Endoscopic supracerebellar infratentorial approach for pineal cyst resection: technical case report

Combined Microscopic and Endoscopic Surgery for Pineal Region Meningiomas Using the Occipital-Parietal Transtentorial Approach

Objective

Pineal region meningiomas are deeply located and adjacent to critical neurovascular structures, making them one of the most challenging areas to access. The authors presented a combined microscopic and endoscopic surgery and investigated its value in resecting pineal region meningiomas.

Methods

Twelve patients with pineal region meningiomas from February 2017 to December 2020 were retrospectively reviewed. All patients underwent combined microscopic and endoscopic surgery using the occipital-parietal transtentorial approach. Perioperative clinical, surgical, and radiographic data were collected.

Results

The endoscope provided a wider view and increased visualization of residual tumors. All tumors were completely resected, and none of the patients died. Total resection was believed to have been achieved in four patients, but the residual tumor was detected after endoscopic exploration and was completely resected with an endoscope. Only one patient had transient visual field deficits. No recurrence was observed during follow-up.

Conclusions

Combined microscopic-endoscopic surgery for pineal region meningiomas eliminates microscopic blind spots, thus compensating for the shortcomings of the traditional occipital transtentorial approach. It is a promising technique for minimally invasive maximal resection of pineal region meningiomas.

Endoscope-Assisted Microsurgery in Pediatric Cases With Pineal Region Tumors: A Study of 18 Cases Series

Background: An endoscope-assisted technique was recently introduced to microsurgery (MS) and may compensate for the disadvantages of MS for deep-seated lesions. This study was performed to identify the effectiveness and safety of endoscopic-assisted microsurgery (EAM) and share our experience of EAM for pediatric cases with pineal region tumors.

Method: We retrospectively analyzed the clinical data of consecutive pediatric cases with pineal region tumors treated by EAM or MS from January 2016 to June 2020. These data included the patient population, clinical manifestations, preoperative examination findings, surgical approach, pathological results, and clinical outcomes. The clinical outcomes were analyzed in the EAM group and MS group with a focus on the gross total resection (GTR) rate, postoperative hydrocephalus remission rate, and Karnofsky performance score (KPS). Studies on the surgical management of children with pineal region tumors in the last decade were reviewed.

Result: Eighteen children successfully underwent tumor resection via MS (n = 8) or EAM (n = 10). The children's mean age was 11.4 ± 4.7 years, and the male to female ratio was 7:2. Seventeen patients (94.4%) complicated preoperative hydrocephalus, and 16 (88.9%) presented headache with nausea and/or vomiting. The pathological examination revealed germ cell tumors in 11 (61.1%) patients, neuroepithelial tumors in 4 (22.2%) patients, and a pineoblastoma, arachnoid cyst, and atypical teratoid rhabdoid tumor in 1 (5.6%) patient each. GTR was more commonly achieved in the EAM than MS group (80.0 vs. 50.0%, respectively), and the postoperative hydrocephalus remission rate was higher in the EAM than MS group (87.5 vs. 50.0%, respectively). At a mean follow-up time of 23.6 ± 11.5 weeks, the mean improvement of the KPS 6 months postoperatively was greater in the EAM than MS group (24.0 ± 9.7 vs. 17.5 ± 7.1 points, respectively).

Conclusion: EAM combines endoscopic and microsurgical techniques and can be safely and effectively performed to achieve GTR of pineal region tumors in pediatric patients. In children with pineal region tumors who have obstructive hydrocephalus, EAM could improves hydrocephalus remission rates by checking and clearing the midbrain aqueduct under visualization.

Laparoscope-Assisted Guidance to the Pineal Region

Tumors arising in the pineal region present a number of challenges when planning for effective removal. This report describes the successful resection of a falcotentorial meningioma occurring in a 56-year-old female using a supracerebellar infratentorial approach. In order to excise the pineal region mass, a unique combination of instrumentation was used, including a microscope, endoscope, and abdominal laparoscope. This technique afforded us passage to the pineal region, which allowed for enhanced visualization and maneuverability and was more amenable to decreasing the physical stress of the operating surgeon. This article is the first to detail the use of an abdominal laparoscope to remove a pineal tumor of this size for near-total resection. The various surgical approaches and tools traditionally used to remove pineal tumors are discussed, and the particular advantages and disadvantages of our hybrid approach are reviewed.

