Journal of Neuro-Oncology 54: 263275, 2001.

2001 Kluwer Academic Publishers. Printed in the Netherlands.

Pineal region tumor: surgical anatomy and approach

Isao Yamamoto
Department of Neurosurgery, Yokohama City University School of Medicine, Yokohama, Japan

Key words: microsurgical anatomy, pineal region, pineal tumor, surgical approach, third ventricle
Summary
The pineal region is one of the surgically inaccessible areas in the brain. Many neurovascular structures form a
formidable obstacle to the operative approach to this region. The approaches suitable for reaching the pineal region
are the infratentorial supracerebellar, occipital transtentorial, posterior transcallosal, posterior transcortical and
posterior subtemporal routes. Considerations important in selecting one of these surgical approaches are reviewed
from the anatomical viewpoint.

For neurosurgeons, the pineal region tumor is one of the

difficult ones to expose and remove. The approaches
suitable for reaching the pineal region are infratentorial supracerebellar, occipital transtentorial, posterior transcallosal, posterior transcortical and posterior
subtemporal (Figure 1). Horsely [1] was the first surgeon to do a direct surgery for the pineal region tumor
through the posterior fossa. Krause [2] in 1926 successfully operated on a tumor of the pineal region
through the infratentorial supracerebellar approach and
Stein [3] then modified this approach with the modern
microsurgical techniques. The occipital transtentorial
approach was first advocated by Brunner [4] and then
Poppen [5] and Jamieson [6] developed and in 1974
Lazar and Clark [7] reported their experiences using
this approach with six cases of pineal region tumor.
The posterior interhemispheric transcallosal approach
was originally described by Dandy [8] in 1921. Then
Horrax [9], Kunicki [10], Araki [11] and Suzuki and
Iwabuchi [12] fostered this approach. Van Wagenen
[13] used posterior transcortical approach through the
dilated ventricle. Sekhar and Goel in 1992 reported the
combined supra/infratentorial-transsinus approach for
the resection of certain large pineal region tumors [14].
Microsurgical anatomy
Selecting an operative approach to the pineal region
tumor involving the third ventricle requires an

E
A

Figure 1. Various surgical approaches to the pineal region:

(A) infratentorial supracerebellar, (B) occipital transtentorial,
(C) posterior transcallosal, (D) posterior transcortical and
(E) posterior subtemporal approaches.

understanding of the microsurgical anatomy of the

posterior third ventricle. The posterior third ventricle
is composed of the roof, floor, posterior wall and both
lateral walls (Figure 2) [15].

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Corp. Call.
Sept. Pel.
Int. Cer. V.
Med. Post. Ch. A.

Fornix

Thalamus

F. Monro
Ant. Comm.

Lam. Ter.
O. Recess

Midbrain

Suprapineal Recess
Pineal
Pineal Recess
Post. Comm.
Aqueduct

O. Ch.
Hypothal. Sulc.
Infund. Recess
Infund.

Post. Perf. Subst.

III
Pons

Pit. Grand

Mam. B.

Tubrer. Cin.
Hypothal.

Figure 2. Midsagittal section of the third ventricle. The roof extends from the foramen of Monro (F. Monro) to the suprapineal recess
and is formed by the fornix and the layers of tela choroidea between which course the internal cerebral vein (Int. Cer. V.) and the
medial posterior choroidal artery (Med. Post. Ch. A.). The hippocampal commissure, the corpus callosum (Corp. Call.) and the septum
pellucidum (Sept. Pel.) are above the roof. The anterior wall extends from the optic chiasm (O. Ch.) to the foramen of Monro and includes
the upper surface of the optic chiasm, the optic recess (O. Recess), the lamina terminalis (Lam. Ter.), the anterior commissure (Ant.
Comm.) and the foramen of Monro. The floor extends from the optic chiasm to the aqueduct and includes the lower surface of the optic
chiasm, the infundibulum (Infund.), the infundibular recess (Infund. Recess), the pituitary gland (Pit. Grand), the tuber cinereum (Tuber
Cin.), the mamillary body (Mam. B.), the posterior perforated substance (Post. Perf. Subst.) and the midbrain. The posterior wall extends
from the suprapineal recess to the aqueduct and includes the habenulla commissure, the pineal body (Pineal), the pineal recess and the
posterior commissure (Post. Comm.). The lateral wall is formed by the thalamus superiorly and the hypothalamus (Hypothal.) inferiorly.
The hypothalamic sulcus (Hypothal. Sulc.) forms a groove between the thalamus and the hypothalamus. (From Yamamoto I, Rhoton AL,
Peace DA: Microsurgery of the third ventricle: Part 1, Microsurgical anatomy. Neurosurgery 8: 334356, 1981.)

