Supracerebellar transtentorial approach to the tentorial incisura and beyond

A Novel Method to Measure the Tentorial Angle and the Implications on Surgeries of the Pineal Region

OBJECTIVE

There is no standard way to define the angle of the tentorium. The current trend to use the Twining line to define this angle has significant pitfalls. The goal of the current study was to provide a new and accurate way to measure the tentorial angle and demonstrate its impact on surgeries of the pineal region.

METHODS

A new technique (n-angle) to measure the tentorial angle was introduced using the floor of the fourth ventricle and the torcula. Comparisons with older techniques were made to illustrate reliability. Midline sagittal MR images were used to measure the tentorial angle in 240 individuals to obtain population-based data. A cohort of 8 patients who underwent either the infratentorial or the transtentorial approach to the pineal or upper vermian region were examined in search of correlations between tentorial angle and surgical approach.

RESULTS

The data in this study showed that the Twining line technique understates the tentorial angle in people with low-lying torcula. The n-angle is more reliable in reflecting the true steepness of the tentorium regardless of torcula position. On average, men have slightly steeper tentoriums. In the clinical cohort, all patients who underwent infratentorial surgery had tentorial angles <55°, whereas the majority of patients who underwent transtentorial surgeries had angles >67°.

CONCLUSION

The n-angle provides a reliable and accurate way to describe the slope of the tentorium. The population-based average of 60° may be a useful measurement to influence the choice of surgical approach, either under or through the tentorium, to the pineal region.