Journal of Neuro-Oncology 54: 287–299, 2001.

© 2001 Kluwer Academic Publishers. Printed in the Netherlands.

Surgical approaches to pineal region tumors

Kenneth M. Little1 , Allan H. Friedman1 and Takanori Fukushima1,2

1
Division of Neurosurgery, Duke University Medical Center, Durham; 2 Carolina Neuroscience Institute for
Skull Base Surgery, Raleigh, NC, USA

Key words: germ cell, infratentorial, occipital, pineal region tumors, supracerebellar, surgical approaches,
transtentorial, ventriculoscopy

Summary

Direct surgical resection of pineal region tumors has become safer, more effective, and now plays an essential role
in their management. Tissue diagnosis allows for the initiation of appropriate therapies and resection can be curative
or improve the efficacy of adjuvant therapies. Several approaches have been reported. Based on our operative
experience with 57 patients over a 20-year period, we conclude that the Infratentorial Supracerebellar and Parieto-
Occipital Paramedian Transtentorial approaches provide excellent exposure while allowing minimally invasive,
relatively low risk access to the majority of pineal region tumors. Indications, positioning, techniques, advantages,
and disadvantages are discussed. A review of other approaches, pertinent historical remarks, and a discussion of the
role of surgery in the contemporary management of pineal region tumors are presented.

Introduction interest in direct surgical treatment began to return and

The repertoire of surgical approaches to pineal region
tumors has evolved considerably over the past 100
years with an associated decline in operative mortal-
ity from 100% to less than 4% [1–8]. Victor Horsley
is credited with the first attempt at pineal tumor resec-
tion in 1905 through an infratentorial approach, but the
first success was not reported until almost a decade
later by Krause through an infratentorial supracerebel-
lar approach [9–11]. Some proposed approaches were
more direct, involving incision or block removal of
parietal and occipital cortex producing homonymous
hemianopsia or hemianesthesia [12,13]. Another stan-
dard approach introduced by Dandy involved division
of the posterior corpus callosum leading to a partial
cerebral disconnection syndrome [14,15]. Given the
associated morbidity, operative mortality (as high as
80%), and a lack of evidence demonstrating a therapeu-
tic benefit from resection, many neurosurgeons came to
rely on indirect therapy, consisting of CSF shunting and
radiation [16–20]. With the introduction of approaches
designed to minimize neurologic deficits, the advent
of the operating microscope and new imaging modal-
ities, and the refinement of microsurgical techniques,
the associated major morbidity and mortality has since
fallen to less than 7% [1–8,21–26].
Based on our experience with 57 pineal region tumor
resections over a 20-year period (1980–2000), we con-
clude that the majority of pineal region tumors can be
approached either from the Infratentorial Supracere-
bellar approach or the Parieto-Occipital Paramedian
Transtentorial (POTT) approach with excellent expo-
sure and minimal morbidity. Our purpose is to discuss
our selection of surgical approaches as well as the appli-
cation of less invasive microsurgical techniques.
Preoperative considerations
A variety of surgical approaches to pineal region
tumors have been proposed (Table 1). These
approaches may be divided into anterior and poste-
rior; posterior approaches being further divided into
supratentorial and infratentorial (Figure 1). Based on
a review of the literature, the most frequently utilized
approaches during the past two decades have been
the Occipital Transtentorial (OTT) and Infratentorial
Supracerebellar (ITSC) [1–5,7,8,24–48].
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Table 1. Summary of important surgical approaches to the pineal region divided into
(1) anterior and (2) posterior with posterior being divided into (a) supratentorial,
(b) infratentorial, and (c) combined.
Approach
Anterior neuroendoscopic
Ventriculofiberscope
Posterior-supratentorial
Parietooccipital paramedian transfalcine
Interhemispheric transcallosal
Interhemispheric retrocallosal
Occipital transtentorial
Posterior-infratentorial
Infratentorial supracerebellar
Infratentorial paramedian supracerebellar
Posterior-combined
Combined supra/infra-tentorial transsinus
Major or original contributors are indicated.
Figure 1. Summary of pineal region surgical approaches.
Approaches to pineal region tumors may be divided into ante-
rior (1) and posterior (2–4). Posterior approaches may be fur-
ther sub-divided into supratentorial (2 & 3) and infratentorial (4).
Most pineal region tumors can be accessed through the operative
corridors depicted by 2 (Parietooccipital Paramedian Transtento-
rial with or without Transfalcine extension) or 4 (Infratentorial
Supracerebellar).
In our series of 57 patients, we primarily utilized
the ITSC and POTT (with or without transfalcine
extension) approaches. The OTT and Infratentorial
Paramedian Supracerebellar approaches have also
proven effective under certain circumstances [49,50].
The most appropriate approach to a particular lesion
depends primarily upon (1) the lateral, rostral–caudal,
and anterior–posterior extension of the tumor, (2) the
tumor’s relation to the vein of Galen venous complex,
(3) the suspected histopathology and vascularity of
the lesion, and (4) the surgeon’s experience with each
approach.