Roof
The roof of the third ventricle extends from the foramen of Monro anteriorly to the suprapineal recess
posteriorly and has four layers: upper neural layer
formed by the fornix, two membranous layers formed
by the tela choroidea and a vascular layer, which consists of the medial posterior choroidal arteries and their
branches and the internal cerebral veins and their tributaries, between the space formed by the sheets of tela
choroidea called velum interpositum cistern (Figures 2
and 3). The fornix is composed of a column, a body and
a crus. Both crura are interconnected by a sheet of white
matter called the hippocampal commissure (Figure 3).
The lateral margin of the roof is formed by the narrow

cleft between the fornix and the thalamus, that is called

the choroidal fissure (Figure 3).
Floor
The floor extends from the optic chiasm anteriorly to
the cerebral aqueduct posteriorly and the posterior half
of the floor is formed by the midbrain, which extends
from posterior and superior to the medial part of the
cerebral peduncles and superior to the tegmentum of
the midbrain (Figure 2). The mamillary body is an only
prominence on the inner surface of the floor and the
posterior part of the floor of the third ventricle posterior to the mamillary bodies is a smooth and concave
surface from side to side (Figure 4).

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(B)

(A)

(C)

Figure 3. The inferior view of the roof of the third ventricle. (A) The cerebral hemispheres below the roof of the third ventricle have
been removed to provide the inferior view of the roof. The internal cerebral vein (Int. Cer. V.) and the medial posterior choroidal
artery (Med. Post. Ch. A.) course below the fornix and two halves of the thalamus. (B) The medial edges of the thalamus have been
removed to provide a wider view of the roof. The internal cerebral veins pass posteriorly above the pineal body (Pineal) and join
to form the great vein of Galen (V. Galen). The choroidal fissure (Chor Fiss.) is a cleft between the fornix and the thalamus. (C)
The choroidal fissure on each side has been removed to expose the neural layer of the roof. The lateral ventricle (Lat. Vent.) is seen
through the enlarged choroidal fissure. The hippocampal commissure (Hippo. Comm.) interconnects the medial margins of the crura
of the fornix above the pineal gland. Anterior commissure (Ant. Comm.), foramen of Monro (F. Monro), choroidal plexus (Ch. Pl.),
habenular commissure (Hab. Comm.), superior choroidal vein (Sup. Ch. V.), lateral posterior choroidal artery (Lat. Post. Ch. A.) (From
Yamamoto I, Rhoton AL, Peace DA: Microsurgical of the third ventircle: Part 1, Microsurgical anatomy. Neurosurgery 8: 334356,
1981.)

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Figure 4. The anterior part of the cerebral hemispheres have been

removed and the median raphe of the fornix have been opened
to expose the full length of the floor of the third ventricle. The
floor extends from the optic chiasm (O. Ch.) to the aqueduct. The
mamillary body (Mam. B.) is an only prominence of the inner
surface of the floor. The habenular commissure (Hab. Comm.)
forms the upper margin of the stalk of the pineal body (Pineal)
and the posterior commissure (Post. Comm.) forms the lower
stalk of the pineal body. The pineal recess is between the two
commissures. Choroidal plexus (Ch. Pl.), superior choroidal vein
(Sup. Ch. V.), medial posterior choroidal artery (Med. Post. Ch.
A.), foramen of Monro (F. Monro), anterior commissure (Ant.
Comm.), infundibular recess (Infund. Recess), optic tract (O. Tr.),
optic nerve (O. N.) stria medullaris (Str. Med.), caudate nucleus
(Caudate Nucl.) (From Yamamoto I, Rhoton AL, Peace DA:
Microsurgery of the third ventricle: Part 1, Microsurgical anatomy
8: 334356, 1998.)

