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Introduction: The surgery of clival chordoma remains one of the most formidable challenges for neurosurgeons because of its location at great depth in the cranium and proximity to critical neurovascular structures. Here, we describe the technique and feasibility of the purely endoscopic far-lateral supracerebellar infratentorial approach (EF-SCITA) for resection of an intradural clival chordoma. Case description: A 68-year-old women presented with sudden ptosis on the left side for two weeks. Imaging examinations revealed an upper-middle clival lesion that transgressed dural confines towards the posterior fossa, which was separated from the sphenoid cavity by an intact thin layer of membrane structure in front. For surgery, the EF-SCITA approach via suboccipital craniotomy was attempted for protecting surrounding neurovascular tissue and the membrane barrier under direct vision. The patients were placed in a "head-up" lateral park-bench position. With the endoscopic holder, endoscopic procedures were performed using standard two-hand microsurgical techniques by one surgeon. Tentorium incision allowed a working corridor toward the clival bulge through the crural cistern, without brain traction seen in traditional retrosigmoid approach. Efficient tumor debulking facilitated the exposure of surrounding critical structures, including ipsilateral CN III and superior cerebellar artery above, the brainstem and basilar artery posteriorly, as well as ipsilateral CN VI displaced laterally, and subsequent tumor separation from them. Step-wise tumor resection was performed within dural and bone confines. After significant tumor removal, the pituitary stalk could be visualized anteriorly, together with contralateral internal carotid artery and CN III. Postoperative MRI depicted gross total excision of the lesion. The patient on follow-up at one year had complete recovery of cranial nerve functions, without signs of cerebrospinal fluid rhinorrhea. Discussion: This technique combines advantages of the posterolateral approach and endoscopy, allowing access to the upper-middle clivus with seemingly low risks of postoperative morbidity. It would be a safe and effective alternative for resection of this rare entity. [ABSTRACT FROM AUTHOR]

IntroductionThe surgery of clival chordoma remains one of the most formidable challenges for neurosurgeons because of its location at great depth in the cranium and proximity to critical neurovascular structures. Here, we describe the technique and feasibility of the purely endoscopic far-lateral supracerebellar infratentorial approach (EF-SCITA) for resection of an intradural clival chordoma.Case descriptionA 68-year-old women presented with sudden ptosis on the left side for two weeks. Imaging examinations revealed an upper-middle clival lesion that transgressed dural confines towards the posterior fossa, which was separated from the sphenoid cavity by an intact thin layer of membrane structure in front. For surgery, the EF-SCITA approach via suboccipital craniotomy was attempted for protecting surrounding neurovascular tissue and the membrane barrier under direct vision. The patients were placed in a “head-up” lateral park-bench position. With the endoscopic holder, endoscopic procedures were performed using standard two-hand microsurgical techniques by one surgeon. Tentorium incision allowed a working corridor toward the clival bulge through the crural cistern, without brain traction seen in traditional retrosigmoid approach. Efficient tumor debulking facilitated the exposure of surrounding critical structures, including ipsilateral CN III and superior cerebellar artery above, the brainstem and basilar artery posteriorly, as well as ipsilateral CN VI displaced laterally, and subsequent tumor separation from them. Step-wise tumor resection was performed within dural and bone confines. After significant tumor removal, the pituitary stalk could be visualized anteriorly, together with contralateral internal carotid artery and CN III. Postoperative MRI depicted gross total excision of the lesion. The patient on follow-up at one year had complete recovery of cranial nerve functions, without signs of cerebrospinal fluid rhinorrhea.DiscussionThis technique combines advantages of the posterolateral approach and endoscopy, allowing access to the upper-middle clivus with seemingly low risks of postoperative morbidity. It would be a safe and effective alternative for resection of this rare entity.

Background: Falcotentorial meningiomas are exceptionally uncommon tumors, presenting a challenge for neurosurgeons due to their close proximity to vital structures. Gross total resection represents the standard of treatment for these tumors. However, care must be taken when surgically approaching these lesions, since damaging neurovascular structures may cause unacceptable morbidity. Selecting the optimal surgical approach for each tumor is of paramount importance when treating these patients. Methods: The authors reviewed medical records to identify all patients with falcotentorial meningiomas who underwent resection at the University Hospital of Freiburg between January 2001 and December 2021. Clinical and imaging data, surgical management, and clinical outcomes were analyzed. Results: Falcotentorial meningiomas occurred in 0.7% (15 of 2124 patients) of patients with intracranial meningiomas. Of these 15 patients, 8 were female and 7 male. The occipital interhemispheric approach was used in nine patients, the supracerebellar infratentorial approach in five patients, and the retrosigmoidal approach in one patient. Three patients developed visual field deficits after surgical resection. Incomplete resection was significantly associated with tumor progression (p < 0.05). Conclusions: Individualized surgical strategies, guided by preoperative imaging and classification systems, play a crucial role in optimizing patient care. Among the available approaches, the occipital interhemispheric and supracerebellar infratentorial approaches are frequently employed and considered among the safest options for these tumors. [ABSTRACT FROM AUTHOR]

This article discusses the feasibility and effectiveness of using the contralateral supracerebellar-infratentorial (cSCIT) approach for the surgical resection of thalamic cavernous malformations (CMs). Thalamic CMs are challenging to treat due to their deep-seated location and proximity to vital neurovascular structures. The cSCIT approach offers a unique perspective for addressing CMs located posteriorly within the thalamus. The study presents the results of a single patient who underwent thalamic CM resection using the cSCIT approach, demonstrating successful lesion removal and minimal postoperative neurological deficits. The findings highlight the potential of the cSCIT approach as a secure and effective surgical alternative for thalamic CMs. [Extracted from the article]

