Anterior interhemispheric transsplenial approach to pineal region tumors: anatomical study and illustrative case

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Pineal region tumors are challenging to access because they are centrally located within the calvaria and surrounded by critical neurovascular structures. The goal of this work is to describe a new surgical trajectory, the anterior interhemispheric transsplenial approach, to the pineal region and falcotentorial junction area. To demonstrate this approach, the authors examined 7 adult formalin-fixed silicone-injected cadaveric heads and 2 fresh human brain specimens. One representative case of falcotentorial meningioma treated through an anterior interhemispheric transsplenial approach is also described. Among the interhemispheric approaches to the pineal region, the anterior interhemispheric transsplenial approach has several advantages. 1) There are few or no bridging veins at the level of the pericoronal suture. 2) The parietal and occipital lobes are not retracted, which reduces the chances of approach-related morbidity, especially in the dominant hemisphere. 3) The risk of damage to the deep venous structures is low because the tumor surface reached first is relatively vein free. 4) The internal cerebral veins can be manipulated and dissected away laterally through the anterior interhemispheric route but not via the posterior interhemispheric route. 5) Early control of medial posterior choroidal arteries is obtained. The anterior interhemispheric transsplenial approach provides a safe and effective surgical corridor for patients with supratentorial pineal region tumors that 1) extend superiorly, involve the splenium of the corpus callosum, and push the deep venous system in a posterosuperior or an anteroinferior direction; 2) are tentorial and displace the deep venous system inferiorly; or 3) originate from the splenium of the corpus callosum.

Article Information

Correspondence Robert F. Spetzler, c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd., Phoenix, AZ 85013. email: neuropub@barrowneuro.org.

INCLUDE WHEN CITING Published online January 13, 2017; DOI: 10.3171/2016.9.JNS16279.

Disclosures Dr. Kaan Yağmurlu is supported by funds from the Barrow Neurological Foundation and the Women's Board of the Barrow Neurological Institute. Funds to support the study came from the University of Florida Foundation and from the Newsome Family Endowed Chair in Neurosurgery Research held by Dr. Preul.

© AANS, except where prohibited by US copyright law.

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    Anatomical relationship of the pineal region to surrounding structures. A: Photograph obtained after the right hemisphere was removed to expose the falx and tentorium. The inferior margin of the posterior part of the falx cerebri slopes toward and comes close to the splenium to meet the tentorium in the midline. The straight sinus originates below the splenium of the corpus callosum and travels on the top of the tentorium to where both sides of the tentorium come together at an angle to meet the falx cerebri. B: Medial view. There are rarely any bridging veins at the pericoronal suture, whereas there are numerous parietal bridging veins. C: Medial view. The pineal gland is positioned underneath the vein of Galen. The internal cerebral veins running through the velum interpositum and the basal veins of Rosenthal come together to form the vein of Galen in the subsplenial area. D: Superior view. The body of the fornix and the hippocampal commissure have been split to expose the deep venous structures and the medial posterior choroidal artery in the velum interpositum. E: Posterior view. The pineal gland and its relationship with deep venous structures. A. = artery; Call. = callosum; Cer. = cerebral; Chor. = choroidal; Corp. = corpus; Gl. = gland; Int. = internal; Lat. = lateral; Med. = medial; Occ. = occipital; Post. = posterior; S. = sinus; Sag. = sagittal; Sup. = superior; V. = vein; Ventr. = ventricle; Verm. = vermian. Dissections were prepared by Kaan Yağmurlu, MD, and the images are reproduced with permission from the Rhoton Collection (http://rhoton.ineurodb.org), CC BY-NC-SA 4.0 (http://creativecommons.org/licenses/by-nc-sa/4.0).

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    A: Superior view of a different specimen from that shown in Fig. 1. The right hemisphere has been dissected to expose the corpus callosum and the parts of the lateral ventricle. The anterior interhemispheric transsplenial trajectory (green arrow) from the frontal craniotomy to the splenium of the corpus callosum is accessed between the falx and the medial side of the hemisphere. B: Posterior view. The falx cerebri and tentorium come together at the falcotentorial junction, just behind the splenium of the corpus callosum in the midline. The pineal region is hidden by the junction of the falx cerebri and tentorium. C: Superior view. The removal of the body of the corpus callosum exposes parts of the lateral ventricle, septum pellucidum, and body of the fornix, and the splenium of the corpus callosum. D: Superior view. The corpus callosum forms the roof of the lateral ventricle. The anterior part of the corpus callosum is called the genu, and the posterior part of the corpus callosum is called the splenium. The cingulum is the white matter of the cingulate gyrus, which forms the lateral limit of the surgical exposure of the corpus callosum. E: The posterior part of the body and a part of the splenium of the corpus callosum have been removed to expose the inside of the lateral ventricle. The hippocampal commissure interconnects both the crura of the fornix between the splenium of the corpus callosum anteriorly and the body of the fornix, which is formed by the juncture of the crura of the fornix in the midline posteriorly. Comm. = commissure; Front. = frontal; Hippo. = hippocampal; Pell. = pellucidum; Plex. = plexus; Sept. = septum; Ventr. = ventricle. Dissections were prepared by Kaan Yağmurlu, MD, and the images are reproduced with permission from the Rhoton Collection (http://rhoton.ineurodb.org), CC BY-NC-SA 4.0 (http://creativecommons.org/licenses/by-nc-sa/4.0).