Posterior wall
The posterior wall within the third ventricle extends
from the suprapineal recess above to the cerebral aqueduct below and consists of suprapineal recess, the
habenular commissure, the pineal body and its recess,
the posterior commisure and the cerebral aqueduct
(Figures 2, 4 and 5). The only structure in the posterior wall in the quadrigeminal cistern is a pineal
body and is concealed by the splenium above, thalamus
Laterally and the quadrigeminal plate and the vermis
below (Figures 2 and 6).

Figure 5. The anterosuperior view of the posterior wall of the

third ventricle after removal of the upper part of the cerebral hemispheres, thalamus and corpus callosum. The suprapineal recess
is above the habenular commissure (Hab. Comm.) and the pineal
recess extends into the stalk of the pineal body (Pineal) above
the posterior commissure (Post. Comm.) and the aqueduct. Lateral ventricle (Lat. Vent.), choroidal fissure (Ch. Fiss.), massa
intermedia (Massa Int.), infundibular recess (Infund. Reccess),
septum pellucidum (Sept. Pel.). (From Yamamoto I, Rhoton AL,
Peace DA: Microsurgery of the third ventricle: Part 1, Microsurgical anatomy. Neurosurgery 8: 334356, 1981.)

Lateral wall
The lateral walls of the third ventricle are formed by the
thalamus superiorly and the hypothalamus inferiorly
(Figures 2 and 7). The habenulae are small eminences
on the dorsomedial surface of the thalamus just in front
of the pineal body. The habenulae are connected across
the midline in the rostral stalk of the pineal body by the
habenular commissure. The massa intermedia connects
the opposing surfaces of the thalamus and is present
in 76% (15).
Operative approach
Among various surgical approaches for the pineal
region tumors, the posterior transcallosal, posterior

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Figure 6. The posterior view of the pineal region after removal of the posterior cerebral hemispheres. The third ventricle (3V) has been
opened above the pineal body (Pineal) by removing the tela choroidea in the roof. Corpus callosum (Corp. Call.), lateral ventricle (Lat.
Vent.), caudate nucleus (Caudate Nucl.), superior choroidal vein (Sup. Ch. V.), pulvinar (Pulv.), choroidal plexus (Ch. Pl.), superior
colliculus (Sup. Coll.), inferior colliculus (Inf. Coll.), posterior cerebral artery (P. C. A.) superior cerebellar artery (S. C. A.). (From
Yamamoto I, Rhoton AL, Pease DA: Microsurgery of the third ventricle: Part I, Microsurgical anatomy. 8: 334356, 1981.)

transcortical and posterior subtemporal approaches are

rarely used because of the adverse effects of dividing
the corpus callosum, incising the parietal cortex and the
retracting the temporal lobe. Therefore, the infratentorial supracerebellar approach and the occipital transtentorial approach are now commonly used.
Infratentorial supracerebellar approach
The infratentorial supracerebellar approach is essentially a midline posterior approach to the pineal region
and has several advantages (Table 1) [16,17]. The main
advantage is that this approach is essentially extra-axial
route to the third ventricle and the pineal region is
located underneath the major deep veins, which diminishes the chance for important neurovascular compromise. However, the disadvantage of this approach is a
narrow operative field because of the presence of the
tentorium, which produces restricted visualization at
both lateral and superior corners [18,19]. Therefore,
this approach should not be used when the tumor is
large and extends dorsally above the tentoriaum and/or
extends laterally into the trigone of the lateral ventricle.