Reference
Fukushima [78,79]
Foerster [61,62], Fukushima [78,79]
Dandy [14]
Glasauer [63], McComb et al. [64]
Heppner, Poppen [67], Jamieson [68]
Krause [48], Stein [49]
Yasargil [46]
Sekhar [6,70]
Figure 2. Sagittal view of the pineal region: Pi = pineal gland;
Sp = splenium of corpus callosum; vG = vein of Galen; vR =
basal vein of Rosenthal; ICv = internal cerebral vein; SS = strait
sinus; C = confluence of sinuses; Te = tentorium cerebelli;
Fa = Falx cerebri.
Pineal region anatomy
The pineal gland is a diencephalic structure protrud-
ing from the posterior wall of the third ventricle, sitting
within the quadrigeminal cistern. The pineal region is
defined dorsally by the splenium of the corpus callo-
sum and tela choroidea; ventrally by the quadrigeminal
plate; rostrally by the posterior third ventricle; caudally
by the vermis of the cerebellum; and laterally by the
thalami and the tentorial edges (see Figure 2).
The pineal region contains critical venous struc-
tures that are often intimately related to pineal region
tumors. They must be surgically negotiated and, with

few exceptions, not sacrificed [51]. In this region, the
great cerebral vein of Galen is formed by the union of
the internal cerebral veins, basal veins of Rosenthal,
precentral cerebellar vein, vermian vein, and the inter-
nal occipital veins. The vein of Galen, in turn, drains
into the strait sinus which runs between dural layers
where the tentorium cerebelli joins the falx cerebri
[51,52]. Identifying the tumor’s position in relation to
these anatomic structures by MRI is critical in select-
ing the surgical approach. Pertinent relationships are
the tumor’s position relative to the vein of Galen com-
plex and its extension laterally, caudally along the
quadrigeminal plate into the cerebellomesencephalic
fissure, and rostrally into the third ventricle.
Management of hydrocephalus
Approximately 90% of patients with pineal region
tumors have hydrocephalus at the time of presenta-
tion and cerebrospinal fluid (CSF) dynamics should be
stabilized prior to further treatments [26,37,53,54]. In
our experience, however, most cases of hydrocephalus
resolve after radical pineal region tumor resection.
Patients presenting with non-acute hydrocephalus
are often managed with a ventriculostomy catheter
placed at the time of resection, leaving it in place during
the perioperative period for intensive care patient (ICP)
management. Patients who present with acute obstruc-
tive hydrocephalus undergo emergent ventriculostomy
or, in some cases, ventriculoperitoneal shunt (VPS)
placement. CSF is sent for tumor markers (β-HCG,
AFP) and cytology during the first CSF diverting pro-
cedure. Because there is a risk of peritoneal metastasis
after VPS placement in patients with malignant germ
cell tumors or pineoblastoma, we avoid VPS placement
whenever possible [55–57].
Patients who present with hydrocephalus may be
managed with a third-ventriculostomy combined with
an attempted tumor biopsy via ventriculoscopy through
an anterior burr hole. Though tumor manipulation with-
out subsequent VPS placement may also increase the
risk of CSF spread, tumor dissemination can some-
times be avoided by careful ventricular irrigation via
externalized ventricular drain (EVD) prior to third-
ventriculostomy [54]. Though the recent trend in
neurosurgery is towards the minimally invasive neu-
roendoscopic third-ventriculostomy, we find that poor
long-term efficacy, the uncertain diagnostic yield from
endoscopic biopsy, the risk of CSF tumor dissem-
ination, and the risk of biopsy-related hemorrhage
289
outweigh the potential benefits. Furthermore, most
cases of obstructive hydrocephalus will resolve after
radical resection. In most cases, therefore, we proceed
with radical resection, trying to avoid permanent CSF
diversion.
Surgical approaches
Infratentorial supracerebellar approach
History
In 1911, Fedor Krause suggested the infratentorial,
supracerebellar approach for tumors in the pineal
region and in 1913 this approach was used with the
patient in the sitting position for the first success-
ful pineal region tumor resection [48–50]. The ITSC
approach was refined with microsurgical techniques
and popularized by Stein [24,58].
Indications
The ITSC approach is best indicated for relatively small
to medium size tumors that are confined to the midline
with rostral/caudal extension in the sagittal plane. The
tumor must lie below the vein of Galen complex with-
out inferior extension into the cerebellomesencephalic
fissure or lateral extension beyond the tentorial edges.
Anatomic considerations
This approach allows for minimal brain retraction
because of the natural plane between the cerebellum
and tentorium. The torcular Heropheli and transverse
sinuses are at risk during opening. A few bridging veins
from the midline superior cerebellar surface to the ten-
torium can be safely sacrificed, however, lateral dor-
sal cerebellar bridging veins and, in particular, petrosal
veins must be avoided to minimize the risk of postop-
erative cerebellar venous congestion and swelling. The
vein of Galen system lies dorsally to tumors selected
for this approach, interfering less with tumor resection.
