Original ArticleMidline and Paramedian Supracerebellar Infratentorial Approach to The Pineal Region: A Comparative Clinical Study in 112 Patients
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.
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Cited by (0)
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.