114 Review Article

Fully Endoscopic Resection of Pineal Region

Tumors
Hrayr Shahinian1 Yoon Ra2

1 Endoscopic Skull Base Surgery, Skull Base Institute, Los Angeles, Address for correspondence Hrayr Shahinian, MD, FACS, Endoscopic
California, USA Skull Base Surgery, Skull Base Institute, 8635 W. 3rd Street, #1170W, Los
2 Clinical Research, Skull Base Institute, Los Angeles, California, USA Angeles, CA 90048, USA (e-mail: [email protected]).

J Neurol Surg B 2013;74:114–117.

Abstract

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Background and Objective Surgical treatment for pineal tumors is technically
challenging—weighing the risks and benefits of microsurgical resection for the patient
with a pineal tumor versus settling for an endoscopic third ventriculostomy and biopsy is
sometimes difficult. Traditional microsurgical resection for pineal region tumors has
typically required large open craniotomies and involvement or retraction of neural
tissue with significant mortality and morbidity. With the advancement of high-resolu-
Keywords tion fiber optics, a fully endoscopic, supracerebellar, infratentorial approach, without
► pineal tumors any cerebellar retraction or manipulation of neural tissue, is introduced for the gross
► parenchymal tumors total resection of pineal region tumors.
► infratentorial Conclusion As an endoscopic modification of the open craniotomy procedure, this
supracerebellar technique combines the advantages and benefits of both open microsurgical resection
► cerebellar tissue and minimally invasive endoscopic surgeries.

Introduction Stein5 and—separately—Jamieson,6 performed a modified

microsurgical infratentorial supracerebellar approach that
Pineal tumors account for approximately 0.5 to 2% of all brain is commonly used today7,8 along with a modified microsur-
tumors, with germ cell and parenchymal tumors being the gical occipital transtentorial approach7,9 that was first pio-
most common. Although pineal tumors were first recognized neered by Brunner.10 These approaches still require
in 1717, initial attempts at surgery in this region were not retraction of cerebellar tissue with associated complications.
performed until the 1900s. The pineal region is positioned at In 2008, a fully endoscopic supracerebellar infratentorial
the geometric center of the brain—one of the most surgically approach for the resection of pineal region tumors was
inaccessible areas. Horsley initially attempted removing a introduced. This procedure is vastly different from the tradi-
pineal mass in 19101; Oppenheim and Krause reported the tional open craniotomy and microsurgical approaches being
first successful removal of a tumor in 1913.2 Beginning with performed today. Rather than creating large openings in the
Dandy (who performed the posterior transcallosal approach skull and manipulating cerebellar tissue to access the tumor
in 1921), Krause (who used the infratentorial supracerebellar for resection, the fully endoscopic approach allows the pro-
approach in 1926), and Van Wagenan (who used the posterior cedure to be performed through a small keyhole opening and
transcortical transventricular approach in 1931), surgical through the use of high-definition fiber optic technology,
treatment of pineal tumors has become more successful reaching the tumor without touching the brain. Using 2.7-
with less mortality and morbidity rates. Refinements and mm endoscopes and high-resolution screens, the tumor and
modifications of these surgical approaches, along with ad- its complete topography from multiple angles is visualized
vances in microsurgery, have reduced the mortality of direct without the complications associated with brain retraction.
surgery to under 5% and morbidity to a minimum.3,4 In 1971, Use of custom endoscopic surgical instrumentation then

received © 2013 Georg Thieme Verlag KG DOI http://dx.doi.org/

December 13, 2012 Stuttgart · New York 10.1055/s-0033-1338165.
accepted ISSN 2193-6331.
January 3, 2013
published online
March 22, 2013
 Fully Endoscopic Resection of Pineal Region Tumors Shahinian, Ra 115

allows for a safe and gradual resection of the tumor, piece by ville, New Jersey, USA). The cerebrospinal fluid is allowed to
piece, through the dime-sized opening. slowly drain. The combination of mild hyperventilation,
Advancements in technology have paralleled advances mannitol, and gravity cause the cerebellar tonsils to hang
in endoscopic skull base surgery, as conventional neuro- dependently and allows the opening of a path in the supra-
surgical and microsurgical instruments are too bulky for cerebellar and infratentorial space. A 2.7-mm, 0-degree
use. Whereas operating microscopes require wide viewing endoscope (Storz, Culver City, California, USA) is then guided
portals for adequate illumination and visualization of the atraumatically along this path with minimal dissection and
operative field, endoscopes utilize minute keyholes to occasional bipolar cauterization of a tentorial vein and no
precisely reach the target area. Adapting and refining retraction of cerebellar tissues. An irrigation sheath attached
regular microinstruments and equipment, such as bipolars to the endoscope clears blood and debris from the lens,
and Cavitron ultrasonic aspirators (CUSAs), to include avoids any heat generation from the endoscope, and elim-
longer more slender shafts and smaller microtips has inates the time-consuming and unsafe practice of removing
been essential for endoscopic skull base surgery. With and reinserting the endoscope. A rigid pneumatic holding
the supracerebellar approach to pineal tumors, customized arm secures the endoscope in position, allowing bimanual