Positioning
Sitting. This position allows for less cerebellar
retracion, decreased venous pressure, and familiar
anatomical orientation [26,49,58]. However, it has been
associated with a higher risk of air embolism, subdu-
ral hematoma, pneumocephalus, and the potential for
decreased brainstem perfusion. Furthermore, the sur-
geon’s arms must remain extended leading to discom-
fort and fatigue.
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Concorde. This position, proposed by Kobayashi
et al., is an alternative to the sitting position that
decreases the risk of air embolism [40]. However,
we have found that the cerebellum must be retracted
against gravity risking contusion. Venous drainage may
be decreased possibly causing elevated intracranial
pressure. To orient the microscope optimally, further-
more, the surgeon must lean sideways at the waist over
the patient. This physically demanding posture can lead
to unnecessary back strain and distraction.
Reverse transsphenoidal. For the past 20 years, we
have been primarily using the reverse transsphenoidal
position , a variation of the Three-quarter Lateral Prone
position (Figure 3). The Mayfield 3-pin headholder is
applied as shown in Figure 3. The left side of the head is
positioned down for right-handed surgeons, right side
down for left-handers. The shoulders are rotated three-
quarters prone with the head rotated nearly prone and
flexed anteriorly. The torso is elevated 30◦ relative to
the floor with the left arm over the top of the bed at
90◦ of shoulder abduction and 90◦ of elbow flexion.
The right arm is supported on an arm-board moder-
ately stretched with 45◦ of anterior extension and 45◦ of
lateral abduction. This position provides comfortable,
efficient surgeon access while allowing the cerebellum
Figure 3. Right-Side-Up Reverse Trans-sphenoidal position for
the ITSC approach. This position is similar to the Three-quarter
Lateral Prone position. Critical positioning details include:
(1) Right shoulder rotated three-quarters prone; (2) Head rotated
nearly completely prone with anterior neck flexion; (3) Torso up
30◦ ; (4) Left arm beyond the top of and below the table with 90◦
of shoulder abduction and 90◦ of elbow flexion; (5) Right arm
moderately stretched with 45◦ of anterior extension and 45◦ lat-
eral abduction supported on an arm board.
to be retracted by gravity. The risks of air embolism
and brain stem hypoperfusion are significantly reduced
compared to the sitting position.
Dissection
A linear skin incision is made beginning 3 cm above
the inion extending to the level of the first cervical ver-
tebra (Figure 4a). Burr holes are made above the trans-
verse sinus, on either side of the superior sagittal sinus
and below the transverse sinus, approximately 5 cm on
either side of the midline. A large bone flap is turned
extending from above the torcular Heropheli and trans-
verse sinuses to the foramen magnum. Extending the
craniotomy above the torcular will allow for a broader
exposure through upward retraction. The dura mater
is opened with an inverse semicircular incision, based
at the transverse sinuses extending the full width of
the craniotomy (Figure 4b). Arachnoid adhesions are
sharply dissected and, as midline bridging veins are
encountered, they are cauterized allowing the cerebel-
lum to fall down from the tentorium with gravity. As
much as possible, lateral bridging veins need to be
preserved to facilitate cerebellar venous drainage. A
2 mm tapered retractor is placed with gentle down-
ward pressure onto the superior vermis and advanced
Figure 4. (A) Skin incision and bone flap for the ITSC approach.
The ITSC approach requires a relatively larger suboccipital osteo-
plastic craniotomy. A linear skin incision is made from 3 to 4 cm
above the inion to the level of the C1 vertebral body. Burr holes
should be made above the transverse sinus on either side of the
superior sagittal sinus and below the transverse sinus medial to
the sigmoid sinuses. The craniotomy should extend from the fora-
men magnum to above the transverse sinus in order to allow
upward retraction of the torcular Heropheli. (B) Dural flap. The
dura mater is opened with an inverse semicircular incision, based
at the transverse sinuses extending the full width of the cran-
iotomy. Relief cuts may be made to allow for maximum upward
retraction. Upward retraction may be used to further elevate the
torcular Heropheli and expand the field of view.

Figure 5. Deep exposure along the ITSC operative corridor. vG =
vein of Galen; vR = basal vein of Rosenthal; PC = precentral
cerebellar vein; Tu = tumor; r = tapered retractor blade; Te =
tentorium cerebelli.
separating the superior cerebellar surface from the ten-
torium along the midline. Once the thick arachnoid
membrane is opened widely to expose the precentral
cerebellar vein and CSF is aspirated, the retractors may
no longer be necessary.
The precentral cerebellar vein will be found within
the arachnoid membrane and can be preserved. How-
ever, in the majority of cases the precentral cerebellar
vein can be coagulated and divided with little conse-
quence. It is essential, however, to preserve the internal
cerebral veins and basal veins of Rosenthal to avoid tha-
lamic venous infarction. The tumor will be found ante-
rior to the precentral cerebellar vein, inferior to the vein
of Galen, and medial to the basal veins of Rosenthal
(Figure 5).
The arachnoid adhesions must be opened widely
to the tentorial edge to gain adequate tumor expo-
sure avoiding damage to critical venous structures.