Fortunately, most of the pineal region tumors are of

modest size and are located infratentorially. For these
reasons, I prefer this approach in most of the cases of
pineal region tumors.
There are several positions that can be used for
this approach, that is, sitting [16], three-quarter prone
[20], lateral decubitus and Concorde positions [21].
The advantage of sitting position is that a gravity
provides cerebellum falling away from the tentorium
and minimizes venous pressure, which causes less
bleeding. However, its disadvantages include the risk
of air embolism and the discomfort to the surgeon who
must operate with his arms extended and neck hyperextended to see above the tentorium. The advantage
of Concorde position is the lower risk of air embolism
and tension pneumocephalus [21], but negates the
advantages of gravity-assisted retractors and hemostasis. The indispensable diagnostic procedure to adopt
this approach in sitting position is the evaluation of
the preoperative sagittal MRI analysis of the angle
of the straight sinus [22]. The tumor is easily exposed
in the cases of low-angle (Figure 8A) and common
types (Figure 8B), but the operative field is restricted

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Figure 7. Midsagittal section of the third ventricle to expose the relationship of the internal cerebral vein (Int. Cer. V.), the great vein
of Galen (V. Galen), the basal vein (Basal V.), the medial posterior choroidal artery, splenial artery (Spl. A.). The lateral wall is formed
by the thalamus superiorly and the hypothalamus inferiorly. Corpus callosum (Corp. Call.), septum pellicudum (Sept. Pel.), pericallosal
artery (Pericall. A.), choroidal plexus (Ch. Pl.), superior colliculus (Sup. Coll.), inferior colliculus (Inf. Coll.), thalamoperforating artery
(Th. Pe. A.), foramen of Monro (F. Monro), massa intermedia (Massa Int.), anterior commissure (Ant. Comm.), lamina terminalis (Lam.
Ter.), anterior cerebral artery (A. C. A.), optic chiasm (O. Ch.), optic nerve (O. N.), carotid artery (C. A.), posterior communicating artery
(P. Co. A.). (From Yamamoto I, Rhoton AL, Peain DA: Microsurgery of the third ventricle: Part 1, Microsurgical anatomy. Neurosurgery
8: 334356, 1981.)
Table 1. Advantages and disadvantages of the infratentorial
supracerebellar approach
Advantages
1. Basically midline and easy orientation
2. Extra-axial to the IIIrd ventricle
3. Beneath the deep venous system
4. Minimal damage to delicate nervous structures
5. No morbidity related to parietal or occipital lobe
Disadvantages
1. Narrow operative field
2. May sacrifice lateral bridging vein and/or precentral
cerebellar vein
3. May split upper vermis
4. Poor visualization of supratentorial structures
5. Difficult to reach paremedian lesions in the IIIrd ventricle
6. Inadequate view of the posterior floor of the IIIrd ventricle

by the steeply inclined tentorium in the case of the

high-angle type (Figure 8C), in that case the occipital
transtentorial or three-quarter prone position would be
more suitable.

The craniotomy or craniectomy should extend just

over the transverse sinus and include the torcular
region so that the view is not obscured by overhanging
bone. Once the dura is opened, many bridging veins
between the tentorium and the superior surface of the
cerebellum, including some of the hemispheric and vermian veins, and the vein of the cerebellomesencephalic
fissure, can be sacrificed without any adverse effect
in order to open the quadrigeminal region (Figure 9)
[23]. However, a cerebellar swelling following the sacrifice of the lateral bridging veins have been reported by
Page [24]. Therefore, I try to preserve lateral bridging
veins as much as possible. The arachnoid membrane
over the quadrigeminal cistern is usually thickened
and opaque in the presence of tumors and is opened
by microdissection techniques to expose the precentral cerebellar vein. The precentral cerebellar vein may
be sacrificed with impunity to further exposure of the
pineal region [16]. However, in rare cases, the vein of
the cerebellomesencephalic fissure or the superior and

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(A)

(B)

(C)

Figure 8. Three types of variations of the spatial relationship between the straight sinus and the corpus callosum in midsagittal MRI:
(A) low-angle type, (B) common type and (C) high-angle type.