How I do it: endoscopic supracerebellar infratentorial approach for torcular meningioma removal

BACKGROUND

Torcular meningioma is a rare type of brain tumor with few reports regarding the appropriate resection approach for this disease. In cases without sinus occlusion, surgeons are advised to spare the sinus; however, the sinus may interfere with the visual field.

METHOD

Endoscopic supracerebellar infratentorial approach for removal of torcular meningioma was performed in the prone position. The tumor attachment to sinus or confluence was removed or coagulate safely due to an optimal look-up view with the 0° and 30° endoscope.

CONCLUSION

Endoscopic supracerebellar infratentorial approach for infratentorial torcular meningioma is a safe and less invasive technique.

[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.

The microsurgical management of benign pineal cysts: Helsinki experience in 60 cases

Background:

Microsurgical resection represents a well-accepted management option for symptomatic benign pineal cysts. Symptoms such as a headache, hydrocephalus, and visual deficiency are typically associated with pineal cysts. However, more recent studies reported over the past years have characterized additional symptoms as a part of the clinical manifestation of this disease and represent additional indications for intervention.

Methods:

We present a retrospective review of patients with histologically confirmed benign pineal cysts that were operated on in our department between 1997 and 2015. A demographic analysis, evaluation of preoperative status, surgical treatment, as well as immediate and long-term clinical and radiological outcomes were conducted.

Results:

A total of 60 patients with benign pineal cysts underwent surgery between 1997 and 2015. Gross total resection was achieved in 58 cases. All patients except one improved in their clinical status or had made a full recovery at the time of the last follow-up. The key steps for surgical resection of pineal cysts are reported, based on an analysis of representative surgical videos.

Conclusions:

We describe in this paper one of the largest series of microsurgically treated pineal cysts. In our opinion, judicious microsurgery remains the most suitable technique to effectively deal with this disease.

Extended endoscopic supracerebellar infratentorial (EESI) approach for a complex pineal region tumour-a technical note

Endoscopic-assisted approaches have been shown to be a suitable alternative to the standard microscopic approach to pineal region tumours. With extension laterally into the ventricles, the 0° endoscope and microscope have significant limitations. We describe the extended endoscopic supracerebellar infratentorial (EESI) approach using angled endoscopes for a complex pineal region tumour that extended into the lateral ventricle. A 15-year-old boy presented with headaches and ataxia. MRI revealed a pineal region tumour extending into the lateral ventricle. The patient was positioned in the sitting position. The supracerebellar infratentorial corridor was accessed through a small craniotomy. The tumour was resected completely via the endoscope. Postoperatively, the patient's symptoms resolved completely. We believe that this case highlights the benefit of using the endoscopic extended supracerebellar infratentorial (EESI) approach to resect pineal region lesions that extend beyond the midline.

Supracerebellar Infratentorial Endoscopic and Endoscopic-Assisted Approaches to Pineal Lesions: Technical Report and Review of the Literature

The pineal gland has a deep central location, making it a surgeon's no man's land. Surgical pathology within this territory presents a unique challenge and an opportunity for employment of various surgical techniques. In modern times, the microsurgical technique has been competing with the endoscope for achieving superior surgical results. We describe two cases utilizing a purely endoscopic and an endoscopic-assisted supracerebellar infratentorial approach in accessing lesions of the pineal gland. We also discuss our early learning experience with these approaches.

[Pineal cyst]

A pineal cyst (PC) is a benign neoplasm in the pineal region, or more precisely in the pineal body. Most cysts are incidental findings and are not associated with symptoms typical of patients seeking medical advice. Symptomatic cysts are discovered less often and, depending on the clinical picture, require different treatment approaches.

MATERIAL AND METHODS

We analyzed the literature data about the clinical picture, diagnosis, and treatment of PCs for more than a century (1914-2016).