• One-stage surgery may be riskier and result in persistent hydrocephalus. • ETV before resection reduces risk of persistent hydrocephalus and complications. • Midbrain tumor invasion is a high risk factor for postoperative hydrocephalus. • ETV helps with perioperative hydrocephalus in posterior thalamic cases. Patients with pulvinar area lesions may develop hydrocephalus at any stage. The role of endoscopic third ventriculostomy (ETV) in this setting remains unclear. We retrospectively enrolled 15 patients with a mean age of 43 years who underwent endoscopic resection of pulvinar area lesions using the supracerebellar infratentorial approach (SCITA). We compared the different modalities of hydrocephalus management and their outcomes. Nine of 15 patients (60.0%) had preoperative obstructive hydrocephalus. Five patients underwent ETV before tumor resection, and none developed postoperative hydrocephalus. Four patients underwent one-stage surgery for tumor removal, and one patient with a polymorphous low-grade neuroepithelial tumor of the young required postoperative ETV. Another patient with diffuse astrocytoma and hydrocephalus underwent concurrent lamina terminalis fenestration and endoscopic resection via the SCITA, which resulted in the resolution of hydrocephalus. The preoperative ETV group had no major postoperative complications, while the non-ETV group had three (0/5 vs. 3/4, P = 0.048). The ETV group also had a shorter intensive care unit stay; however, the difference was not significant (1.2 vs. 2.8; P = 0.188). ETV was effective in alleviating symptoms of postoperative hydrocephalus in patients with midbrain-invading tumors. Endoscopic surgery via the SCITA can address both tumor and hydrocephalus issues in some cases but has a higher surgical risk and postoperative hydrocephalus rate. Preoperative ETV can prevent these complications and improve postoperative outcomes. [ABSTRACT FROM AUTHOR]

Background: Trigeminal schwannomas (TSs) are mostly benign tumors. However, dumbbell-shaped TSs are most challenging for surgeons and pose a high surgical risk. Objective: We describe the technique of the purely endoscopic far-lateral supracerebellar infratentorial approach (EFL-SCITA) for removing dumbbell-shaped TSs and further discuss the feasibility of this approach and our experience. Methods: EFL-SCITA was performed for resection of 5 TSs between January 2020 and March 2023. The entire procedure was performed endoscopically with the goal of total tumor resection. During the operation, the tumor was exposed in close proximity and multiple angles under the endoscope, and the peri-tumor nerves were carefully identified and protected, especially the normal trigeminal fiber bundles around the tumor. Results: All the tumors of 5 patients involved the middle and posterior cranial fossa, of which total removal was achieved in 2 patients and near-total removal in 3 patients. The most common preoperative symptoms were relieved after surgery. Two patients had postoperative mild facial paralysis (House-Brackmann grade II), and 1 patient had abducens palsy; both recovered during the follow-up period. Two patients experienced new postoperative facial hypesthesia, and 1 experienced mastication weakness, which did not recover. There was no tumor recurrence or residual tumor growth during the follow-up period in any of the patients. Conclusion: EFL-SCITA is a new and effective alternative for the surgical treatment of TSs. For dumbbell-shaped TSs, this approach provides sufficient surgical field exposure and freedom of operation. [ABSTRACT FROM AUTHOR]

Background: Management options for treatment of quadrigeminal arachnoid cysts (QAC) include microsurgical/endoscopic fenestration or shunt. There is an open debate about which method is the best. Microsurgical fenestration is well suited for treatment of QAC with predominant infratentorial component and without hydrocephalus making endoscopic procedures more challenging. Method: We describe the microsurgical technique and related anatomy to fenestrate infratentorial QAC through supracerebellar infratentorial approach. We also discuss our experiences with this approach, some of the drawbacks and nuances. Conclusion: Navigation-guided microsurgical fenestration of infratentorial QAC is the authors' surgical approach of choice for treating these rare challenging lesions when not associated with hydrocephalus. [ABSTRACT FROM AUTHOR]

Neuroendoscopic resection via supracerebellar infratentorial (SCIT) approach is adequate for some indicated pineal region tumors with the natural infratentorial corridor. We described this full endoscopic approach through a modified 'head-up' park-bench position to facilitate the procedure. We reviewed the clinical and radiological data of four patients with pineal region lesions who underwent pure endoscopic tumor resection through the SCIT approach with this modified position. The related literature concerning fully endoscopic pineal region tumor resection was also reviewed. This cohort included four patients with pineal region tumors. External ventricular drainage (Ommaya reservoir) was performed in three patients with hydrocephalus in advance. The average tumor volume was 19.2 ± 17.2 cm3. Pathological examination confirmed two mixed germinomas, one glioblastoma multiforme, and one hemangioblastoma. Gross total resection (GTR) was achieved in all patients, and all patients recovered well without neurological deficits or surgical complications. Hydrocephalus was relieved among all patients. The pure endoscopic SCIT approach could enable safe and effective resection of pineal region tumors, even for relatively large lesions. The endoscope could provide a panoramic view and illumination of the deep-seated structures. Compared with the sitting position, this modified ergonomic position could be implemented easily. [ABSTRACT FROM AUTHOR]

