Seetahal-Maraj Panduranga, Knight Patrick, Ramnarine Narindra
Department of Neurosurgery, Southern Medical Clinic, San Fernando, Victoria, Trinidad and Tobago.
Surg Neurol Int. 2021 Nov 30;12:582. doi: 10.25259/SNI_977_2021. eCollection 2021.
Pineal tumors are very rarely encountered, with an incidence of <1% of intracranial lesions in adults. Life-threatening hydrocephalus due to obstruction of the third ventricle can result from the location of these tumours. Endoscopic third ventriculostomy (ETV) and tumor biopsy is a safe and feasible strategy, particularly if the tumor appears benign. This mitigates the high risks of uncontrollable venous bleeding from open and stereotactic biopsies. While typically performed using either ipsilateral single or dual bur holes, the location of the tumor may require modifications to the standard endoscopic techniques.
A 55-year-old male presented with signs of intracranial hypertension and was found to have obstructive hydrocephalus due to a pineal tumour. The tumour displayed a right-sided dominance when the pre-operative imaging was assessed, which would risk forniceal injury if biopsied via a right-sided burr hole. Craniometric measurements revealed a superior trajectory to the tumour via the left foramen of Monro. A biforaminal approach was performed, with a traditional ETV using a right coronal bur hole and biopsy via a left frontal bur hole. This minimized forniceal stretching and allowed a safe biopsy.
The bi-foraminal approach has not been widely described in the literature but can potentially avoid morbidity with biopsy in patients with right-sided pineal tumours. We believe this technique should be considered, particularly in low-resource settings where neuroendoscopy is not commonly done, and where the use of ipsilateral single or dual-bur holes may lead to forniceal injury.
松果体肿瘤非常罕见，在成人颅内病变中的发生率<1%。这些肿瘤的位置可导致因第三脑室梗阻而危及生命的脑积水。内镜下第三脑室造瘘术（ETV）和肿瘤活检是一种安全可行的策略，尤其是当肿瘤看起来为良性时。这降低了开放活检和立体定向活检不可控静脉出血的高风险。虽然通常使用同侧单孔或双孔钻孔进行操作，但肿瘤的位置可能需要对标准内镜技术进行调整。
一名55岁男性出现颅内高压症状，经检查发现因松果体肿瘤导致梗阻性脑积水。术前影像学评估显示肿瘤偏向右侧，如果通过右侧钻孔进行活检，有损伤穹窿的风险。颅骨测量显示经左侧室间孔至肿瘤的路径较优越。采用双孔入路，通过右侧冠状缝钻孔进行传统的ETV，并通过左侧额部钻孔进行活检。这样可最大程度减少穹窿的拉伸，并实现安全活检。
双孔入路在文献中尚未得到广泛描述，但对于右侧松果体肿瘤患者，在活检时可能避免并发症。我们认为应考虑采用这种技术，特别是在资源有限的环境中，那里不常进行神经内镜检查，且使用同侧单孔或双孔钻孔可能导致穹窿损伤。
