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

2. 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

3. The Pineal Region
Anterior: Quadrigeminal plate, pineal body, habenular complex
Lateral: Mesial temporal and occipital lobes, pulvinar
Roof: Splenium
Floor: Vermis

4. The 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

5. The 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

6. Approaches Supracerebellar – Infratentorial Occiptial – Transtentorial
Combined Supratentorial – Infratentorial Transsinus

7. Supracerebellar – Infratentorial
Sitting or concord position
Midline or inverted U-shaped incision

8. Supracerebellar – Infratentorial

9. Supracerebellar – Infratentorial

10. Supracerebellar – Infratentorial

11. Occipital - Transtentorial
Three – quarters prone position
Operative side in dependent position
Inverted J

12. Occipital - Transtentorial

13. Occipital - Transtentorial

14. Combined Supratentorial – Infratentorial Transsinus
Semiprone position
Operative side in dependent position
Inverted J
Craniotomy made in three pieces

15. Combined Supratentorial – Infratentorial Transsinus

16. Complications and Considerations
Supracerebellar – Infratentorial:
Air embolism
Ventricluar collapse  SDH, pneumocephalus
Not suitable for superior extending lesions
Gravity retracting cerebellum

17. Complications and Considerations
Occiptial – Transtentorial:
Retraction of occipital lobes  visual field defects
Disconnection syndrome
Limited exposure of contralateral side
Good view of quadrigeminal plate

18. Complications and Considerations
Combined Supratentorial – Infratentorial Transsinus:
Brain edema
Venous infarcts
Very wide exposure
Consider primary re-anastomosis or patch graft

19. References
Fossett TF and Caputy JC. Operative Neurosurgical Anatomy. Thieme: New York 2002
Haye AH and Laws ER. Brain Tumors. Churchill Livingstone: Edinburgh 1995