Background: Virchow–Robin spaces (VRS) or peri-vascular spaces (PVS) are normal anatomical structures within the brain, typically small in size and asymptomatic. Rarely, they can enlarge, adopt bizarre single or multi-cystic configurations and become pathological lesions that may necessitate surgical intervention to relieve mass effect or hydrocephalus. Case report: We present the case of a 41-year-old female who presents with epilepsy, Parkinsonism symptoms, diplopia, and gait imbalance. She was diagnosed with mesencephalic giant tumefactive perivascular spaces exerting significant focal mass effect but causing no hydrocephalus. The patient underwent a direct cyst fenestration via the endoscopic Infratentorial Supracerebellar (ITSC) approach. Postoperative follow-up was uneventful. Clinically, symptoms improved with evidence of some decrease in cystic size. Discussion and conclusion: Accepted surgical strategies to address symptomatic mesencephalic Virchow robin spaces dilation include conventional ventriculoperitoneal or cysto-peritoneal shunting to neuroendoscopic decompression with cystocisternotomy or ventriculocystostomy. We report the first application of a purely endoscopic ITSC approach for the fenestration of a mesencephalic enlarged Virchow robin space. This minimally invasive approach provided great exposure and adequate access to the lesion. Unlike the endoscopic trans-ventricular approach, this alternative technique poses no risk to the fornices and can be applied regardless of ventricular size, resulting in a decrease in the size of the cyst and a diminishment of symptoms.

Objective To investigate the clinical experience and application value of endoscopic tumor resection in the pineal region by using a flushable suction device for continuous pressurized flushing and performing the arachnoid membrane dissection technique of quadrigeminal cistern by the supracerebellar infratentorial approach. Methods The clinical data of one patient who were removed the lesions of the pineal region and its adjacent area with endoscopy in October 2021 by the Department of Neurosurgery, Zhongshan Hospital Affiliated to Fudan University and a technique of quadrigeminal cistern arachnoid membrane dissection using a flushable suction device for a continuous pressurized flushing in a hydroscopy were analyzed retrospectively. Result The surgical resection was completed and the arachnoid membrane dissection technique of quadrigeminal cistern in a hydroscopy was applied with good surgical results and a better prognosis for the patient. Conclusions Endoscopic resection of pineal region tumors via supracerebellar infratentorial approach, together with the arachnoid membrane dissection technique of quadrigeminal cistern in a hydroscopy with a flushable suction device for a continuous pressurized flushing, can safely and effectively resect pineal region tumors and their adjacent regional lesions, and provide a new therapeutic direction for the application of a hydroscopy. [ABSTRACT FROM AUTHOR]

Background: Falcotentorial meningioma is a rare tumor of pineal region, arising from the dural folds where the tentorium and falx meet. Due to the deep location and near closeness to significant neurovascular structures, gross-total tumor resection in this area can be complicated. Pineal meningiomas can be resected using a variety of approaches; however, all these approaches are associated with a significant risk of postoperative complications. Case Description: A 50-year-old female patient who presented with several headaches and visual field defect and diagnosed with pineal region tumor is discussed in the case report. Patient was successfully managed surgically by combined supracerebellar infratentorial and right occipital interhemispheric approach. Cerebrospinal fluid circulation was restored after surgery and neurological defects were regressed. Conclusion: Our case shows that it is possible to completely remove giant falcotentorial meningiomas with minimal brain retraction, preserve the straight sinus and vein of Galen, and prevent neurological impairments by combining two approaches. [ABSTRACT FROM AUTHOR]

This study was to analyze the advantages and disadvantages of endoscopic midline and paramedian supracerebellar infratentorial approaches (EM-SCITA and EPM-SCITA) for pineal region tumors. We retrospectively analyzed the clinical data of 58 patients who underwent EM-SCITA and EPM-SCITA for pineal region tumors. Among them, 23 patients were treated with EM-SCITA, and 35 with EPM-SCITA. The patients were followed up for 6–84 months with magnetic resonance imaging and Karnofsky Performance Status scores. The average age of the patients was 37.98 years, and there were 16 women (27.6%). The average maximum diameter of the tumors was 2.92 cm. Gross total resection was achieved in 46 patients (79.31%). There were 45 patients (77.6%) whose Karnofsky Performance Status score was >70 at the final follow-up. There was no significant difference among the above items between EM-SCITA and EPM-SCITA. However, EM-SCITA required a longer craniotomy and closure time, with a larger bone and dural flap, with more bridging veins sacrificed. EPM-SCITA simplified the opening of the quadrigeminal cistern, and it was beneficial to expose the contralateral wall of the third ventricle. The longer and angled path limited the exposure of the anterior third ventricle and the ipsilateral wall of the third ventricle. Both approaches had remarkable clinical effects. The anatomy of EM-SCITA was easy to understand and has a larger operating space; it is suitable for neurosurgical beginners. In contrast, EPM-SCITA has limited operation space, an intricate anatomy, and is suitable for experienced operators. The occurrence of postoperative hydrocephalus should be alerted by EPM-SCITA. [ABSTRACT FROM AUTHOR]

The deep location of the thalamus and the complex neural circuits in the surrounding area make surgery extremely challenging. Feasibility and advisability of using a supracerebellar infratentorial approach (SCITA) for endoscopic resection of thalamic lesions remains to be further evaluated. Fifteen patients who underwent endoscopic resection of thalamic via SCITA from 2014 to 2021 were retrospectively collected. We analyzed preoperative tumor-related variables and surgical procedures in detail, as well as postoperative outcomes. Lesions mainly located in the posterior and/or medial part of the thalamus, and some of them expanded downward, or backward. The mean size of them was 30 × 24 mm. Five of the nine patients with preoperative hydrocephalus underwent cerebrospinal fluid shunts to relieve increased intracranial pressure. Among the 15 patients, 4 were glioblastoma, 3 were pilocytic astrocytoma, and the rest included 1 case of anaplastic astrocytoma, melanoma, polymorphous low-grade neuroepithelial tumor of the young, rosette-forming glioneuronal tumor, inflammatory lesion, diffuse midline glioma, and cavernous hemangioma. The majority of patients (10/15) achieved gross total resection, which has become more pronounced since paramedian SCITA was used in place of the midline approach in 2020 (6/8). Three patients had unresolved or new onset of clinical symptoms after surgery, resulting in a decreased KPS score at discharge. Neuro-endoscopic techniques can ameliorate many of the shortcomings of the SCITA. With the accumulation of experience and technological progress, more deficiencies of this approach may be improved, enabling safe and effective resection of posterior and/or medial part thalamic lesions. [ABSTRACT FROM AUTHOR]