Ultra-long microinstruments such as those used in
the transsphenoidal approach are necessary to perform
accurate microsurgical dissection in the pineal region.
After the tumor is exposed, tumor tissue is taken for
intraoperative frozen sections and gross-total removal
is performed.
Advantages
This approach provides central access to the mid-
line pineal region from below the vein of Galen and
its tributaries. Once these venous structures are sep-
arated from the tumor, they no longer significantly
obstruct the surgeon’s view of this region. The reversed
transspenoidal position requires only modest cerebellar
291
retraction resulting in minimal morbidity, less risk of
cerebellar swelling, and greater surgeon comfort.
Disadvantages
Because of the tentorium cerebelli, the vein of Galen
system, and the inability to look down at the midbrain,
the ITSC exposure is narrow and deep, providing dif-
ficult access to larger tumors and tumors with lateral
or superior–inferior extension. This approach is con-
traindicated when the tumor extends superiorly above
the apex of the straight sinus, inferiorly into the cere-
bellomesencephalic fissure, or laterally beyond the ten-
torial edge. In cases with dominant midline cerebellar
drainage, ligation of bridging veins still carries the risk
of postoperative cerebellar swelling with obstructive
hydrocephalus or tonsilar herniation [59].
Parietooccipital paramedian transtentorial
approach
History
In 1921, Dandy proposed the posterior transcallosal
exposure of pineal region tumors in humans [14,60].
His exposure was associated with significant morbid-
ity as it involved a large parieto-occipital bone flap,
sacrificing bridging veins, retracting the brain against
gravity, and incising the splenium of the corpus cal-
losum [15]. In 1929, Foerster described his experi-
ence in three patients in whom he exposed the pineal
region and quadrigeminal plate through an interhemi-
spheric approach. His dissection proceeded between
the falx and the occipital lobe dividing the inferior
sagittal sinus and falx cerebri medially and the tento-
rium posteriorally [62]. In 1970, Glasauer reported a
variation of the OTT approach that involved a more
anterior approach along the mesial border of the occipi-
tal lobe [63]. The advantage over the OTT approach was
better access to inferiorly extending tumors while pre-
serving the splenium of the corpus callosum. McComb
et al. described a similar approach; the posterior intra-
hemispheric retrocallosal approach to the third ven-
tricle region [64]. To gain access to the pineal region
while preserving the splenium, the approach is directed
through the tentorial incisura. To expand the exposure,
they suggest tentorial incision, falx incision, and sple-
nial retraction. The POTT described here begins more
anterior than those described by Foerster, Glasauer
and McComb et al. but more posterior than Dandy’s
approach.
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Indications
We recommend this approach for larger tumors or
tumors extending too far beyond the midline to be
managed by the ITSC approach. It is excellent for
tumors with extension inferiorly into the cerebellomes-
encephalic fissure, superiorly above the apex of the
straight sinus, or laterally beyond the tentorial edge.
Also, with posterior extension of the bone flap, the
microscope angle can be changed and access can be
gained to tumors arising from or extending into the
third ventricle.
Anatomic considerations
Though preserving the superior sagittal sinus is a con-
cern, the primary risk early in the dissection is asso-
ciated with negotiating the parasagittal veins. Though
the posterior one-thirds of the superior sagittal sinus
receives few draining veins, veins are likely to be
encountered at the anterior limits of the dissection.
Major draining veins from the occipital lobe often
travel along the mesial superior border of the brain
for some distance prior to entering the sagittal sinus.
This allows the surgeon a corridor to the mesial pari-
etal surface. Sacrificing these veins should be avoided.
The other venous structures to be preserved by the sur-
geon through this approach are the internal cerebral
veins and internal occipital vein. They are likely to be
encountered dorsal to the tumor and should be pre-
served to avoid venous hypertension and hemorrhage.
While preservation of these veins is common wisdom,
there is a lack of definitive evidence supporting this
fear [64]. Should the falx need to be incised to broaden
access to the contralateral quadrigeminal cistern, the
inferior sagittal sinus may be coagulated and divided,
we have encountered no ill effects contributable to its
sacrifice. The splenium of the corpus callosum will be
encountered in the deep, anterior aspects of the expo-
sure. Excessive retraction or incision of this structure
should be avoided to prevent hemialexia [65]. Finally,
the tentorium may be divided to gain better access
to the caudal quadrigeminal cistern; in doing so care
must be taken to preserve the straight and transverse
sinuses.
Positioning
The 3-pin Mayfield headholder is placed as shown in
Figure 6. The head is oriented with the operative side
down and the falx cerebri parallel to the floor in the
anterior–posterior direction. If the tumor is primar-
ily eccentric to the left, the patient is positioned with
Figure 6. Positioning for the POTT approach. Critical position-
ing details include: (1) Operated-side down; (2) Torso in lateral
decubitus position 30◦ to the floor; (3) head flexed laterally to
allow a comfortable microscope viewing angle of 45◦ . An elon-
gated, three-sided skin incision is made over the parieto-occipital
juncion based just over the midline.
the left side in the dependent orientation. If the tumor
has roughly equal lateral extension, the non-dominant
hemisphere is placed in the dependent orientation. The
vertex is tilted up until the falx is at a 45˚ viewing angle
from the surgeon’s perspective. The body is placed in
the supine position if the patient is relatively thin with a
mobile neck and in the lateral decubitus position when
the patient is relatively large with an immobile neck.
