Surgical treatment of posterior fossa tumors via the occipital transtentorial approach: evaluation of operative safety and results in 14 patients with anterosuperior cerebellar tumors

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Object. To determine the safety and usefulness of performing surgery via the occipital transtentorial approach to treat anterosuperior cerebellar tumors, evaluation of 14 patients was performed over a 5-year period.

Methods. The study was performed in 14 patients, aged 6 months to 71 years, who harbored anterosuperior cerebellar tumors of the posterior fossa including four hemangioblastomas, three cerebellar astrocytomas, three medulloblastomas, two metastatic tumors, one recurrent astrocytoma, and one rhabdoid cell tumor. All patients underwent surgical treatment by the same surgical team and via the same surgical approach. Endoscopy combined with neuronavigation was used for large, deep-seated tumors extending to the fourth ventricle. Of the 14 patients, total or gross-total removal was achieved in 12 patients and subtotal removal in two patients. There was no incidence of mortality or morbidity in the 14 patients, and all functional outcomes were good to excellent postoperatively. Postoperative magnetic resonance imaging revealed that none of the patients had suffered brain damage or infarction around the cerebellum, brainstem, or occipital lobe.

Conclusions. Although this study was the first in which a specific examination of the efficacy of the occipital transtentorial approach in patients with anterosuperior cerebellar tumors was undertaken, our findings suggest that this surgical approach is very useful, safe, and accurate for removing the primary tumor and evaluating the surrounding anatomy, as well as for determining operative strategy.

Article Information

Address reprint requests to: Reizo Shirane, M.D., Ph.D., Department of Neurosurgery, Tohoku University School of Medicine, 1–1 Seiryomachi Aobaku, Sendai 980–8574, Japan. email: reizo@nsg.med.tohoku.ac.jp.

© AANS, except where prohibited by US copyright law.

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Figures

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    Surgical planning. Left: The degree of head and neck flexion was guided by the angle of the tentorium, which was determined on the basis of sagittal MR images. Arrows indicate angles of the microscope. Right: Schematic drawing of the U-shaped skin incision, cranial window, and dural incision.

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    Intraoperative photographs. Upper Left: A tentorial incision is made by creating a small hole apart from the border of the transverse sinus with the aid of a monopolar coagulator. Lower Left: The incised tentorium is tented separately to allow the surface of the anterosuperior cerebellum to come into microsurgical view. Upper Right: The tumor is dissected from the posterior fossa. Lower Right: An endoscope was used to access the remnant of the tumor.

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    Case 2. Upper: Gadolinium-enhanced T1-weighted MR images obtained in a 6-month-old girl, revealing a large rhabdoid cell tumor in the posterior fossa and pineal region that displays homogeneous enhancement. Lower: Postoperative MR images obtained after the tumor was removed.

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    Case 3. Gadolinium-enhanced T1-weighted MR images obtained in a 1-year-old girl, revealing a large ring-enhancing anterosuperior cerebellar cystic mass lying beneath the tentorium and extending to the midbrain (left), which was diagnosed as a pilocytic astrocytoma after being partially resected via a left occipital transtentorial approach (center). The bottom of the tumor bed was left and 2 weeks later total resection of the residual tumor was performed (right). Pre = preoperative; post = postoperative (after first surgery).

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    Case 4. Upper: Gadolinium-enhanced MR images and an MR venographic (MRV) image obtained in a 1-year-old boy, revealing a medulloblastoma located in the upper vermis. Lower: Postoperative MR images confirming gross-total removal of tumor.

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    Case 6. Upper: Gadolinium-enhanced T1-weighted images obtained in a 7-year-old girl, revealing the presence of a pilocytic astrocytoma. Lower: Postoperative CT scans with contrast enhancement confirming total removal of tumor.

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    Case 9. Gadolinium-enhanced T1-weighted MR images (upper left and center) and right vertebral artery angiogram (upper right) obtained in a 19-year-old man, revealing a hemangioblastoma located in the CPA and the vessels feeding it. Postoperative MR images (lower) demonstrate no sign of tumor.

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    Case 13. Upper: Gadolinium-enhanced MR images obtained in a 70-year-old woman, revealing a metastatic tumor. Lower: Contrast-enhanced CT scan obtained postoperatively, demonstrating no sign of tumor.

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    Case 14. Upper: Gadolinium-enhanced T1-weighted MR images obtained in a 71-year-old man, revealing a recurrent hemangioblastoma in the anterosuperior cerebellum. Lower Left: Left vertebral artery angiogram demonstrating the tumor and surrounding blood vessels. Lower Center and Right: Postoperative MR images confirming total removal of the tumor.

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