IntroductionThe surgery of posterior clinoid meningioma (PCM) remains one of the most formidable challenges for neurosurgeons because of its location at great depth in the cranium and proximity to vital neurovascular structures. Herein, we aim to describe the technique and feasibility of a novel approach, the purely endoscopic far-lateral supracerebellar infratentorial approach (EF-SCITA), for resection of this extremely rare entity.Case descriptionA 67-year-old women presented with gradually deteriorating vision in right eye for 6 months. Imaging examinations revealed a right-sided PCM, and the EF-SCITA approach was attempted for tumor resection. Tentorium incision allowed a working corridor toward the PCM in the ambient cistern through the supracerebellar space. During surgery, the infratentorial part of the tumor was found to compress the CN III and posterior cerebral artery medially and encase the CN IV laterally. Following debulking of the infratentorial tumor, the supratentorial part could be exposed and then excised, which had dense adhesions to the ICA and the initial part of the basal vein in front. After total tumor removal, its dural attachment was detected at the right posterior clinoid process and then coagulated under direct vision. The patient on follow-up at 1 month had improvement in visual acuity in right eye, with no restriction of extra-ocular movements.DiscussionEF-SCITA approach combines advantages of the posterolateral approach and endoscopic technique, allowing access to PCMs with seemingly low risks of postoperative morbidity. It would be a safe and effective alternative for resection of lesions in the retrosellar space.

Introduction: The management of retroinfundibular craniopharyngioma (CP) remains the ultimate challenge for both transsphenoidal and open transcranial surgery because of their anatomical location and proximity to vital neurovascular structures. In this report, we aim to describe the technique and feasibility of a novel approach, the purely endoscopic far-lateral supracerebellar infratentorial approach (EF-SCITA), for resection of retroinfundibular CP. Case description: A 63-year-old women presented with progressive visual disturbance, polyuria, and spiritlessness of a 3-month duration. Imaging studies revealed a typical retroinfundibular CP containing solid and cystic components with calcification, which extended inferiorly in front of the brainstem and upward into the third ventricle. The EF-SCITA approach was attempted for resection of the tumor. During surgery, lateral prone positioning with upper flexion of the head and early CSF release allowed for download retraction of the cerebellum. This, in combination with tentorium incision, created a working corridor toward retrosellar and suprasellar spaces. This approach required working between neurovascular structures in the crural cistern, with tumor removal permitted in supra-oculomotor and infra-oculomotor spaces. After aspiration of the fluid contents through the supra-oculomotor triangle, the solid lesion was found tightly adhering to the distal part of the pituitary stalk, and subtotal resection was achieved for maintaining the integrity of pituitary function. In the immediate postoperative period, the patients exhibited oculomotor paralysis and was discharged with hormonal replacement therapy three weeks after operation. At her three-month follow-up appointment, she reported obvious vision improvement. Physical examinations showed partial alleviation of oculomotor paralysis. Pathological analyses confirmed the diagnosis of papillary CP. Discussion: The purely EF-SCITA approach combines the advantages of both the posterolateral approach and endoscopic technique, which offers access to retrosellar and suprasellar spaces with seemingly low risks of postoperative morbidity. It would be a safe and effective alternative for the treatment of retroinfundibular CP, especially those with lateral extension to the temporal lobe or posterolateral extension to the petroclival region. Further observational studies in a larger cohort are urgently needed to assess the long-term efficacy of this minimal access approach. [ABSTRACT FROM AUTHOR]

Pilocytic astrocytoma is a low-grade tumor that can affect the pineal region and has a potential life-threatening presentation with obstructive hydrocephalus. This video presents the case of a child who underwent an endoscopic third ventriculostomy with tumor biopsy and for whom a supracerebellar infratentorial approach was chosen after confirmation of the diagnosis of a pilocytic astrocytoma. Herein, we discuss the technical details of both procedures, such as the single burr hole in the neuroendoscopic approach, the ventricular landmarks and identification of the venous sinus through neuronavigation, the anatomical landmarks during the supracerebellar infratentorial approach, and the use of ultrasonographic aspiration.

Pineal cysts are typically detected in around 1.3% to 4.3% of patients during routine magnetic resonance imaging (MRI) scans. 1,2 The vast majority of pineal cysts are benign, asymptomatic, and typically do not necessitate surgical intervention. Large pineal cysts are known to cause hydrocephalus with its associated symptoms and thus can require in rare cases surgical resection. Even in the absence of hydrocephalus, selected patients with large pineal cysts causing headaches and visual disturbances can find relief after surgical resection. 3,4 The supracerebellar infratentorial (SCIT) approach is widely used and represents an extraparenchymatous approach through a natural corridor to the pineal region. 5 Performing this approach in a semisitting position allows for an optimal retraction of the cerebellum by gravity. We employ a minimally invasive paramedian SCIT approach for the resection of pineal cysts. In our experience, the paramedian SCIT approach allows for a less steep operating angle and a smaller craniotomy compared with the midline SCIT approach. We present a 24-year-old female complaining of headache. The initial MRI was conducted 2 years before surgery. Following the initial evaluation, the patient experienced progressive headaches without neurologic deficits. A subsequent MRI revealed enlargement of the pineal cyst, leading to the indication for surgical resection. The surgery was performed mainly under the operating microscope with endoscopic visualization in suitable situations as our small approach restricts bimanual dissection with an endoscope. In our experience, this approach provides a versatile and minimally invasive access to the pineal region, making it optimally suitable for pineal cysts requiring surgical resection. [ABSTRACT FROM AUTHOR]