This orientation allows for decreased intracranial
venous pressure without significantly increasing the
risk of air embolism. The right cerebral hemisphere
falls away from the falx with gravity, thus minimizing
the need for retraction. This position has the advan-
tages of allowing a comfortable position for the sur-
geon, and allowing the operative cerebral hemisphere
to be retracted away from the falx cerebri by gravity
(facilitated by CSF drainage). Also, with the operative
corridor oriented to allow a neutral microscope view-
ing angle of 45◦ , it is convenient to manipulate the
microscope over a wide range of angles to maximize
the excellent exposure provided by this approach.
Dissection
A three-sided, elongated skin incision is made cen-
tered over the parieto-occipital junction with the medial
aspect just across the midline (Figure 6). Burr holes are
placed on the dependant side of the midline, just lateral
to the superior sagittal sinus, at the anterior and poste-
rior aspects of the proposed flap. Additional burr holes
are place at the inferior corners. A large osteoplastic

bone flap is removed. The dura is opened in a similar
manner and reflected with its base towards the superior
sagittal sinus, taking care to preserve the superficial
cortical veins.
The dependent cerebral hemisphere is dissected
from the falx while taking care to preserve the bridg-
ing veins when possible, particularly at the anterior
extent of the exposure. Bridging veins at risk for avul-
sion are sharply dissected from the arachnoid allowing
safer mobilization of the hemisphere away from the
falx with gravity. Small veins that must be sacrificed
are coagulated and divided. After CSF decompression
through an EVD, lumbar drain, or brian needle and gen-
tle pressure against the mesial aspect of the dependent
hemisphere, 2 mm tapered retractors are placed against
the brain laterally and the falx medially (Figure 7).
After the incisura is reached, greater anterior exposure
may be gained with gentle anterior retraction of the
splenium. Access to the cerebellomesencephalic fis-
sure may be gained by incising the tentorium paral-
lel to the straight sinus. Contralateral access may be
gained by coagulating and dividing the inferior sagittal
sinus and incising the falx. Stay sutures may be placed
to retract the divided falx and tentorium. The tumor
will be visualized beneath the vein of Galen complex.
Extreme care should be taken to preserve these veins.
Figure 7. Deep exposure along the POTT operative corridor. The
parietal (Par) and occipital (Oc) lobes are retracted gently down-
ward with two tapered retractor blades (r). The tentorium cere-
belli (Te) is incised lateral to the strait sinus (SS) to expose the
quadrigeminal cistern. The falx (F) is retracted upward and, if
necessary for contralateral exposure, incised after coagulation of
the inferior sagittal sinus (ISS). The tumor (Tu) is visualized after
gentle anterior retraction of the splenium (Sp) beneath the vein
(vG) of Galen system. ICv = internal cerebral vein; vR = basal
vein of Rosenthal; IOv = internal occipital vein.
293
Long microinstruments should be used to allow effec-
tive microdissection.
Advantages
The primary advantage of this approach over other pos-
terior approaches is that it provides a better view of
the caudal quadrigeminal cistern for tumors extend-
ing inferiorly. Infratentorial approaches would require
extensive cerebellar retraction to gain access into
this region. As with the more posterior supratentorial
approaches discussed above, the splenium is preserved
but may be retracted anteriorly to extend the exposure.
Similar to the posterior interhemispheric approaches,
Dandy’s approach, and Foerster’s approach, the infe-
rior sagittal sinus and falx may be divided to expose
the contralateral cerebellomesencephalic cistern bet-
ter. Furthermore, this approach is less invasive than
the combined supra/infratentorial transsinus approach
described by Sekhar [6].
Disadvantages
This approach places the anterior occipital and poste-
rior parietal bridging veins at risk. In our experience,
however, we have been able to preserve most or all of
these by opening a large craniotomy flap which allows
for small adjustments in the approach. The second dis-
advantage is related to operator experience. The ori-
entation is not as straightforward as with the concorde
position and may require frequent reorientation.
Other approaches
Infratentorial paramedian supracerebellar
approach
A variation on the ITSC approach was described by
Yasargil [46]. In 1990, Van den Berg described this
approach for the resection of pineal region tumors [47].
It is indicated for tumors located below the vein of
Galen complex that project laterally beyond the mar-
gins of the tentorial incisura or inferiorly into the cere-
bellomesencephalic fissures. This approach may be
used when the midline supracerebellar approach will
not allow lateral access beyond the tentorial incisura
or deep into the cerebellomesencephalic fissure, where
access would lead to excessive cerebellar retraction.
