Combined infratentorial and supratentorial transtentorial approach to pineal region tumors: A technical note

Complete resection of tumors of the pineal region without complications or damage to adjacent structures has been a continuing challenge to neurosurgeons. Although several approaches have been described, these tumors may attain such a large size that they involve the entire pineal region and also extend into the third or fourth ventricle. Tumors may be very firm in consistency, which also interferes with removal. Traditional approaches provide limited exposure in this circumstance and carry the risk of damage to the deep venous system. A combined infratentorial and supratentorial approach, aiming for total removal without surgical complications, is discussed here. Two patients, one with astrocytoma and the other with metastatic adenocarcinoma, underwent resection using a combined infratentorial supracerebellar and occipital interhemispheric transtentorial approach after bilateral occipital and suboccipital craniotomy. Total tumor removal was achieved in both, patients. This combined approach provided wide exposure, permitting tumor removal from multiple directions, reducing the need for cerebellar and occipital retraction, and avoiding damage to the brain stem, deep veins, and bridging veins. Minimizing manipulation of the brain and Galenic venous system is considered responsible for the good surgical outcome. The combined infratentorial supracerebellar and occipital interhemispheric transtentorial approach has proven very useful for these large and complex tumors, offering several advantages over single standard exposures.