The supracerebellar infratentorial approach (SCITA) is a standard approach used in a neurosurgical practice. It carries some risk of associated complications including cerebellar venous infarction with possible serious sequelae. The objective of this study is to address the incidence of cerebellar venous infarction in SCITA. A search through the currently available literature was performed in September 2019 from the year 2000 until September 2019 dealing with 'supracerebellar infratentorial approach'. Out of the 578 patients found in thirteen case series, two venous infarctions were present; the remaining four patients were published as case reports. By analysing the case series, we calculated the risk of such a complication to be 0.345% (95% CI [0.061%, 1.248%]). Case reports were not included. The real risk is estimated to be higher. The risk of cerebellar venous infarction is an unpredictable, infrequent but real complication with potentially dreadful sequelae. Each neurosurgeon using this approach should be aware of this event when employing this approach. The avoidance of cerebellar venous infarction can be lowered by leaving as many bridging veins intact as possible. [ABSTRACT FROM AUTHOR]

The extreme lateral supracerebellar infratentorial (ELSI) approach has the potential to access several distinct anatomical regions that are otherwise difficult to reach. We have illustrated the surgical anatomy through cadaveric dissections and provided an extensive review of the literature to highlight the versatility of this approach, its limits, and comparisons with alternative approaches. The surgical anatomy of the ELSI has been described using 1 adult-injected cadaveric head. Formalized noninjected brain specimens were also dissected to describe the brain parenchymal anatomy of the region. An extensive review of the literature was performed according to each targeted anatomical region. Illustrative cases are also presented. The ELSI approach allows for wide exposure of the middle and posterolateral incisural spaces with direct access to centrally located intra-axial structures such as the splenium, pulvinar, brainstem, and mesial temporal lobe. In addition, for skull base extra-axial tumors such as petroclival meningiomas, the ELSI approach represents a rapid and adequate method of access without the use of extensive skull base approaches. The ELSI approach represents one of the most versatile approaches with respect to its ability to address several anatomical regions centered at the posterior and middle incisural spaces. For intra-axial pathologies, the approach allows for access to the central core of the brain with several advantages compared with alternate approaches that frequently involve significant brain retraction and cortical incisions. In specific cases of skull base lesions, the ELSI approach is an elegant alternative to traditionally used skull base approaches, thereby avoiding approach-related morbidity. [ABSTRACT FROM AUTHOR]

Introduction: We present a consecutive case series and a systematic review of surgically treated pediatric PCs. We hypothesized that the symptomatic PC is a progressive disease with hydrocephalus at its last stage. We also propose that PC microsurgery is associated with better postoperative outcomes compared to other treatments. Methods: The systematic review was conducted in PubMed and Scopus. No clinical study on pediatric PC patients was available. We performed a comprehensive evaluation of the available individual patient data of 43 (22 case reports and 21 observational series) articles. Results: The review included 109 patients (72% females). Ten-year-old or younger patients harbored smaller PC sizes compared to older patients (p < 0.01). The pediatric PCs operated on appeared to represent a progressive disease, which started with unspecific symptoms with a mean cyst diameter of 14.5 mm, and progressed to visual impairment with a mean cyst diameter of 17.8 mm, and hydrocephalus with a mean cyst diameter of 23.5 mm in the final stages of disease (p < 0.001). Additionally, 96% of patients saw an improvement in their symptoms or became asymptomatic after surgery. PC microsurgery linked with superior gross total resection compared to endoscopic and stereotactic procedures (p < 0.001). Conclusions: Surgically treated pediatric PCs appear to behave as a progressive disease, which starts with cyst diameters of approximately 15 mm and develops with acute or progressive hydrocephalus at the final stage. PC microneurosurgery appears to be associated with a more complete surgical resection compared to other procedures. [ABSTRACT FROM AUTHOR]

The midline supracerebellar infratentorial (SCIT) approach and its paramedian development are commonly used for dealing with pineal lesions. Comparative clinical studies are lacking, however. We aim to establish the better performance of the paramedian SCIT approach in terms of clinical safety in surgically treated pineal cysts and pineal region tumors. Procedural functionality and effectiveness have been also analyzed. A comparative analysis of clinical, radiologic, pathologic, and surgical features, and outcome was performed between 55 midline and 57 paramedian SCIT approaches that were exclusively performed in 112 patients (57 pineal cysts and 55 tumors of the pineal region) operated in sitting position by a single surgeon. Information was retrieved from hospital records and microsurgical videos. The paramedian SCIT approach linked with fewer postoperative complications (odds ratio [OR]: 0.40) and fewer approach-related complications (OR: 0.28) than the midline SCIT approach. The SCIT paramedian approach was achieved in a shorter time, by a smaller bone flap, and with fewer complex procedural steps than the midline approach. The SCIT paramedian approach did not require the opening of the falx cerebelli, midline cerebellar retraction, section of the midline cerebellar draining veins, nor wide opening of the dura. Gross total resection, size of the lesion, microsurgical time for removal, histopathological diagnosis and postoperative outcome were statistically similar in both groups. The SCIT approach represents a safer and more functional approach for the removal of cysts and tumors of the pineal region than the classic midline approach, while maintaining the same effectiveness. [ABSTRACT FROM AUTHOR]