At our institution, we have used this approach in
three cases (two pinealoblastomas and one midbrain
exophytic glioma). In general, we find that the lateral
and inferior access offered by this approach can be
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better gained through the POTT approach (with or with-
out division of the falx). Though not reported, the risk
of cerebellar infarction and swelling is theoretically
greater in the infratentorial paramedian supracerebel-
lar approach compared to the midline approach as
anatomic studies suggest that more bridging veins
from the cerebellar surface to the tentorial sinuses
may have to be sacrificed over the lateral superior
cerebellar surfaces [66]. This approach can be help-
ful when the patient has a steep tentorial apex and a
midline approach would require excessive cerebellar
compression.
Occipital transtentorial approach
The OTT approach was described by Heppner in
1959 and popularized by Poppen in 1966 [49,67].
Because Poppen’s variation was technically difficult
and revealed a narrow exposure, the modification pro-
posed by Jamieson in 1971 has become the preferred
version [49,68]. The OTT approach has been utilized
to access pineal region tumors with superior extension
above the incisura, inferior extension into the cerebel-
lomesencephalic fissure, and lateral extension beyond
the medial borders of the tentorium.
Patients are positioned in the concorde position or
in the three-quarters prone position with the dominant
hemisphere down. Though orientation may be easier
to maintain, the concorde position is not recommended
due to its association with decreased venous drainage
and surgeon discomfort [69].
Compared to the ITSC approach, the OTT approach
allows for wider dissection around tumors or vascu-
lar lesions [69]. By incising the tentorium adjacent and
parallel to the strait sinus, access into the quadrigem-
inal cistern is gained without cerebellar retraction.
Because of the orientation of the operative corridor,
this approach also allows a better view of the third
ventricle. The risk of venous infarction is less, as just
above the tentorium, there are less likely to be bridging
veins between the occipital lobe surface and the supe-
rior sagittal sinus.
In our experience, the benefits gained from the OTT
approach are greater with the POTT approach, with-
out a significant increase in morbidity. Though the
OTT approach provides an excellent view into the
third ventricle, it limits the surgeon’s ability to visu-
alize ipsilateral tumor extension, the distance between
the surgeon and the pineal region is increased, and
the surgeon is more likely to be limited by narrow
operative corridors between the veins of the Galenic
system.
Combined supra/infratentorial transsinus
approach
Initially described by Sekhar for the resection of a
pineal region meningioma, this approach has been pro-
posed for the resection of giant pineal region tumors
[6,70]. The indications set forward by Ziyal et al. are
(1) tumors with a large diameter (>4.5 cm), (2) tumors
that extend well above and below the plane of the ten-
torium, (3) tumors that extend well below the plane of
cerebellar retraction, (4) tumors that are very vascular
or that encase important venous structures as they may
need to be approached from many sides.
The primary benefit of this approach is that it pro-
vides the combined access of the ITSC and OTT
approaches. The complications of transverse sinus lig-
ation after intraoperative test occlusion are reportedly
modest but the risk of permanent venous drainage com-
promise remains a considerable concern. Many tumors
that meet the criteria outlined above could be resected
more safely with greater exposure using the POTT
approach.
Posterior interhemispheric trans/retro-callosal
In 1915, Dandy described the posterior transcallosal
exposure of pineal region tumors in canines and in 1921
proposed its use in humans [14,60,71]. From that time
until a decade later, he had seven fatalities before he
succeeded in resecting a pineal region tumor [15]. His
exposure involved a large parieto-occipital bone flap,
sacrificing bridging veins, retracting the brain against
gravity, and incising the splenium of the corpus cal-
losum. The deep veins were not infrequently sacri-
ficed. Although this approach was associated with a
mortality rate of up to 90%, it was preferred by most
neurosurgeons before the introduction of the operating
microscope [24].
Modern microsurgical techniques have been incor-
porated to make this approach safer and more versatile
for accessing pineal region tumors [64]. With modi-
fications including tentorial or falcine incision, better
quadrigeminal cistern exposure is gained. With gentle
retraction of the splenium or a posterior transcallosal
incision, access to the posterior third ventricle can be
gained. McComb et al. provide an excellent discus-
sion of the posterior interhemispheric retrocallosal and

transcallosal approaches in the right lateral decubitus
and three-quarters prone positions [64,72].
Anterior approaches
Pineal region tumors may be approached anteriorly
when there is significant anterior extension into the
third ventricle. These approaches are particularly effec-
tive for tumors arising from within the third ventricle
with extension into the pineal recess and quadrigemi-
nal cistern. The primary approaches are transcallosal–
transchoroidal and transcortical–subchoroidal. The
pineal region or third ventricle should only be accessed
through the transcortical route if ventricular dilatation
is present. With the transcallosal approach, the ven-
tricle is entered medially and the choroidal fissure is
opened above the choroid plexus [73,74]. With this
approach, there is less risk to central venous structures
draining the basal ganglia and internal capsule. With
the transcortical approach, the choroidal fissure should
be entered sub-choroidally to avoid excessive lateral
retraction [75].
