Endoscopic Midline and Paramedian Supracerebellar Infratentorial Approaches to Pineal Region Tumors: A Clinical Study and Approach Comparison.

OBJECTIVE: This study was to analyze the advantages and disadvantages of endoscopic midline and paramedian supracerebellar infratentorial approaches (EM-SCITA and EPM-SCITA) for pineal region tumors. METHODS: We retrospectively analyzed the clinical data of 58 patients who underwent EM-SCITA and EPM-SCITA for pineal region tumors. Among them, 23 patients were treated with EM-SCITA, and 35 with EPM-SCITA. The patients were followed up for 6-84 months with magnetic resonance imaging and Karnofsky Performance Status scores. RESULTS: The average age of the patients was 37.98 years, and there were 16 women (27.6%). The average maximum diameter of the tumors was 2.92 cm. Gross total resection was achieved in 46 patients (79.31%). There were 45 patients (77.6%) whose Karnofsky Performance Status score was >70 at the final follow-up. There was no significant difference among the above items between EM-SCITA and EPM-SCITA. However, EM-SCITA required a longer craniotomy and closure time, with a larger bone and dural flap, with more bridging veins sacrificed. EPM-SCITA simplified the opening of the quadrigeminal cistern, and it was beneficial to expose the contralateral wall of the third ventricle. The longer and angled path limited the exposure of the anterior third ventricle and the ipsilateral wall of the third ventricle. CONCLUSIONS: Both approaches had remarkable clinical effects. The anatomy of EM-SCITA was easy to understand and has a larger operating space; it is suitable for neurosurgical beginners. In contrast, EPM-SCITA has limited operation space, an intricate anatomy, and is suitable for experienced operators. The occurrence of postoperative hydrocephalus should be alerted by EPM-SCITA.

Endoscopic Far-Lateral Supracerebellar Infratentorial Approach for Petroclival Region Meningioma: Surgical Technique and Clinical Experience.

BACKGROUND: The management of petroclival region meningioma remains the ultimate achievement in neurosurgery, because of the formidable technical challenges involved. OBJECTIVE: To describe the technique and feasibility of the purely endoscopic far-lateral supracerebellar infratentorial approach (EF-SCITA) for the treatment of petroclival region meningiomas. METHODS: We reviewed the clinical data of 10 consecutive cases of petroclival region meningiomas treated with the EF-SCITA from August 2018 to August 2020. The clinical outcomes were analyzed. The patient was placed in the lateral position, and then, a "C" shaped incision and craniotomy with exposed sigmoid and transverse sinuses were performed. With the endoscopic holder, endoscopic procedures were performed using standard 2-hand microsurgical techniques. Whether the tentorium or Meckel cave was handled depended on the tumor extension. RESULTS: The mean diameter was 45 × 25 mm. Dizziness and headache were the main symptoms. All 10 patients achieved gross total or subtotal resection (Petroclival Meningioma Grade I-III) with good neurological outcomes. The EF-SCITA provides satisfactory, direct exposure to the petroclival region. Cranial nerve deficits are the main postoperative complications. Two patients had a trochlear nerve injury, 3 patients had transient facial paralysis, and 2 patients had oculomotor paralysis (1 total and 1 incomplete), but both of them recovered during the follow-up period. One patient experienced an ipsilateral superior cerebellar artery infarction, and another patient had transient hemiparesis. CONCLUSION: The EF-SCITA is effective for most petroclival region meningiomas, except for the cavernous sinus type. This approach simplifies craniotomy procedures, omits burdensome petrosectomy, and avoids crossing posterior neurovascular structures.

The Use of Micro Retractor in Endoscopic Endonasal Posterior Pseudocapsule Resection of Pituitary Macroadenoma. Technical Note.

BACKGROUND: The endoscopic endonasal approach and extra-pseudocapsule resection may be the main progress in modern pituitary surgery. However, for pituitary macroadenomas, discerning the pseudocapsule in the posterior plane of the tumor may be difficult. When the anterior-inferior debulking is performed, the early subsidence of the thinning normal pituitary gland and enlarged diaphragm may obstruct the surgical dissection view. METHOD: We describe the technique of using a micro retractor for the endoscopic endonasal posterior pseudocapsule resection of pituitary macroadenomas. This micro retractor that was 2 mm in width was placed at the 12 o'clock position on the nostrils, and the end was fixed in the flexible arms of the self-retaining retractor system. The head of the micro retractor elevated the herniated diaphragm sellae in order to continue the posterior pseudocapsule resection of the pituitary macroadenoma. RESULT: The technique was performed very easily and no complication was observed. CONCLUSION: The use of this micro retractor can increase the view of the posterior margin of the adenomas to facilitate the pseudocapsule dissection.