Pineal region tumors represent challenging surgical lesions with wide ranges of survival reported in different surgical series. In this article, we emphasize the role of complete microsurgical resection (CMR) to obtain a favorable long-term outcome of pineal region tumors. We report a retrospective study of pineal region tumors operated on in Helsinki Neurosurgery between 1997 and 2015. Information was obtained from the hospital records, and an evaluation of the Finnish population register was conducted in July 2018 to determine the current status of the patients. A total of 76 pineal region tumors were operated on. The survival was 62% at a mean follow-up of 125 ± 105 months (range, 0–588 months), and the disease-related mortality was limited to 14 patients (18.4%). Up to July 2018, 29 patients had died. Two patients died 1 and 3 months after surgery of delayed thalamic infarctions, 12 patients of disease progression, and 15 had non–disease-related deaths. Only 1 patient was lost in the long-term follow-up. Ten of 14 disease-related deaths occurred during the first 5 years of follow-up: 5 diffuse gliomas, 3 germ cell tumors, 1 grade II–III pineal parenchymal tumor of intermediate differentiation, and 1 meningioma. CMR was linked to better tumor-free survival and long-term survival, with the exception of diffuse gliomas. CMR, in the setting of a multidisciplinary management of pineal region tumors, correlates with favorable survival and with minimal mortality. Surgically treated grade II–IV gliomas constitute a particular group with high mortality within the first 5 years independently of the microsurgical resection. [ABSTRACT FROM AUTHOR]

The cerebellomesencephalic vein (CMV) was frequently sacrificed in surgery approached via the supracerebellar infratentorial (SCIT) route for resecting pineal region tumors, which resulted in potential risk of neurologic deficit. Preserving the CMV in the SCIT approach could enhance the safety and effectiveness of this natural corridor surgery. The aim of this article was to identify the probability and safety of preserving the CMV through the application of neuroendoscopy in the SCIT approach. Clinical data of patients who underwent pineal region tumor resection through a purely endoscopic SCIT approach were retrospectively analyzed, focusing on surgical techniques and clinical outcomes. The study included 8 patients with pineal region tumors. The CMV was preserved intact in all patients. Total tumor removal was achieved in 7 of 8 patients. In 1 patient with 2 tumors in the pineal region and roof of the third ventricle, the tumor in the pineal region was resected completely, followed by subsequent chemotherapy combined with radiotherapy, after which the other tumor disappeared totally. All patients recovered normally with uneventful postoperative outcomes. The advantage of close observation and panoramic view provided by neuroendoscopy combined with meticulous manipulation improved the ability to preserve the CMV in resecting pineal region tumors via the SCIT approach. The neuroendoscopic technique enhances the safety and efficacy of the SCIT approach. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The extreme lateral supracerebellar infratentorial (ELSI) approach was initially proposed to treat lesions of the posterolateral surface of the pons principally cavernomas. The versatility of the approach allowed its use for other pathologies like gliomas, aneurysms, epidermoids, and meningiomas. Method: We describe here the ELSI approach along with its advantages and limits in comparison with other surgical approaches for the treatment of meningiomas of the petroclival region. Conclusion: ELSI is a versatile approach that allows access to the anterolateral brainstem surface including extensions to the midbrain diencephalic junction when needed. ELSI compares favorably to other surgical alternatives with respect to the approach-related morbidity, while allowing adequate access to treat the pathology. [ABSTRACT FROM AUTHOR]

Background Pineal parenchymal tumors of intermediate differentiation (PPTIDs) are rare lesions with particular features compared with other pineal parenchymal tumors. Methods We present a retrospective review of patients with histologically confirmed PPTIDs who were operated on in our department between 1997 and 2015. A demographic analysis and an evaluation of preoperative status, surgical treatment, as well as immediate and long-term clinical and radiologic outcomes were conducted. Results Fifteen patients with PPTIDs were operated on between 1997 and 2015. Gross total removal was achieved in 11 cases; 2 patients underwent near-total resection, 1 partial resection, and 1 received brachytherapy after an endoscopic biopsy. Nine patients required external radiation therapy (4 due to a pleomorphic histology of their lesion including pineoblastoma features in 3 of them; 3 after a subtotal resection; and 2 for tumor recurrence). No patient received chemotherapy. The survival rate of our patients was 57.1% at a mean follow-up of 137.2 ± 77.6 months (39–248 months). Conclusions A proper multidisciplinary management of PPTIDs based on a gross total removal of the lesion, and an adjuvant radiotherapy in selected cases, may improve the overall survival of these aggressive tumors. [ABSTRACT FROM AUTHOR]

Pineal region tumors represent 1.5–8.5% of the pediatric brain tumors. Management includes endoscopic third ventriculostomy and biopsy in cases presenting with hydrocephalus. In addition, surgical resection provides survival advantage in selected cases. The supracerebellar infratentorial approach is a widely preferred approach for such region. After approval of the local ethics committee of Alexandria University and acquisition of the appropriate formal consents according to the committee’s standards, we have reviewed the records of fifteen cases presenting with pineal region tumors in Alexandria main university hospital from 2013 to 2016. The mean age at the diagnosis was 14 years (2–54 years). All cases had supracerebellar infratentorial approach for surgical resection. Follow up period was from 12 to 59 months. All 15 cases presented with hydrocephalus and increased intracranial pressure manifestations. Out of the 15 cases, 3 cases were germ-cell tumors, 2 cases were pineoblastomas, one parenchymal tumor with intermediate differentiation (PPID), one pineocytoma, 2 cases were anaplastic ependymomas and 6 cases were astrocytomas. Gross total resection (GTR) was achieved in 4 cases, subtotal resection was achieved in 7 cases and partial resection in 4 cases. Major surgical complications included severe post-operative cerebellar edema in 2 cases that required further decompression and hemorrhage in one case that has been managed conservatively. In Alexandria university, the supracerebellar infratentorial approach is considered a safe approach with minimal morbidity and no surgery related mortality. [ABSTRACT FROM AUTHOR]

