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Interhemispheric Transtentorial Approach to a Teratoma of the Pineal Region
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The video describes the posterior interhemispheric transtentorial approach to a teratoma of the pineal region. A 7-year old boy was admitted for gait disorder and visual impairment associated with Parinaud’s syndrome. MRI showed a solid-microcystic lesion of pineal region associated with triventricular hydrocephalus. Third-ventriculostomy and tumor biopsy were performed. Hystology was inconclusive but CSF β-HCG was mildly elevated. Chemotherapy following GCT protocol was performed but tumor progressed at two months. Direct surgical approach via interhemispheric transtentorial route was therefore decided with the aim of maximum safe removal.
The tumor was located in the pineal region, bulging inside the posterior part of the third ventricle. Its presence determined a significant downward compression of the tectal plate and of the upper vermis, and upward stretching of both internal cerebral veins. MRI showed an heterogeneous texture with areas of contrast enhancement alternated with cystic areas. Due to the pineal origin and downward displacement of the tectal plate, telovelar approach was not considered. Due to the very low position of the lower pole, the supracerebellar approach was discarded as well. Interhemispheric transcallosal transchoroidal approach was considered as an excellent possibility but interhemispheric transtentorial approach was preferred because it allows to reach the tumor without callosal incision and without the need of extended choroidal dissection.
MRI showed total removal of the tumor, that histology confirmed as teratoma. The patient did not develop any post-operative motor or memory deficit. MRI shows no residual tumor or regrowth at two-year follow up. The child follows his normal school activity without any external support and with excellent results.
Introduction
Interhemispheric Transtentorial Approach to a Teratoma of the Pineal Region avoids any venous sacrifice with a more neutral head position.
About The Authors
Dr. Giuseppe Cinalli is Chief of the Department of Pediatric Neurosurgery and of the Department of Neurosciences at the Santobono-Pausilipon Children’s Hospital, where he began working in October 1999. He started the residency program in Neurosurgery at the “Federico II” University in Naples, and completed it at the Department of Pediatric Neurosurgery of the Hôpital Necker Enfants Malades in Paris, France. In 1993 he spent a period as a visiting fellow at the Department of Pediatric Neurosurgery of the New York University Medical Center directed by Fred Epstein, and at the Department of Pediatric Neurosurgery of the Primary Children’s Medical Center of Salt Lake City directed by Marion “Jack” Walker. In the same year he began his University career in France as Chef de Clinique-Assistant and later as Praticien Hospitalo-Universitaire. He is an active member of 7 scientific societies, has written 116 indexed papers, edited 4 books, and is a founding member of the International Study Group on Neuro Endoscopy (ISGNE), which later became the International Federation of Neuroendoscopy (IFNE). In 2017 he was elected President of the IFNE for a two-year term.
Marcello Barbato completed a MD training at Federico II Medical School, University of Naples, Italy. His main areas of interest are neurosurgical oncology, neuroendoscopy and Spine Surgery.
About this video
- Author(s)
- Giuseppe Cinalli
- Marcello Barbato
- DOI
- https://doi.org/10.1007/978-3-030-95496-3
- Online ISBN
- 978-3-030-95496-3
- Total duration
- 50 min
- Publisher
- Springer, Cham
- Copyright information
- © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
Video Transcript
[MUSIC PLAYING]
In this video, we will describe the interhemispheric transtentorial approach to teratoma of the pineal region. I am Giuseppe Cinalli, director of the Department of Neurosciences and of the Division of Pediatric neurosurgery of Santobono-Pausilipon Children’s Hospital in Naples, Italy.
The video describes the case of a seven-year-old boy admitted to for a gait disorder and visual impairment associated with Parinaud’s syndrome. MRI showed a solid microcystic lesion of pineal region associated with a triventricular hydrocephalus. Third-ventriculostomy and tumor biopsy were performed.
Histology was inconclusive, but CSF BETA-HCG was mildly elevated. Chemotherapy following GCT protocol was performed, but the tumor progressed at two months. Direct surgical approach via interhemispheric route was therefore decided, with the aim of maximum safe removal.
Axial MRI shows the presence of a mass in the posterior third ventricle, with heterogeneous components, three-ventricular hydrocephalus that is also well seen in the coronal section, where the relationship with the internal cerebral vein is evident. And certainly, the cut that is more important for decision of the surgery is the sagittal MRI with contrast enhancement that shows very nicely the relationship of the tumor with the vein of Galen and with the complex of the deep veins.
Among the approaches treatable for this region, we excluded the transcallosal transchoroidal approach and the telovelar approach from below, but we considered to perform a supracerebellar infratentorial approach. With this approach, in fact, the vision of the tumor is very good, with good access to both sides and the good possibility of dissection of the vein of Galen and of the deep vein complex.
But this approach requires the sacrifice of bridging veins from the cerebellum to the tentorium. And for this reason, we also considered the interhemispheric transtentorial approach, the OITA approach.
To select this approach, the method is very simple. On a sagittal cut, we identify the lowest point of the vein of Galen complex. Then we identify the highest point of the Torcular Herophili complex. And on these two points, we trace the line that we called the Herophilus- Galen line.
This line represents the highest possible line of sight of an operating microscope, and it is easily seen on this example. 100% of the tumor is located below this line. And therefore, this makes this patient a perfect candidate for an interhemispheric transtentorial approach.
Preoperative planning with a 3D model is extremely helpful in understanding how the positioning can help in choosing the surgical approach. We can imagine the angle of sight during surgery. We can magnify our surgical vision during magnification with the operating microscope. And we can imagine how inclination of the microscope can change our visibility of the tumor, giving access to the highest part of the vein of Galen complex.