Endoscopic supracerebellar infratentorial retropineal approach for tumor resection

Abstract

Background: Lesions located in the pineal region represent a surgical challenge. Multiple approaches to this region have been described, each with its advantages and disadvantages. We report the first application of the endoscopic supracerebellar infratentorial approach for complete resection of a pineal tumor. Unlike transventricular endoscopy, this technique poses no risk to the fornices and can be applied independent of ventricular size.

Case description: A 21-year-old man sought treatment for diplopia. Magnetic resonance images of brain revealed a heterogeneous, contrast-enhancing mass that originated from the pineal gland. This tumor exerted the mass effect on the tectum and invaded to the bilateral dorso-medial thalamus and hypothalamus but caused no obstructive hydrocephalus. The results of a cytological study of the cerebrospinal fluid, alpha-fetoprotein, and beta-human chorionic gonadotropin were negative. The patient was referred for the surgical work-up.

Technique: The patient was positioned in the semi-sitting position. The supracerebellar infratentoria corridor was accessed through two paramedian burr holes, which provided natural by-gravity cerebellar traction. The excellent illumination and magnification without sacrificing the inferior occipital sinus could be achieved with the aid of the endoscope. The pineal tumor was resected completely via the full-endoscopic approach. Postoperatively, the patient's diplopia resolved completely, and his hospital course was uneventful.

Conclusions: Taking the advantages of the endoscope and peculiar supracerebellar infratentoria corridor, we could successfully remove the gross-total tumor without violating the critical neurovascular structures. Moreover, this approach can be performed regardless of the size of the ventricle. Consequently, it is an excellent minimally invasive surgical option for resection of symptomatic pineal tumor.