Objective: The lateral aspect of the cerebellomesencephalic fissure frequently harbors vascular pathology and is a common surgical corridor used to access the pons tegmentum, as well as the cerebellum and its superior and middle peduncles. The quadrangular lobule of the cerebellum (QLC) represents an obstacle to reach these structures. The authors sought to analyze and compare exposure of the cerebellar interpeduncular region (CIPR) before and after QLC resection and provide a case series to evaluate its clinical applicability., Methods: Forty-two sides of human brainstems were prepared with Klingler's method and dissected. The exposure area before and after resection of the QLC was measured and statistically studied. A case series of 59 patients who underwent QLC resection for the treatment of CIPR lesions was presented and clinical outcomes were evaluated at 1-year follow-up., Results: The anteroposterior surgical corridor of the CIPR increased by 10.3 mm after resection of the QLC. The mean exposure areas were 42 mm2 before resection of the QLC and 159.6 mm2 after resection. In this series, ataxia, extrapyramidal syndrome, and akinetic mutism were found after surgery. However, all these cases resolved within 1 year of follow-up. Modified Rankin Scale score improved by 1 grade, on average., Conclusions: QLC resection significantly increased the exposure area, mainly in the anteroposterior axis. This surgical strategy appears to be safe and may help the neurosurgeon when operating on the lateral aspect of the cerebellomesencephalic fissure.

Objective: Anatomical triangles provide neurosurgeons with the specificity required to access deep targets, supplementing more general instructions, such as craniotomy and approach. The infragalenic triangle (IGT), bordered by the basal vein of Rosenthal (BVR), precentral cerebellar vein (PCV), and the quadrangular lobule of the cerebellum, is one of a system of anatomical triangles recently introduced to guide dissection to brainstem cavernous malformations and has not been described in detail. This study aimed to quantitatively analyze the anatomical parameters of the IGT and present key nuances for its microsurgical use., Methods: A midline supracerebellar infratentorial (SCIT) approach through a torcular craniotomy was performed on 5 cadaveric heads, and the IGT was identified in each specimen bilaterally. Anatomical measurements were obtained with point coordinates collected using neuronavigation. Three cadaveric brains were used to illustrate relevant brainstem anatomy, and 3D virtual modeling was used to simulate various perspectives of the IGT through different approach angles. In addition, 2 illustrative surgical cases are presented., Results: The longest edge of the IGT was the lateral edge formed by the BVR (mean ± SD length 19.1 ± 2.3 mm), and the shortest edge was the medial edge formed by the PCV (13.9 ± 3.6 mm). The mean surface area of the IGT was 110 ± 34.2 mm2 in the standard exposure. Full expansion of all 3 edges (arachnoid dissection, mobilization, and retraction) resulted in a mean area of 226.0 ± 48.8 mm2 and a 2.5-times increase in surface area exposure of deep structures (e.g., brainstem and thalamus). Thus, almost the entire tectal plate and its relevant safe entry zones can be exposed through an expanded unilateral IGT except for the contralateral inferior colliculus, access to which is usually hindered by PCV tributaries. Exposure of bilateral IGTs may be required to resect larger midline lesions to increase surgical maneuverability or to access the contralateral pulvinar., Conclusions: The IGT provides a safe access route to the dorsal midbrain and reliable intraoperative guidance in the deep and complex anatomy of the posterior tentorial incisura. Its potential for expansion makes it a versatile anatomical corridor not only for intrinsic brainstem lesions but also for tumors and vascular malformations of the pineal region, dorsal midbrain, and posteromedial thalamus.

Objective In recent decades endoscopic techniques have been increasingly used in neurosurgery as they may offer a valuable close-up view of the working area through a minimally invasive surgical corridor. Herein, we present an inexpensive and efficient endoscopic surgical model using a borescope, which was used for a “modified pure endoscopic approach” to the pineal region. Methods A borescope video camera was connected to a 16-inch personal computer monitor. A standard midline suboccipital craniotomy was performed on 2 cadaveric heads in the Concorde position. Then, a “borescopic” supracerebellar infratentorial approach was executed, thus reaching the pineal region, which was exposed through an extensive arachnoid dissection. Results Using the previously described model, we were able to provide excellent exposure of the main neurovascular structures of the pineal region, as shown by the intraoperative videos. In 1 specimen we identified an incidental pineal cyst that was meticulously dissected and removed. Conclusions Our proposed “borescopic” surgical model may represent an inexpensive and efficient alternative to conventional endoscopic techniques and could be used for training purposes, as well as even for clinical procedures, after a proper validation, particularly in economically challenging environments. [ABSTRACT FROM AUTHOR]

Background This study analyzes the results of surgical treatment in 377 patients with colloid cysts (CCs) of the third ventricle who were treated at the Burdenko Neurosurgery Institute from 1981 to 2015. Operations were performed by a single surgeon (the first author of the article). Methods The transcallosal approach was used to remove CCs in 97% of cases. Total cyst removal was performed in 96% of cases (in 4% of cases, a small cyst capsule fragment was left on the veins and fornix); in 3 cases, the cyst recurred, which required its repeated removal. Results Hydrocephalus symptoms regressed in 98% of patients. The most frequent complications in the early postoperative period were memory impairments of varying severity, with a tendency to regress by the time of discharge. Two patients had an intraventricular hematoma, which required operative exploration in 1 patient. There were 4 cases of meningitis (including 1 shunt-associated meningitis) and 5 cases of transient pyramidal insufficiency. Conclusions We made a preliminary assessment of the reasonability of the infratentorial supracerebellar approach for removal of CCs in 10 cases. [ABSTRACT FROM AUTHOR]