CONCLUSION

To date, there is no single approach for managing PC patients. The indications for surgical treatment of symptomatic PCs are still not fully defined. It remains unclear which PC cases should be followed-up, and how often control examinations should be performed. More research of PCs is needed to develop new approaches to treatment of PC patients.

Endoscope-Assisted Combined Supracerebellar Infratentorial and Endoscopic Transventricular Approach to the Pineal Region: A Technical Note

Neoplasms of the pineal region comprise less than 2% of all intracranial lesions. A variety of techniques have been adapted to gain access to the pineal region. Classic approaches employ the use of the microscope. More recently, the endoscope has been utilized to improve access to such deep-seated lesions. A 62-year-old female presented with a heterogeneously enhancing lesion in the pineal region with associated hydrocephalus. On exam, the patient exhibited Parinaud's syndrome. The patient initially underwent a single burr hole endoscopic third ventriculostomy and biopsy of the lesion. Initial pathology was consistent with a grade III astrocytoma. Following a period of recuperation, she returned for definitive surgical resection. A suboccipital craniectomy was performed in the sitting position. Prior to dural opening, an endoscope was inserted into the right lateral ventricle through the prior burr hole.The endoscope was passed through the foramen of Monro and the tumor could be visualized along the posterior third ventricle. The patient underwent a standard supracerebellar infratentorial approach aided by the microscope. After initial debulking of the pineal lesion, an endoscope was utilized to guide the depth of resection and assist in dissection with transventricular manipulation of the tumor. During the final stages of resection from the craniotomy, the endoscope was used to help visualize the posterior supracerebellar corridor. This assisted in the assessment of the extent of resection. The endoscope was also utilized for the removal of intraventricular blood products following tumor resection. The patient was extubated and transferred to the intensive care unit. A postoperative contrast-enhanced magnetic resonance imaging (MRI) revealed greater than 95% resection, with expected residual within the midbrain. The combined supracerebellar infratentorial and transventricular endoscope-assisted approach provided maximum visualization and aided in optimal resection of a traditionally difficult pineal region tumor. Further experience with this combined technique may allow for improved surgical outcomes for these complex lesions.

Pineal cyst resection in the absence of ventriculomegaly or Parinaud's syndrome: clinical outcomes and implications for patient selection

OBJECT

Surgical indications for patients with pineal cysts are controversial. While the majority of patients harboring a pineal cyst require no treatment, surgery is a well-accepted option for a subset of those patients with secondary hydrocephalus or Parinaud's syndrome. The majority of pineal cysts are identified incidentally during workup for other potential conditions, which may or may not be related to the presence of the cyst. In the absence of clear obstruction of CSF pathways, the treatment of presumed symptomatic pineal cysts is debatable. To clarify the role of surgery in these borderline cases, the authors reviewed their experience with resection of pineal cysts in the absence of ventriculomegaly or Parinaud's syndrome.

METHODS

The authors retrospectively reviewed medical records and imaging of all patients surgically treated between 2001 and 2014 with a pineal cyst in the absence of ventriculomegaly and Parinaud's syndrome. The presenting symptoms, preoperative cyst size, preoperative radiographic aqueductal compression, extent of resection, and radiographic and clinical follow-up were documented.

RESULTS

Eighteen patients (14 female and 4 male; mean age 24 years, range 4–47 years) underwent cyst resection in the absence of ventriculomegaly or Parinaud's syndrome. Presenting symptoms included headache (17 patients), visual disturbances (10 patients), gait instability (5 patients), dizziness (5 patients), episodic loss of consciousness (2 patients), and hypersomnolence (1 patient). The mean preoperative cyst diameter was 1.5 cm (range 0.9–2.2 cm). All patients had a complete resection. At a mean clinical follow-up of 19.1 months (range postoperative to 71 months), 17 (94%) patients had resolution or improvement of their presenting symptoms.

CONCLUSIONS

The authors' results suggest that ventriculomegaly and Parinaud's syndrome are not absolute requisites for a pineal cyst to be symptomatic. Analogous to colloid cysts of the third ventricle, intermittent occlusion of cerebrospinal fluid pathways may cause small pineal cysts to become intermittently symptomatic. A select cohort of patients with pineal cysts may benefit from surgery despite a lack of hydrocephalus or other obvious compressive pathology.