One of the major limitations of this approach is
encountered with tumors that extend below the col-
licular plate. The risks associated with this approach
include damage to bridging veins or the superior sagit-
tal sinus, forniceal damage with memory deficits, and
damage to centrally draining veins with basal gan-
glia or internal capsule hypertension. The transcortical
approach carries the additional risk of postoperative
seizures.
Endoscopic management
The appeal of neuroendoscopy is that it may pro-
vide a minimally invasive means of both (1) treat-
ing hydrocephalus and (2) obtaining tissue diagnosis
in patients who may have chemo- or radiosensitive
tumors. Neuroendoscopic procedures initially devel-
oped as an approach to intraventricular lesions, specifi-
cally third ventricular [76,77]. Fukushima first reported
the use of the flexible ventriculofiberscope for pineal
region tumor biopsies [78,79]. This method is less
invasive than with rigid ventriculoscopes because it
is more likely that both the posterior third ventricle
and the floor of the third ventricle can be accessed for
tumor biopsy and third-ventriculostomy, respectively,
through a single anterior burr hole. With rigid scopes,
it is often necessary to enter through two burr holes
(the ‘biportal’ approach); one on the coronal suture
295
for access to the floor of the third ventricle and one
more anterior for access to the posterior third ventri-
cle [54,80]. To minimize CSF dissemination, Oi et al.
suggest irrigation through the coronal burr hole EVD
during and after endoscopic tumor manipulation [54].
After this, the floor of the third ventricle is opened. CSF
should again be obtained for cytology from the EVD
prior to removing it in the postoperative period. Endo-
scopic biopsies may be more accurate than stereotactic
biopsies because of the heterogenatity of pineal region
tumors [80]. It may be possible to obtain a more exten-
sive and representative biopsy after direct visualization
of the tumor’s gross morphology by ventriculoscopy.
Discussion
Historical remarks
Initial attempts at pineal region tumor resection were
frequently met with unsatisfactory results including an
inability to reach the pineal region, limited resections,
and high morbidity and mortality [9–11]. Despite these
frustrations, there were many noteworthy innovations
prior to the era of microneurosurgery that contributed
greatly to contemporary pineal region surgery.
Victor Horsley is credited with attempting the first
surgical resection of a pineal tumor in 1905 [11]. He
used an infratemporal approach and, after an additional
failed attempt in 1909, he recommended a supraten-
torial approach with splitting of the tentorium [9,10].
Other unsuccessful attempts were reported from 1908
to 1911 [11].
In 1910 Ludwig Pussep is reported to have been the
first to successfully reach the pineal region by a direct
surgical approach via an occipital approach in which
he split the transverse sinus and tentorium [11]. His
success was limited as the child died on the third post-
operative day. Regardless of high morbidity and mor-
tality rates, some surgeons persisted and developed less
invasive approaches that were later improved to yield
better results.
An important accomplishment occurred in 1913
when Fedor Krause successfully resected a 4 cm pineal
tumor with good results [11]. With the patient in
the sitting position, the tumor was resected using an
infratentorial–supracerebellar approach. The impor-
tance was that this approach took advantage of a natural
plane between the cerebellum and tentorium without
the need for sacrificing neural structures.
296
In 1915, Dandy described the posterior transcallosal
exposure of pineal region tumors in canines and in 1921
proposed its use in humans [14,60,71]. From that time
until a decade later, Dandy had seven fatalities before
he succeeded in resecting a pineal region tumor [15].
Although this approach was associated with a mortality
rate of up to 90%, it was preferred by most neurosur-
geons before the introduction of the operating micro-
scope [24].
Van Wagenen in 1931 reported a direct trans-
temporoparietal cortex, transventricular approach to
the pineal region [13,81]. The approach relied on dilata-
tion of the right lateral ventricle and left patients with
visual field deficits. In 1937, Horrax reported an occipi-
tal and partial temporoparietal lobectomy for the resec-
tion of a pineal tumor [81]. Extensive cortical resection
was carried out to access a huge pineal region tumor.
These posterior transcortical approaches have been
largely abandoned and are not recommended due to
the concomitant high morbidity and the availability of
safer, more effective approaches.
The OTT approach was initially described by
Heppner in 1959, popularized by Poppen in 1966,
and modified to its most preferred form by Jamieson
in 1971. It is one of the most frequently reported
approaches in recent literature [1–5,27,32].
The most formidable obstacles to pineal region
approaches at the beginning of the 20th century were
the lack of an operating microscope and a limited
understanding of the surrounding anatomy, particularly
critical deep venous structures that were often sacri-
ficed. Prior to microneurosurgery, the high operative
morbidity and mortality led most neurosurgeons to pur-
sue more conservative therapy consisting of CSF shunt-
ing and radiation therapy [16–18,20]. After the advent
of microneurosurgery, CT, and MRI, interest in direct
surgical treatment began to return [21–26,38].
The role of surgery in the management of
pineal region tumors
Pineal region tumors are challenging to treat because
they consist of a broad spectrum of histopathalogy
and are intimately related to critical neurovascular
structures; the indications for and timing of direct
surgical resection remain subjects of debate. Direct sur-
gical resection can provide (1) tissue diagnosis with
a greater diagnostic yield than stereotactic biopsy,
(2) a cure with benign lesions such as meningioma
and benign teratoma, (3) cytoreduction to improve the
efficacy of chemotherapy and radiation therapy, and
(4) the relief of mass effect and, potentially, obstructive
hydrocephalus [53].
