Department of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, FL, USA.
Adv Tech Stand Neurosurg. 2024;52:207-227. doi: 10.1007/978-3-031-61925-0_15.
Pineal lesions represent less than 1% of all brain tumors (Villani et al., Clin Neurol Neurosurg 109:1-6, 2007). The abysmal location and critical neurovascular structures remain a surgical challenge, despite the advent of microneurosurgery. The classical wide surgical suboccipital craniotomy with the supracerebellar infratentorial approach, described by Sir Victor Horsley (Victor, Proc R Soc Med 3:77-78, 1910), is infamous for its considerable surgical morbidity and mortality. This was later upgraded microneurosurgically by Stein to improve surgical outcomes (Stein, J Neurosurg 35:197-202, 1971).Ruge et al. reported the first purely endoscopic fenestration of quadrigeminal arachnoid cysts via this corridor (Ruge et al., Neurosurgery 38:830-7, 1996). A cadaver-based anatomical study by Cardia et al. demonstrated the viability for endoscope-assisted techniques (Cardia et al., J Neurosurg 2006;104(6 Suppl):409-14). However, the first purely endoscopic supracerebellar infratentorial (eSCIT) approach to a pineal cyst was performed in 2008 by Gore et al. (Gore PA et al., Neurosurgery 62:108-9, 2008).Unlike transventricular endoscopy, eSCIT approach poses no mechanical risk to the fornices and can be utilized irrespective of ventricular size. More vascular control and resultant reduction in uncontrolled hemorrhage improve the feasibility of attaining complete resection, especially around corners (Zaidi et al,, World Neurosurg 84, 2015). Gravity-dependent positioning and cerebrospinal fluid (CSF) diversion aid cerebellar relaxation, creating the ideal anatomical pathway. Also, angle of the straight sinus, tentorium, and tectal adherence can often influence the choice of approach; thus direct endoscopic visualization not only counteracts access to the engorged Galenic complex but also encourages sharp dissection of the arachnoid (Cardia et al., J Neurosurg 104:409-14, 2006). These tactics help provide excellent illumination with magnification, making it less fatiguing for the surgeon (Broggi et al., Neurosurgery 67:159-65, 2010).The purely endoscopic approach thwarts the dreaded risk of air embolisms, via simple copious irrigation from a small burr hole (Shahinian and Ra, J Neurol Surg B Skull Base 74:114-7, 2013). The tiny opening and closure are rapid to create, and the smaller wound decreases postoperative pain and morbidity. Recent literature supports its numerous advantages and favorable outcomes, making it a tough contender to traditional open methods.
松果体病变在所有脑肿瘤中占比不足 1%（Villani 等人，Clin Neurol Neurosurg 109:1-6, 2007）。尽管微创神经外科学已经问世，但由于其位置深在，毗邻关键的神经血管结构，松果体病变的手术治疗仍然是一个挑战。经典的广泛的枕下开颅术和小脑幕上经小脑幕下入路，由 Victor Horsley 爵士（Victor，Proc R Soc Med 3:77-78, 1910）描述，因其极高的手术发病率和死亡率而臭名昭著。后来，Stein 进行了微创神经外科升级，以改善手术结果（Stein，J Neurosurg 35:197-202, 1971）。Ruge 等人首次通过该入路经单纯内镜下四叠体蛛网膜囊肿造瘘（Ruge 等人，Neurosurgery 38:830-7, 1996）。Cardia 等人的一项基于尸体的解剖研究证明了内镜辅助技术的可行性（Cardia 等人，J Neurosurg 2006;104(6 Suppl):409-14）。然而，2008 年 Gore 等人首次采用单纯内镜下小脑幕上经小脑幕下入路（eSCIT）治疗松果体囊肿（Gore PA 等人，Neurosurgery 62:108-9, 2008）。与经脑室内镜手术不同，eSCIT 入路对穹窿无机械风险，并且可以在不考虑脑室大小的情况下使用。更完善的血管控制和由此减少的无法控制的出血提高了实现完全切除的可行性，尤其是在拐角处（Zaidi 等人，World Neurosurg 84, 2015）。重力依赖的定位和脑脊液（CSF）引流有助于小脑松弛，创造理想的解剖路径。此外，直窦、天幕和脑桥附着的角度常常会影响入路的选择；因此，直接内镜可视化不仅可以对抗对充血的 Galenic 复合体的进入，还可以鼓励蛛网膜的锐性解剖（Cardia 等人，J Neurosurg 104:409-14, 2006）。这些策略有助于提供出色的照明和放大效果，减轻外科医生的疲劳感（Broggi 等人，Neurosurgery 67:159-65, 2010）。单纯内镜入路通过从小骨孔简单大量冲洗来阻止可怕的空气栓塞风险（Shahinian 和 Ra，J Neurol Surg B Skull Base 74:114-7, 2013）。微小的开口和闭合可以快速创建，较小的伤口减少了术后疼痛和发病率。最近的文献支持其众多优点和良好的结果，使其成为传统开放方法的有力竞争者。