Endoscopic approaches to brainstem cavernous malformations: Case series and review of the literature

Background:

Symptomatic cavernous malformations involving the brainstem are frequently difficult to access via traditional methods. Conventional skull-base approaches require significant brain retraction or bone removal to provide an adequate operative corridor. While there has been a trend toward limited employment of the most invasive surgical approaches, recent advances in endoscopic technology may complement existing methods to access these difficult to reach areas.

Case Descriptions:

Four consecutive patients were treated for symptomatic, hemorrhagic brainstem cavernous malformations via fully endoscopic approaches (endonasal, transclival; retrosigmoid; lateral supracerebellar, infratentorial; endonasal, transclival). Together, these lesions encompassed all three segments of the brainstem. Three of the patients had complete resection of the cavernous malformation, while one patient had stable residual at long-term follow up. Associated developmental venous anomalies were preserved in the two patients where one was identified preoperatively. Three of the four patients maintained stable or improved neurological examinations following surgery, while one patient experienced ipsilateral palsies of cranial nerves VII and VIII. The first transclival approach resulted in a symptomatic cerebrospinal fluid leak requiring re-operation, but the second did not. Although there are challenges associated with endoscopic approaches, relative to our prior microsurgical experience with similar cases, visualization and illumination of the surgical corridors were superior without significant limitations on operative mobility.

Conclusion:

The endoscope is a promising adjunct to the neurosurgeon's ability to approach difficult to access brainstem cavernous malformations. It allows the surgeon to achieve well-illuminated, panoramic views, and by combining approaches, can provide minimally invasive access to most regions of the brainstem.

Arterial vascularization of the pineal gland

PURPOSE

The arterial vascularization of the pineal gland (PG) remains a debatable subject. This study aims to provide detailed information about the arterial vascularization of the PG.

METHODS

Thirty adult human brains were obtained from routine autopsies. Cerebral arteries were separately cannulated and injected with colored latex. The dissections were carried out using a surgical microscope. The diameters of the branches supplying the PG at their origin and vascularization areas of the branches of the arteries were investigated.

RESULTS

The main artery of the PG was the lateral pineal artery, and it originated from the posterior circulation. The other arteries included the medial pineal artery from the posterior circulation and the rostral pineal artery mainly from the anterior circulation. Posteromedial choroidal artery was an important artery that branched to the PG. The arterial supply to the PG was studied comprehensively considering the debate and inadequacy of previously published studies on this issue available in the literature.

CONCLUSIONS

This anatomical knowledge may be helpful for surgical treatment of pathologies of the PG, especially in children who develop more pathology in this region than adults.

Pineal cysts in children: case-based update

PURPOSE

Pineal cysts (PC) are found in children as often asymptomatic and without change in their size over the time. However, there are some debatable issues about their evolution and management in the pediatric population. The aim of the present paper is to update the information regarding pathogenesis, clinical presentation, and management of these lesions.

METHODS

All the pertinent literature was reviewed, and a meta-analysis of operated on cases was carried out. An illustrative case regarding the clinical evolution of a 13-year-old girl is also presented.

RESULTS AND CONCLUSIONS

PC are often asymptomatic and do not evolve over the time. However, since there is a certain risk of clinical and/or radiological progression, or even sudden and severe clinical onset (apoplexy), both a clinical and radiological follow-up is recommended in the pediatric age. The surgical excision is usually limited to symptomatic patients or to cases with clear radiological evolution.

Supracerebellar infratentorial endoscopically controlled resection of pineal lesions: case series and operative technique

OBJECT

The heterogeneous clinical manifestations and operative characteristics of pathological entities in the pineal region represent a significant challenge in terms of patient selection and surgical approach. Traditional surgical options have included endoscopic transventricular resection; open supratentorial microsurgical approaches through the midline, choroidal fissure, lateral ventricle, and tentorium; and supracerebellar infratentorial (SCIT) approaches through the posterior fossa. The object of the current study was to review the preoperative characteristics and outcomes for a cohort of patients treated purely via the novel endoscopically controlled SCIT approach.