Tissue diagnosis. Histopathology is the most reliable
prognostic factor and it guides the type and extent
of adjuvant therapy [83–87]. Germinomas, for exam-
ple, are extremely radiosensitive yet their course is
unaffected by resection whereas benign teratomas and
meningiomas are curable with radical resection alone
and are poorly responsive to chemotherapy or radi-
ation. Pineal region low-grade gliomas, furthermore,
are best treated with radical resection alone whereas
patients with high-grade gliomas should be treated with
chemotherapy and radiation after resection.
Radical resection versus stereotactic and neuroen-
doscopic biopsy. Compared to ventriculoscopic or
stereotactic biopsy, open radical resection offers
several benefits. For non-germinomatous germ cell
tumors, an increase in survival is correlated with the
extent of resection [87]. Furthermore, cytoreduction
enhances the efficacy of adjuvant therapis, especially
in the case of malignant germ cell tumors [84]. Addi-
tionally, open resection may relieve aqueductal steno-
sis and obstructive hydrocephalus.
Mortality rates between open resection and stereo-
tactic biopsy are comparable. Regis et al. in a review
of 370 cases of pineal region tumor biopsies, reported
an overall mortality of 1.3%, morbidity of 0.8%, and
diagnostic yield of 94% [88]. Thus, a sub-optimal diag-
nostic rate with no possible benefit of gross-total resec-
tion or cytoreduction are achieved in the context of a
mortality rate comparable to open resection. Stereo-
tactic biopsy may not adequately sample tumors of
mixed-germ-cell histopathology, leading to diagnostic
errors and possibly suboptimal treatment. Furthermore,
some of the patients undergoing stereotactic biopsy
may require open resection based on biopsy results,
placing them at the additional risk associated with a
second surgery. In our practice, we first perform a ven-
ticuloscopic biopsy if there is concomitant obstruc-
tive hydrocephalus, allowing for concurrent third-
ventriculostomy. Stereotactic biopsy is performed if
the tumor has strong radiographic and tumor marker
(serum and/or CSF) evidence of germinoma. In addi-
tion, we avoid open resection in patients with evidence
of multifocal or disseminated disease at presentation.
Timing of surgery. Because of the importance of
obtaining a tissue diagnosis, direct surgical resec-
tion, endoscopic biopsy, or stereotactic biopsy are

recommended by many authors as an initial step in
the management of pineal region tumors. On the other
hand, others recommend test-dose radiation, with sur-
gical resection only if the tumor does not respond
[89,90]. The rationale for test-dose radiation is that
71.2% and 80% of pineal region tumors are germ cell
tumors in Japan and Korea, respectively. In Western
countries, on the other hand, 51% are germ cell tumors
and 42.9% are neuroectodermal in origin [89,90]. The
relatively higher incidence of radiosensitive tumors in
the Japanese and Korean populations has justified the
empiric radiation of pineal region tumors reported by
many Japanese neurosurgeons [91]. Among Japanese
neurosurgeons, however, this approach is not universal
and the debate persists [85,92].
Germinomas and gliomas have similar incidences
in North America and Europe, making early tissue
diagnosis critical in determining the optimum man-
agement. Radical surgery with tissue biopsy is there-
fore the currently accepted initial management step
[34,89,90,93,94]. Some authors have advocated tailor-
ing the initial treatment, test radiation versus radical
surgery with tissue diagnosis, to the relative incidences
of radiosensitive tumors within the patient population
being treated [80,90].
Summary
It is clear that direct surgical resection has an essen-
tial role in the management of pineal region tumors.
Because pineal region tumors consist of a broad spec-
trum of histopathology portending different prognoses
and requiring different adjuvant therapies, the impor-
tance of tissue diagnosis is recognized. Direct sur-
gical resection not only provides this benefit when
a less invasive ventriculoscopic biopsy is not possi-
ble, but it allows radical resection with the potential
for a cure and, at least, subtotal resection is associ-
ated with an improved response to adjuvant therapies.
With advances in minimally invasive, microsurgical
techniques these benefits can be gained with minimal
morbidity.
To achieve a maximum resection and minimize com-
plications, choosing the appropriate surgical approach
to pineal region tumors should be based on achieving
the most complete, minimally invasive exposure. In
our experience with 57 operative cases, the two most
effective have been the Infratentorial-Supracerebellar
and POTT (with or without transfalcine extension)
approaches as described.
297
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Address for offprints: Takanori Fukushima, Professor of
Neurosurgery, Duke University Medical Center, Director,
Carolina Neuroscience Institute for Skull Base Surgery, Gallery
Park, 4030 Wake Forest Road, Suite 115, Raliegh, NC 27609,
USA; Tel.: (919) 239–0264; Fax: (919) 239–0266; E-mail:
fukshima@carolinaneuroscience.com