Liu James K
Department of Neurological Surgery, Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey.
Neurosurg Focus. 2016 Jan;40 Video Suppl 1:2016.1.FocusVid.15450. doi: 10.3171/2016.1.FocusVid.15450.
The angle of the straight sinus and tentorium cerebelli can often influence the choice of surgical approach to the pineal region. The supracerebellar infratentorial approach can be technically challenging and a relative contraindication in cases where the angle of the straight sinus and tentorium is very steep. Similarly, an occipital transtentorial approach, which uses a low occipital craniotomy at the junction of the superior sagittal sinus and transverse sinus, may not provide the best trajectory to the pineal region in patients with a steep tentorium. In addition, this approach often necessitates retraction on the occipital lobe to access the tentorial incisura and pineal region, which can increase the risk of visual compromise. In this operative video, the author demonstrates an alternative route using an endoscopic-assisted interhemispheric parieto-occipital transtentorial approach to a pineal region tumor in a patient with a steep straight sinus and tentorium. The approach provided a shorter route and more direct trajectory to the tumor at the tentorial incisura, and avoided direct fixed retraction on the occipital lobe when performed using the lateral position, thereby minimizing visual complications. This video atlas demonstrates the operative technique and surgical nuances, including the application of endoscopic-assisted microsurgical resection and operative pearls for preservation of the deep cerebral veins. In summary, the parieto-occipital transtentorial approach with endoscopic assistance is an important approach in the armamentarium for surgical management of pineal region tumors. The video can be found here: https://youtu.be/Ph4veG14aTk .
直窦与小脑幕的夹角常常会影响松果体区手术入路的选择。小脑上幕下入路在技术上可能具有挑战性，在直窦与小脑幕夹角非常陡峭的情况下属于相对禁忌证。同样，枕下经小脑幕入路，即在矢状窦上缘与横窦交界处进行低位枕骨开颅，对于小脑幕陡峭的患者可能无法提供到达松果体区的最佳路径。此外，这种入路通常需要牵拉枕叶以进入小脑幕切迹和松果体区，这会增加视力受损的风险。在本手术视频中，作者展示了一种替代路径，即采用内镜辅助的半球间顶枕经小脑幕入路，治疗一名直窦和小脑幕陡峭患者的松果体区肿瘤。该入路为到达小脑幕切迹处的肿瘤提供了更短的路径和更直接的轨迹，并且在采用侧卧位进行手术时避免了对枕叶的直接固定牵拉，从而将视觉并发症降至最低。本视频图谱展示了手术技术和手术细节，包括内镜辅助显微手术切除的应用以及保留大脑深部静脉的手术技巧。总之，内镜辅助的顶枕经小脑幕入路是松果体区肿瘤手术治疗手段中的一种重要入路。视频链接如下：https://youtu.be/Ph4veG14aTk 。