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    A: In a stepwise manner, the body of the corpus callosum has been removed to expose the lateral ventricle, while the left cingulum was preserved. B: The cingulum was removed and the hippocampal commissure was opened. The floor of the lateral ventricle is formed by the thalamus and the body of the fornix, while the lateral wall of the lateral ventricle is formed by the caudate nucleus. Both crura of the fornix meet to form the body of the fornix in the midline. C: The splitting of the body of the fornix and the opening of the hippocampal commissure expose the third ventricle and pineal region. The quadrigeminal cistern is located underneath the splenium of the corpus callosum. D: Superior view. Splitting the body of the fornix and the hippocampal commissure exposes the third ventricle and pineal region. In the subsplenial area, the pineal gland, posterior commissure, and habenular commissure that form the posterior wall of the third ventricle are exposed. The anterior commissure and massa intermedia within the third ventricle can also be seen. Ant. = anterior; For. = foramen; Inter. = intermedia; Nucl. = nucleus; Quad. = quadrigeminal. Dissections were prepared by Kaan Yağmurlu, MD, and the images are reproduced with permission from the Rhoton Collection (http://rhoton.ineurodb.org), CC BY-NC-SA 4.0 (http://creativecommons.org/licenses/by-nc-sa/4.0).

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    Surgical procedure in a stepwise manner. A: The patient is placed supine, with the sagittal plane of the head turned parallel to the floor. B: The head is elevated 45° to decrease venous pressure and allow the frontal lobe to retract gravitationally. C: The linear incision is made precoronally, one-third contralateral to the craniotomy side and two-thirds to the ipsilateral side. D: Two bur holes are placed over the superior sagittal sinus, and 2 bur holes are placed 3 cm off midline. The craniotomy is performed in the order shown by the numbers. The medial edge of the craniotomy flap (indicated by 4) is placed at the contralateral side using the 2 bur holes over the sinus. E: After removal of the craniotomy flap, any bleeding from the sinus is controlled using Surgicel. F: The dura is opened in a U shape, reflected, and retracted with retention sutures over the sinus. G: The interhemispheric fissure is accessed and easily opened without using a retractor. H: There is 1 or no bridging vein at the level of the pericoronal suture; the vein can be coagulated, if necessary. I: At the deeper portion of the interhemispheric fissure, the corpus callosum has a white appearance. Thereafter, it is accessed posteriorly to reach the splenium of the corpus callosum. J: After exposure of the splenium, the pericallosal arteries are retracted laterally. Fiss. = fissure; Inf. = inferior; Interhem. = interhemispheric; Pericall.= pericallosal. Panels A and B are used with permission from Barrow Neurological Institute, Phoenix, Arizona. Dissections in Panels C–J were prepared by Kaan Yağmurlu, MD, and the images are reproduced with permission from the Rhoton Collection. (http://rhoton.ineurodb.org), CC BY-NC-SA 4.0 (http://creativecommons.org/licenses/by-nc-sa/4.0).

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    Pineal region tumor extensions. A tumor that extends superiorly and pushes the splenium of the corpus callosum is a good indication for the anterior interhemispheric transsplenial approach. The internal cerebral veins can be pushed by the tumor superiorly (arrow) (A), inferiorly (arrow) (B), or laterally (C). Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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    Preoperative and postoperative MR images and intraoperative photographs. The preoperative MR images (A, axial; B, sagittal; C, coronal) show a homogeneously enhancing mass that arises from the falcotentorial junction and rises above the internal cerebral veins. It is associated with anterior and inferior displacement of the splenium of the corpus callosum. The intraoperative photographs show microsurgical dissection over the splenium of the corpus callosum (D, with illustration in inset showing patient position); exposure of the tumor in the interhemispheric space (E); the operative field after debulking and dissection of the capsule of the tumor from surrounding structures (F); and the operative field after removal of the tumor (G). The postoperative MR images (H, axial; I, sagittal; J, coronal) show removal of the tumor. Panels D–G are used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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    Preoperative (A, axial; B, sagittal) contrast-enhanced MR images showing a pineal region tumor with infratentorial extension that does not displace the splenium of the corpus callosum. The posterior (parietooccipital) interhemispheric approach was used to remove the tumor. Preoperative (C, axial; D, sagittal) and postoperative (E, axial) contrast-enhanced MR images show a pineal region tumor with no supratentorial extension, which has been operated on through the supracerebellar infratentorial approach.

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