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Figure 9. Bridging veins between cerebellum and overlying tentorial surface are located medially as well as laterally.

inferior quadrigeminal veins are so well developed that

the tumor cannot be approached directly from behind.
In that case, the tumor should be approached slightly
obliquely between these veins and the basal vein [25].
One of the important things to appreciate the deep
venous structures, such as great vein of Galen, internal
cerebral veins and the basal vein, is to open the thick
arachnoid widely at the initial maneuvers. Once the
arachnoid is dissected from these veins, the relationship between the tumor and deep venous structures is
identified (Figure 10). As the great vein of Galen and
the internal cerebral veins in the germ cell tumor and
teratoma are usually well above the tumor, the tumor
capsule is dissected free from the surrounding structures. If a meningioma is arising at the falacotentorial
junction, these deep cerebral veins are displaced anteriorly and lie on the anterior surface of the tumor. If a
glioma is arising from the quadrigeminal plate, these
vessels are displaced superiorly. What is done at this
point depends upon the patients pathology. If the tumor
is a glioma, a modest decompression should be done.
If the tumor is a benign pineal tumor, a total removal
is the goal. Some small and well-encapsulated tumor
can be removed without internal decompression. If the
tumor is large in size, the capsule is opened and the

tumor is debulked with suction, ultrasonic aspirator and

laser so on. After internal decompression, the superior
and lateral margins of the tumor can be dissected from
surrounding velum interpositum, pulvinar and walls of
the third ventricle. Removal of the inferior portion of
the tumor is the most difficult since it is often adherent
to the colliculi. After completion of the tumor removal,
the cavity of the third ventricle is visualized with normal neural structure such as foramen of Monro and
cerebral aqueduct with the aid of endoscope or dental mirror. In sitting position, meticulous hemostasis is
very impornat, but hemostatic agent such as Surgicel
should be placed carefully so that it does not float and
obstruct the aqueduct when the third ventricle fills with
CSF [26].
Occipital transtentorial approach
The main advantage of occipital transtentorial
approach over the infratentorial supracerebellar
approach is more extensive view of the entire pineal
region (Table 2) [17,19,27,29]. There is significant
variation in the size of the tentorial notch [19,28]. The
transection and reflection of the tentorium provides
an excellent view of the pineal region both above and

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Figure 10. Infratentorial supracerebellar view into the pineal region. The precentral cerebellar vein (Pre. Cent. Cereb. V.) has been divided.
The internal occipital (Int. Occ. V.), basal vein (Bas. V.) and pineal veins (Pineal V.) drain into the great vein of Galen (V. Galen). The
vermis is retracted downward to expose the superior (Sup. Cill.) and inferior colliculi (Inf. Coll.). The posterior cerebral (P. C. A.) and
medial posterior choroidal arteries (Med. Post. Ch. A.) are lateral to the pineal gland (Pineal). Tentorium (Tent.), occipital lobe (Occ.
Lobe). Tentorium (Tent.) (From Yamamoto I, Rhoton AL, Peace DA: Microsurgery of the third ventricle: Part 1, Microsurgical anatomy.
Neurosurgery 8: 334356, 1981.)
Table 2. Advantages and disadvantages of the occipital transtentorial approach
Advantages
1. Wide operative field
2. No veins crossing from occipital lobe into superior sagittal
sinus
3. Easy visualization of deep venous structure
4. Largely extra-axial above the tentorium
5. Good visualization of ipsilateral dorsal and lateral extension
of the midbrain
Disadvantages
1. Risk of damage to occipital lobe or internal occipital vein
2. Risk of damage to deep venous structure
3. Variation in anatomy of the tentorial notch
4. Poor visualization of contralateral half of quadrigeminal
region and ipsilateral thalamus
5. May need to split splenium

below the tentorial opening. As there are infrequently

bridging veins between the medial occipital pole
and the transverse, straight and sagittal sinuses, the
occipital pole can be retracted superolaterally without

sacrificing these medial bridging veins [29]. However,

the inferior cerebral vein, which drains from occipital
lobe into the transverse sinus, should be preserved,
because its interruption may produce infarction and
edema of the occipital lobe [7,30]. The disadvantage of
this approach is a poor visualization of the contralateral quadrigeminal region and ipsilateral pulvinar in
the posterior third ventricle. Therefore, this approach
is suitable for approaching tumors in the pineal region,
especially those centered at the tentorial edge or above
and if there is no major extension to the opposite
side [27].
This approach was traditionally performed with the
patient in the sitting position with the attendant risk
of air embolism and a high frequency of the postoperative visual field defect [6]. An alternative to the sitting poisiton is prone, Concorde, three-quarter prone or
park bench position. The advantages of three-quarter
prone position are the less risk of air embolism and the
reduced retraction of the occipital lobe [20]. Therefore,
I prefer three-quarter prone position.

