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Large Pineoblastoma: Paramedian Supracerebellar Approach

January 25, 2016


Here is another application of the paramedian Supracerebellar Approach for resection of large pineal region tumor, and more specifically a pineoblastoma. This is a 32 year old female who presented with intractable headaches. And on MRI evaluation was noted to have a relatively heterogeneous well-defined mass in the area of their pineal region. There was also some mild hydrocephalus associated with a mass. Patient underwent a left sided paramedian superacerebellar approach for resection of the tumor. The linear incision is in the middle of the distance between the mastoid and the area of the midline. One third of the incision is above and two third is below the transfer sinus. That bare hole can be made through the superior aspect of the incision to tap the ventricle if necessary, before the dura is in size. If cerebral tension is encountered due to the presence of mild hydrocephalus. The paramedian approach in my opinion is superior than the midline approach. Here is again the configuration of the incision, and the anatomical landmarks is the transfer sinus that is unroofed. Two sutures were placed within the posterior aspect of the tentorium to elevate the transfer sinus and expand the operative corridor. This patient is quite young, and the cerebellum is full. Here's the fourth nerve along the latter aspect of our exposure. Branches of the superacerebellar artery. Here's the midline close to the air of the falx cerebelli. The posterior capsule of the tumor is incised and the tumors aggressively debulked. This tumor is quite fibrous, It's a pinealoblastoma. Pituitary rongeurs were not quite effective in its removal, therefore an ultrasonic aspirator was used. Here's again, the location of the midline, you'll see some of the images from the neuro navigation to orient you. Here's the contralateral tectum, you can see the magnified view of our operative corridor. Further debulking was accomplished. Different working angles were used to de-bulk the superior and inferior aspects of the tumor. This capsule was quite adherent to the ipsilateral tectum, I continued to dissect the tumor despite minor injury to the tectum. Although the patient had some mild, extra awkward movements abnormality after surgery, these deficits resolved within two weeks. You saw a view of the posterior aspect of the third ventricle a moment ago. Continue to mobilize the tumor and its superior pull into the resection cavity. You can see the vein of Galen, which is very adherent to the capsule of this tumor. Sharp dissection was used however, I felt aggressive. Remove the tumor in this area would be too risky, and a small part of the tumor was left adherent to the wall of the vein of Galen. You can see the vein of Galen. Further attempts are relatively nonconclusive in terms of dissecting the vein from the tumor capsule. A clear plain could not be developed. You can see some of the other veins that are very densely adherent to the capsule. Sharp dissection was used as much as possible to mobilize some of these veins. Ultimately, a piece of tumor along the superior capsule was left behind. Here's the dissection of the tumor from the contralateral tectum. In a mild parinaud syndrome was apparent in this patient after surgery, but these symptoms disappeared within two weeks of the operation. Here's the posterior aspect of the third ventricle, CSF is evident. The cotton is placed at the location of the ventricle to avoid bleeding into the ventricular system. Additional pieces of tumor are being dissected for the posterior aspect of the thalamus. This piece of the tumor is being mobilized posterially, and ultimately removed. The part of the tumor that was very adherent to the veins is being further debulked. Here are the bilateral walls of the third ventricle. Additional tumor is being removed piecemeal. From again, the capsule the tumor that is very adherent and superiorly. You can see both walls of the ventricle, posterior aspect of the pulvinar. Here's our operative corridor and postoperative MRI demonstrates radical subtotal resection of the tumor with potentially small residual tumor adherent to the dying cephalic veins. Thank you.

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