METHODS

A single-institution series of 9 consecutive patients (4 male and 5 female patients [10 total cases]; mean age 21 years, range 6-37 years) treated via the endoscopically controlled SCIT approach for a pathological entity in the pineal region was retrospectively reviewed. The mean follow-up time was 13.2 months.

RESULTS

The endoscopically controlled SCIT approach was successfully used to approach a variety of pineal lesions, including pineal cysts (6 patients), epidermoid tumor, WHO Grade II astrocytoma (initial biopsy and recurrence), and malignant mixed germ cell tumor (1 patient each). Gross-total resection and/or adequate cyst fenestration was achieved in 8 cases. Biopsy with conservative debulking was performed for the single case of low-grade astrocytoma and again at the time of recurrence. The mean preoperative tumor and cyst volumes were 9.9 ± 4.4 and 3.7 ± 3.2 cm(3), respectively. The mean operating times were 212 ± 71 minutes for tumor cases and 177 ± 72 minutes for cysts. Estimated blood loss was less than 150 ml for all cases. A single case (pineal cyst) was converted to an open microsurgical approach to enhance visualization. There were no operative complications, as well as no documented CSF leaks, additional CSF diversion procedures, or air emboli. Seven patients underwent concomitant third ventriculostomy into the quadrigeminal cistern. At the time of the last follow-up evaluation, all patients had a stable or improved modified Rankin Scale score.

CONCLUSIONS

The endoscopically controlled SCIT approach may be used for the biopsy and resection of appropriately selected solid tumors of the pineal region, in addition to the fenestration and/or resection of pineal cysts. Preoperative considerations include patient presentation, anticipated disease and vascularity, degree of local venous anatomical distortion, and selection of optimal paramedian trajectory.

Pure endoscopic removal of pineal region tumors

PURPOSE

Endoscopic resection of pineal tumors using an endoscope with a mounted rigid suction that allows bimanual handling of the tumor for resection. This contrasts to the established method of biopsy of pineal tumors through intraventricular approach.

METHODS

Two patients, one with a cystic lesion in the pineal region and one with a large pineal tumor, were operated in sitting position through a subtorcular approach. Endoscope was held in the left hand with suction tip extending beyond the tip through its instrument channel. Regular microsurgical instrumentation/CUSA/Nico Aspirator was used with the right hand for dissection, cutting, and removing the tumor under endoscopic vision.

RESULT

Surgeon comfort was superior to when microscope is used in sitting position. Complete resection was achieved in all cases.

CONCLUSION

The two-handed endoscopic technique using a mounted suction on the endoscope as described is a safe and effective strategy for resecting pineal region tumors.

Prevalence and natural history of pineal cysts in adults

OBJECT

We reviewed our experience with pineal cysts to define the natural history and clinical relevance of this common intracranial finding.

METHODS

The study population consisted of 48,417 consecutive patients who underwent brain MR imaging at a single institution over a 12-year interval and who were over 18 years of age at the time of imaging. Patient characteristics, including demographic data and other intracranial diagnoses, were collected from cases involving patients with a pineal cyst. We then identified all patients with pineal cysts who had been clinically evaluated at our institution and who had at least 6 months of clinical and imaging follow-up. All inclusion criteria for the natural history analysis were met in 151 patients.

RESULTS

Pineal cysts measuring 5 mm or larger in greatest dimension were found in 478 patients (1.0%). Of these, 162 patients were male and 316 were female. On follow-up MR imaging of 151 patients with pineal cyst at a mean interval of 3.4 years from the initial study, 124 pineal cysts remained stable, 4 increased in size, and 23 decreased in size. Cysts that were larger at the time of initial diagnosis were more likely to decrease in size over the follow-up interval (p = 0.004). Patient sex, patient age at diagnosis, and the presence of septations within the cyst were not significantly associated with cyst change on follow-up.

CONCLUSIONS

Follow-up imaging and neurosurgical evaluation are not mandatory for adults with asymptomatic pineal cysts.