatomical regions centered at the posterior and middle incisural spaces. For intra-axial pathologies, the approach allows for access to the central core of the brain with several advantages compared with alternate approaches that frequently involve significant brain retraction and cortical incisions. In specific cases of skull base lesions, the ELSI approach is an elegant alternative to traditionally used skull base approaches, thereby avoiding approach-related morbidity.
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Affiliation(s)
| | - Daniele Starnoni
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Vladimir Benes
- Department of Neurosurgery, Charles University and Military University Hospital, Prague, Czech Republic
| | | | - Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Francois Borsotti
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Martin Májovsky
- Department of Neurosurgery, Charles University and Military University Hospital, Prague, Czech Republic
| | - Albert A Sufianov
- Department of Neurosurgery, Federal Centre of Neurosurgery, Tyumen, Russia; Department of Neurosurgery, Sechenov University, Moscow, Russia
| | - Arianna Fava
- Department of Neurosurgery, Lariboisière Hospital, Paris, France
| | - Paolo di Russo
- Department of Neurosurgery, Lariboisière Hospital, Paris, France
| | - Samer K Elbabaa
- Department of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Pablo González-López
- Department of Neurosurgery, Hospital General Universitario de Alicante, Alicante, Spain
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Roy T Daniel
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland; Department of Neurosurgery, Sechenov University, Moscow, Russia; Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
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The Anatomy of the Sigmoid-Transverse Junction According to the Tentorial Angle. J Craniofac Surg 2019; 30:2280-2284. [PMID: 31369515 DOI: 10.1097/scs.0000000000005793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Dural sinuses have critical importance during intracranial approaches. Detailed anatomical knowledge of the dural sinuses is crucial for surgeons to reduce unexpected venous bleeding. The aim of this study was to investigate anatomical relation of sigmoid sinus and tentorium cerebelli according to clinically palpable landmarks and cranial morphometry. The authors evaluated 222 individuals' (94 women, 128 men) 3-dimensional computed tomography angiograms, retrospectively. The authors also studied on 12 mid-sagittal cut dried hemiskulls and 8 formalin fixed cadaver heads hemisected midsagitally. All measurements were completed using Osirix-Lite version 9 software. Craniometrical values were measured to define cranium morphology. Furthermore, level of the sigmoid sinus according to asterion and tentorial angle were evaluated in detail. Our results demonstrated that there were significant differences between parameters and genders, except vertical angle of the tentorium cerebelli. Distance between asterion and sigmoid sinus was statistically different between right and left sides in favor of the left side. This also varied depending on the position of the sigmoid sinus, as well. Only transverse angle between the upper point of external acoustic meatus and asterion demonstrated a significant correlation with age. This study evaluated the detailed 3D anatomy of sigmoid sinus and tentorium cerebelli related with the cranium morphology. Determining to sigmoid sinus anatomy according to clinically palpable landmarks has advantages for setting surgical protocols and reducing to unexpected injuries while surgery to these structures.
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