Elsevier

World Neurosurgery

Volume 137, May 2020, Pages e194-e207
World Neurosurgery

Original Article
Midline and Paramedian Supracerebellar Infratentorial Approach to The Pineal Region: A Comparative Clinical Study in 112 Patients

https://doi.org/10.1016/j.wneu.2020.01.137Get rights and content

Objective

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.

Methods

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.

Results

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.

Conclusions

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.

Introduction

The pineal region, also called posterior incisural space or quadrigeminal cistern, is a deeply located surgical area where different type of cysts and tumors may develop. The supracerebellar infratentorial (SCIT) approach and the occipital interhemispheric approach are the most common approaches to this region in the Department of Neurosurgery, Helsinki University Hospital (HUH).1, 2, 3, 4, 5 The SCIT approach is performed in around 90% of all surgically treated pineal tumors, as well as in almost 100% of pineal cysts operated in HUH.1,2 The SCIT approach, initially introduced in HUH as a midline approach, has been progressively modified to a more sophisticated and less invasive paramedian approach.3 Thus, the paramedian SCIT approach resulted from a development of the midline approach. During the past few years, the paramedian SCIT approach became the standard approach to the pineal region in HUH. Our previous publication on the microsurgical management of cysts and tumors of the pineal region already gave us some clues about the benefits of the paramedian SCIT approach.1,2 However, no comparative clinical study has been performed so far between both SCIT approaches.6, 7, 8, 9, 10, 11, 12, 13, 14 We aim to compare the differences of these 2 approaches in terms of clinical safety and procedural outcome. We hypothesized that the paramedian SCIT approach could have a better surgical performance than the midline SCIT approach in patients with pineal cysts and pineal region neoplasms undergoing surgery in sitting position. Overall, the surgical performance was evaluated in terms of clinical safety. Procedural functionality and effectiveness were also analyzed.

Section snippets

Population Study and Design

This project, which was approved by the ethics committee of HUH, is a retrospective case-control study to evaluate the safety, functionality, and effectiveness of the paramedian SCIT approach versus the midline SCIT in all patients who were surgically treated for pineal region neoplasms and cysts in the Department of Neurosurgery, HUH, between 1997 and 2015. We included only the patients operated in the sitting position by the same neurosurgeon (J.H.) who exclusively underwent the SCIT

Results

During the study period, 137 patients (60 pineal cysts and 76 pineal tumors) were operated. Of these, 14 patients underwent different surgical approaches, and 2 patients were not operated in sitting position. Two more patients were operated by a different surgeon. Six patients (3 midline and 3 paramedian SCIT approaches) underwent multiple approaches and were excluded from the study. Finally, 112 patients were classified as 55 midline and 57 paramedian SCIT approaches.

The distribution of the

Discussion

We present the results of a comparative clinical analysis between the midline and the paramedian SCIT approaches for the management of pineal region cysts and neoplasms. The superior safety and better functionality of the SCIT paramedian approach versus the classic midline approach was associated with a similar effectiveness in the management of the pineal region lesions (Figure 7). A limitation of the project is represented by the fact that it is a retrospective single-center and

Conclusions

The SCIT paramedian approach has a better surgical performance than the midline SCIT in patients undergoing pineal region surgery in the sitting praying position. 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. Overall, the SCIT paramedian approach maintains the same effectiveness as the midline approach.

CRediT authorship contribution statement

Joham Choque-Velasquez: Conceptualization, Methodology, Data curation, Writing - original draft. Julio Resendiz-Nieves: Methodology, Data curation, Writing - review & editing. Behnam Rezai Jahromi: Data curation, Writing - review & editing. Roberto Colasanti: Writing - review & editing. Szymon Baluszek: Data curation, Formal analysis. Sajjad Muhammad: Writing - review & editing. Juha Hernesniemi: Supervision, Project administration.

References (28)

  • J. Mascitelli et al.

    Contralateral supracerebellar-infratentorial approach for resection of thalamic cavernous malformations

    Oper Neurosurg (Hagerstown)

    (2018)
  • B. La Pira et al.

    The paramedian supracerebellar infratentorial approach

    Acta Neurochir (Wien)

    (2017)
  • S. Matsuo et al.

    Midline and off-midline infratentorial supracerebellar approaches to the pineal gland

    J Neurosurg

    (2017)
  • C. Kulwin et al.

    Lateral supracerebellar infratentorial approach for microsurgical resection of large midline pineal region tumors: techniques to expand the operative corridor

    J Neurosurg

    (2016)
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    Prof. Juha Hernesniemi is an Aesculap counselor.

    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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