Objective The supracerebellar infratentorial (SCIT) paramedian approach in sitting position represents one of the most used surgical routes for dealing with pineal region lesions. The purpose of this study is to determine the cornerstones to perform this approach in a simple, safe, and effective way, so that it could be easily reproduced in other neurosurgical centers, particularly in those with modest resources. Methods We reviewed and analyzed the surgical videos of 24 pineal region lesions that were operated on through an SCIT approach between June 2012 and October 2015. The SCIT approach may be divided into 3 main steps: 1) skin-muscle incision; 2) craniotomy; and 3) dura opening and access to the pineal region. Results Complete lesion removal was accomplished in 23 cases, and subtotal removal was accomplished in 1 case. The pineal region was effectively and safely reached through the SCIT approach in the sitting position with a mean time of 14 minutes, using a basic set of microsurgical instruments. Cornerstones and potential delaying events were carefully recorded for each of the 3 main steps of the approach. Moreover, we present in a short video a step-by-step guide to perform the SCIT approach in a fast and safe way. Conclusions A correct application of microsurgical principles may allow to safely and rapidly perform the SCIT approach, therefore offering an effective and relatively atraumatic route for dealing with pineal region lesions. [ABSTRACT FROM AUTHOR]

Background: Lesions of the superior cerebellar surface, pineal region, lateral and dorsal midbrain and mesial temporal lobe are challenging to treat and often require neurosurgical intervention. Methods: The paramedian variation of the supracerebellar infratentorial approach utilizes the downward slope of the cerebellum to facilitate exposure and the lower density of cerebellar bridging veins away from the midline decreases the need to sacrifice larger venous channels. We also discuss our experiences with the approach, and some of the drawbacks and nuances that we have encountered as it has evolved over the years. Conclusions: This approach is versatile and effective and the authors' surgical approach of choice for resecting these challenging lesions. [ABSTRACT FROM AUTHOR]

Introduction Intracranial fat migration following autologous fat graft and placement of a lumbar drain for cerebrospinal fluid leak after pineal cyst resection surgery has not been previously reported. Case presentation The authors present a case of a 39-year-old male with a history of headaches who presented for removal of a pineal cyst from the pineal region. He subsequently experienced cerebrospinal fluid leak and postoperative Escherichia coli (E. Coli) wound infection, and meningitis, which were treated initially with wound washout and antibiotics in addition to bone removal and primary repair with primary suture-closure of the durotomy. A lumbar drain was left in place. The cerebrospinal fluid leak returned two weeks following removal of the lumbar drain; therefore, autologous fat graft repair and lumbar drain placement were performed. Three days later, the patient began experiencing right homonymous hemianopia and was found via computed tomography and magnetic resonance imaging to have autologous fat in the infra‑ and supratentorial space, including intraparenchymal and subarachnoid spread. Symptoms began to resolve with supportive care over 48 hours and had almost fully resolved within one week. Discussion This is the first known report of a patient with an autologous fat graft entering the subarachnoid space, intraparenchymal space, and ventricles following fat graft and lumbar drainage. Conclusion This case highlights the importance of monitoring for complications of lumbar drain placement. [ABSTRACT FROM AUTHOR]

Surgical excision of rare, large-to-giant posterior third ventricular (PTV) meningiomas [including velum-interpositum meningiomas (VIM; postero-superior venous complex displacement; without falco-tentorial attachment) and falco-tentorial meningiomas (FTM; falco-tentorial attachment; displacing major veins antero-inferiorly)] is extremely challenging. To study the management nuances in the excision of large-to-giant PTV meningiomas. Tertiary care referral center. Four patients with large (> 3 cm; n = 2) and giant (>5 cm; n = 2) meningiomas (FTM = 2; VIM = 2, mean tumor size = 4.9 cm) underwent occipital transtentorial approach (OTT) for tumor excision. One also underwent a second-stage supracerebellar infratentorial (SCIT) approach. The side of approach was determined by lateral tumor extension and venous displacement (right = 3, left = 1). Near-total removal or subtotal excision (< 10% remaining) with radiotherapy was performed in 2 patients each, respectively. At follow-up (mean: 14.75 months), clinical improvement without tumor recurrence/re-growth was achieved. Extent of excision was determined by position of great vein of Galen; tumor attachment to falco-tentorium or major veins; its consistency; its lateral and inferior extent; and, presence of a good tumor-neuraxial arachnoidal plane. OTT is the preferable approach for large-to-giant meningiomas as it provides a wider corridor and better delineation of tumor-neurovascular arachnoidal interface. [ABSTRACT FROM AUTHOR]

Background: The supracerebellar infratentorial approach is a commonly used route in neurosurgery. It provides a narrow and deep corridor to the dorsal midbrain and pineal region. The authors describe a surgical technique to expand the operative corridor and the surgeon's working angles during this approach. Methods: Thirteen cases of patients who underwent resection of their lesions using this extended approach were reviewed. During their suboccipital craniotomy, additional bone over the transverse sinus (paramedian approach) and the confluence of the sinuses (midline approach) were removed. Two sutures (tentorial stay sutures) were anchored to the tentorium anterior to the transverse sinus and tension was applied. A video narrated by the senior author describes the details of technique. Results: This additional bone removal and tentorial stay sutures led to gentle elevation of the tentorium and partial mobilization of the dural venous sinuses superiorly. This technique enhanced operative viewing through improved illumination and expanded working angles for microsurgical instruments while minimizing the need for fixed retractors and extensive cerebellar retraction. All patients underwent satisfactory removal of their lesions. No patient suffered from any related complication. Conclusion: The use of stay sutures anchored on the tentorium is a simple and effective technique that expands the surgical corridor during supracerebellar infratentorial approaches. [ABSTRACT FROM AUTHOR]