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endoscopic bipolars with insulated sheaths and small mi- surgical dexterity. ►Fig. 2 illustrates the pathway of the
crotips are used for easy introduction, 360-degree rotation, endoscope in this approach.
and maneuverability through the keyhole opening. In ad- Upon entering the supracerebellar infratentorial space, the
dition, major improvements such as cold light sources, surgeon conducts a preliminary survey and looks for any
high-definition digital cameras and monitors, lens irriga- minor tentorial veins. These are electrocoagulated and sharp-
tion systems, and pneumatically powered robotic holding ly divided. Following this the endoscope is gradually ad-
arms have all complemented the advances in endoscopic vanced to the area of the pineal tumor, which is normally
technology and stimulated the creation of dedicated endo- surrounded by a confluence of veins and arachnoid adhe-
scopic equipment specifically designed to fulfill the unique sions. Once the surrounding critical structures are identified,
requirements of endoscopic skull base surgery for pineal tumor dissection takes place guided by the 0-degree endo-
region tumor excision. scope in much the same manner as the microsurgical proce-
dure. Using microdissecting instruments that are custom
designed for this endoscopic procedure, as well as the CUSA
Surgical Technique
ultrasonic dissector, the interior of the pineal tumor is
The surgical procedure begins with the patient in a semi- debulked first, followed by the microdissection and excision
sitting position (►Fig. 1). The patient’s head is secured in a
Mayfield three-pin head clamp. The head is then slightly
flexed. A 2.5-cm incision is placed at the inion; this is
followed by dissection of the soft tissues of the scalp
down to the cranium using electrocautery and periosteal
elevators. Hooks are used to retract the skin and soft tissues.
A Stryker (Kalamazoo, Michigan, USA) saber drill is used to
perform a 1.5-to-2–cm keyhole craniotomy centered at the
inion just at the confluence of the transverse sinuses and
superior sagittal sinus; diamond burrs are used to mitigate
any inadvertent injury to the venous sinuses. A curvilinear
incision is made in the dura, which is then retracted superi-
orly and held in place with Nurolon sutures (Ethicon, Somer-

Fig. 1 Photograph of patient positioning for the fully endoscopic Fig. 2 Illustration depicting pathway of endoscope for the fully
infratentorial, supracerebellar approach. endoscopic infratentorial, supracerebellar approach.

Journal of Neurological Surgery—Part B Vol. 74 No. B3/2013

116 Fully Endoscopic Resection of Pineal Region Tumors Shahinian, Ra

not taken to an intensive care unit but are transferred to a

private room with one-to-one nursing care for about 24 hours.
Most patients are discharged within 48 hours.
This technique is used for a variety of pineal region tumors,
including pineocytomas, pineoblastomas, meningiomas, ger-
minomas, astrocytomas, gliomas, teratomas, epidermoids,
and complex pineal and arachnoid cysts.

Illustrative Case
►Fig. 3 and ►Fig. 4 show the preoperative and postoperative
magnetic resonance imaging (MRI) images of a 30-year-old
female patient with a 2.7-cm pineoblastoma that underwent
a gross total resection via the fully endoscopic supracerebellar
Fig. 3 Preoperative magnetic resonance imaging of 30-year-old

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female patient with a 2.7 cm pineoblastoma. infratentorial approach.

Conclusion
Surgery for pineal region tumors has traditionally required
large craniotomies, either going through neural tissue in the
posterior transcortical and posterior transcallosal ap-
proaches or—at a minimum—requiring significant brain re-
traction in the infratentorial supracerebellar approach. Thus
far, endoscopic approaches to the pineal region have been
limited to transventricular approaches to perform an endo-
scopic third ventriculostomy (ETV), with a simultaneous
biopsy of the pineal tumor while in the third ventricle. We
describe a novel, fully endoscopic approach that is performed
through a 1.5-to-2–cm occipital bur hole centered at the
inion. This approach requires no violation of neural tissues,
nor any cerebellar retraction, and allows the gross total
Fig. 4 Magnetic resonance imaging 3 months post-gross total re- resection of pineal region tumors such as pineocytomas,
section via fully endoscopic approach. pineoblastomas, meningiomas, etc. This innovative technique
combines the benefits of the traditional, open, supracerebel-
lar infratentorial technique and avoids any of the complica-
of the capsule. Depending on the overall size and histology of tions secondary to retraction of the cerebellum. The fully
the tumor, sharp dissection of the tumor off of the quad- endoscopic supracerebellar infratentorial approach also ben-
rigeminal plate inferiorly and chasing of the tumor into the efits from all the advantages of minimally invasive endoscopic
third ventricle is often required. Great care is taken to avoid techniques, such as shorter surgical time (2 hours), shorter
any injury to the surrounding critical neurovascular struc- hospitalization (48 hours), and fewer complications overall.
tures. Once gross tumor resection is complete, the 0-degree We have been using this technique exclusively since 2008 and
endoscope is removed and a 30-degree endoscope is inserted are currently in the process of compiling data for a follow-up
to perform a circumferential survey and examine the quad- article on a series of pineal region tumors using the above-
rigeminal plate, the inner walls of the third ventricle, and the mentioned technique.
opening of the aqueduct of Sylvius. Once the inspection is
completed, the 30-degree endoscope is removed and a final
survey of the tumor bed and surrounding structures is References
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Journal of Neurological Surgery—Part B Vol. 74 No. B3/2013

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