Elsevier

Surgical Neurology

Volume 70, Issue 6, December 2008, Pages 576-583
Surgical Neurology

Technique
Microsurgical management of pineal region lesions: personal experience with 119 patients

https://doi.org/10.1016/j.surneu.2008.07.019Get rights and content

Abstract

Background

Lesions of the pineal region are histopathologically heterogeneous but often accompanied with severe progression of clinical signs. Surgical treatment remains challenging because of the close vicinity of the deep venous system and the mesencephalo-diencephalic structures in this region. We present the surgical approaches and techniques in a consecutive series of 119 patients treated by the senior author (J.H.) between 1980 and 2007 at 2 different neurosurgical university centers in Kuopio and Helsinki, Finland.

Methods

Of the included patients, 107 (90%) presented with pineal region tumors and 12 (10%) with vascular malformations. The ITSC route was used for removal of the lesion in 111 (93%) patients and the OIH approach in 8 (7%) patients. All except one patient were operated on in a sitting position.

Results

We reviewed all clinical data and radiographic images and analyzed all surgical videos. The pineal lesions were removed completely in most cases (88%). There was no surgical mortality. Twenty-two (18%) of the patients had complications in the postoperative period; these included 1 epidural hematoma, 9 transient Parinaud syndrome, 2 meningitis, 3 wound infections, 2 transient memory disturbances, 2 mild hemiparesis, 1 CSF fistula, and 2 cranial nerves palsies (IV and VI). During a 3.5-year follow-up, 12 patients with malignant lesions died; all patients with benign tumors survived.

Conclusions

The ITSC route is a safe and effective surgical approach, associated with low morbidity, complete lesion removal, and definitive histopathologic diagnosis. Considering risk vs benefit, we therefore believe that the surgical treatment can be offered in most cases as the first treatment option for pineal tumors.

Section snippets

Introduction and historical background

Every man owes it a debt to his profession to put on record whatever he has done that might be of use to others.

Francis Bacon (1561-1626) [20]

The deep site of the pineal region surrounded by vital structures was long considered inaccessible for surgery. The first neurosurgical approaches performed by Horsley, Brummer, and Schloff had disastrous consequences [6], [7], [78]. Oppenheim and Krause reported the first successful removal of a pineal tumor removal in 1913 [40], [53]. Dandy [17]

Patient population

We retrospectively reviewed the case histories of all 119 consecutive patients with pineal lesions who were operated on by the senior author (JH) between 1980 and 2007 (1980-1997 Kuopio, 1997-2007 Helsinki).

Of these 119 patients, 14 (12%) were younger than 16 years. The patients' mean age was 34 years (0-78 years). Sixty-eight patients (57%) were women.

The mean follow-up was 40 months (6-60 months).

Preoperative clinical signs and symptoms

Signs of increased intracranial pressure were observed in 71 patients (60%), and 26 patients

Results

The data were obtained from the patients' charts during hospitalization or ambulatory consultation. In addition, we analyzed all surgical videos that are routinely made during every (micro)surgical operation. Follow-up information is received from the patients' general practitioner if it was indicated.

Discussion

To the best of our knowledge, we present one of the largest consecutive surgical series of pineal region tumors that are microsurgically treated and published.

The presenting clinical findings in our patient population were similar to those in other large series, including mild headache, Parinaud syndrome, hemisyndromes, cerebellar findings, and cognitive/memory impairment [1], [5], [7], [11], [21], [24], [29], [32], [34], [37], [45], [49], [62], [71]. These manifestations were related to

Conclusions

The ITSC route is a safe and effective surgical approach for pineal region tumor, associated with low morbidity, complete lesion removal, and definitive histopathologic diagnosis. Because of this good postoperative outcome, routine stereotactic biopsy is no more mandatory before pineal tumor removal. In most cases, direct surgical treatment can be offered as the first treatment option for pineal tumors.

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