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Open access

Alessia Imperato, Alessandra Marini, Pietro Spennato, Giuseppe Mirone, and Giuseppe Cinalli

The authors present a pediatric case of a pineoblastoma treated with gross-total removal through an occipital interhemispheric transtentorial approach (OITA). The child presented with acute hydrocephalus that was treated by endoscopic third ventriculostomy (ETV) and tumor biopsy through a single burr hole. Histology revealed a pineoblastoma. Microsurgical total removal was performed 3 months after neoadjuvant chemotherapy. OITA was chosen on the basis of the tumor’s location below the Herophilus-Galen line of sight. In this video, the authors show the positioning, the operating devices, the approach, and the microsurgical dissection, indicating all the neurovascular structures encountered.

The video can be found here:

Open access

Cristina Mancarella, Alessandra Marini, Rocco Severino, Paolo Missori, Cristina Santoro, and Sergio Paolini


Factor XI deficiency, also known as hemophilia C, is a rare inherited bleeding disorder that may leave routine coagulation parameters within normal range. Depending on the mutation subtype, prolonged activated partial thromboplastin time may occasionally be found. The disease has an autosomal transmission, with an estimated prevalence in the general population of approximately 1 in 1 million. Heterozygosis accounts for partial deficits, but the tendency to bleed is unrelated to the measured activity of factor XI. Diagnosis usually follows unexpected hemorrhages occurring spontaneously or after trauma or surgical procedures.


Few cases have been reported in the neurosurgical literature, all occurring spontaneously or after head trauma. Owing to its subtle features, the true incidence of the disease is probably underestimated. The authors report a case of a patient with previously undiagnosed factor XI deficiency who underwent uncomplicated resection of a fourth-ventricle papilloma and experienced delayed, severe hemorrhagic complications.


The known association between choroid plexus tumors and intracranial bleeding raised differential diagnosis issues. This report may serve to help to investigate delayed hemorrhages after cranial surgery.

Open access

Giuseppe Cinalli, Maria Rosaria Scala, Alessandra Marini, Alessia Imperato, Giuseppe Mirone, and Pietro Spennato

In this video, the authors present an interhemispheric transcallosal transchoroidal approach to a pineal mass in a 15-year-old boy. He received emergency endoscopic third ventriculostomy (ETV), then an endoscopic biopsy that revealed an immature teratoma. Surgical removal was selected. The mass was located very high in the posterior third ventricle, hidden behind the splenium of the corpus callosum and the vein of Galen, so an interhemispheric transcallosal approach followed by a complete dissection of the whole choroidal fissure was chosen and allowed complete removal of the tumor. Microsurgical dissection is presented, showing clearly in detail all the neurovascular structures encountered.

The video can be found here:

Restricted access

Giuseppe Cinalli, Alessandra Marini, Carmela Russo, Pietro Spennato, Giuseppe Mirone, Claudio Ruggiero, Lucia Quaglietta, Maria Serena de’ Santi, and Eugenio Covelli


The goals of this study were to evaluate the extent of resection (EOR) obtained with an occipital interhemispheric transtentorial approach (OITA) in a series of pediatric patients with pineal region tumors and to define preoperative radiological factors predictive of the EOR.


This is a retrospective cohort study of a series of pediatric patients with pineal tumors who underwent surgery through a microsurgical OITA performed by the senior author during the period from January 2006 to January 2020. The tumor volume was measured preoperatively, and then on sagittal midline cuts the authors identified the most cranial point of the torcular Herophili (defined as the “Herophilus point”) and the lowest point of the inferior profile of the vein of Galen (defined as the “Galen point”). The line joining these two points (defined as the "Herophilus-Galen line" [H-G line]) was used to identify the "Herophilus-Galen plane" (H-G plane) perpendicular to the sagittal plane. Tumor volumes located below and above this plane were measured. EOR was evaluated by measuring residual tumor volume visible on T1 volumetric injected sequences of immediate postoperative MRI.


Thirty patients were selected for study inclusion. The preoperative mean tumor volume was 15.120 cm3 (range 0.129–104.3 cm3). The mean volumes were 2.717 cm3 (range 0–31 cm3) above the H-G plane and 12.40 cm3 (median 5.27 cm3, range 0.12–72.87 cm3) below the H-G plane. Three patients underwent only biopsy. Of the remaining 27 patients, gross-total resection (GTR; 100% tumor volume) was achieved in 20 patients (74%). In the remaining 7 patients, the mean residual tumor volume was 7.3 cm3 (range 0.26–17.88 cm3). In 3 of these patients, GTR was accomplished after further surgical procedures (1 in 2 patients, 3 in 1 patient) for an overall GTR rate of 85.18%. Larger tumor volume was significantly associated with incomplete resection (p < 0.001). A tumor volume ≤ 2 cm3 above the H-G plane (p = 0.003), linear extension ≤ 1 mm above the H-G line, and pineal histology were predictive of GTR at first OITA procedure (p = 0.001).


The H-G line is an intuitive, easy-to-use, and reliable indicator of the superior anatomical limit of visibility during the microsurgical OITA. This anatomical landmark may be useful as a predictor of EOR for pineal tumors performed through this approach. The main limitations of this study are the small number of patients and the exclusively pediatric age of the patient population.