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One of the important points at the craniotomy is that
the transverse and sagittal sinuses must be visualized
through their extent in the operative field by rongeur
or airdrill. After opening the dura, the occipital lobe is
exposed. The inferior cerebral vein may occasionally
be seen at the lateral inferior edge of the craniotomy
(Figure 11). It is necessary to take care to preserve this
vein to prevent the occipital lobe infarction [30]. The
important point here is to avoid excess retraction to
the medial occipital lobe and to preserve the internal
occipital vein. Therefore, the retractor should be placed
on the inferior surface of the occipital lobe rather than
on the calcaline fissure. If three-quarter prone position
is used, it is easy to retract the occipital lobe without excess retraction pressure, because the gravity falls
the occipital lobe away spontaneously. The internal
occipital vein usually across from the quadrigeminal
cistern to the anteromedial surface of the occipital
lobe and sacrificing this vein may cause hemianopsia
[31]. However, in my personal experience, an excessive
occipital lobe retraction takes more part in the cause
of postoperative visual field defect than the transection of the internal occipital vein. The retractor is then
advanced until it reaches the tentorial free edge and

the tentorium is incised to expose the superior cerebellar surface along a line parallel and 11.5 cm lateral
to the straight sinus from a point anterior to the transverse sinus to the tentorial free edge, and then the lateral flap is reflected laterally. The dense arachnoid over
the quadrigeminal cistern is opened. One of the disadvantages of this approaches is that the great vein of
Galen and its tributaries often obstruct the approach to
the pineal region (Figure 12) [27]. To gain more access
to the pineal region, it is necessary to dissect the deep
venous system far laterally as well as the lower portion
of the splenium. Fortunately, the splenium is usually
elevated and thinned by the tumor and therefore can
be spared. This exposure provides sometimes an inadequate view of the contralateral half of the quadrigeminal plate and an ipsilateral lateral wall of the third
ventricle. Pineal region tumor may extend inferiorly
down under the vermis. If this is the case, the vermis
is divided to expose the lower pole of the tumor. The
surgeon should be aware that the division of the upper
vermis produces little in the way of neurological deficit
[29], but the sacrifice of the splenium may produce a
disconnection syndrome [17]. The tumor is removed
according to the principles outlined previously.

Figure 11. The inferior cerebral vein (arrow) is between the inferior surface of the lateral occipital lobe and the tentorium of transverse
sinus.

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Table 3. Advantages and disadvantages of the posterior transcallosal approach
Advantages
1. Irrevelant to ventricular size
2. Largely extra-axial above tentorium
3. No disruption of hemispheric tissue
4. Shorter transit to the diencephalic roof
5. Ability to develop exposure of the entire IIIrd ventricular
cavity
Disadvantages
1. Damage of parietal bridging veins
2. Excessive parietal lobe retraction
3. Poor landmark identification
4. Split corpus callosum
5. Risk of damage to deep venous structures
6. Poor visualization of the pineal and quadrigeminal regions

Figure 12. Occipital transtentorial view into the pineal region.

The right half of the tentorium (Tent.) has been divided. The
cerebellum is retracted inferiorly. The occipital lobe (Occ. Lobe)
is retracted laterally to expose the splenium and to show the
relationship of the great vein of Galen (V. Galen) and its tributaries, including the internal cerebral (Int. Cer. V.), internal occipital (Int. Occ. V.) and the basal veins (Bas. V.). Straight sinus
(Str. Sinus), posterior cerebral artery (P. C. A.), medial posterior
choroidal artery (Med. Post. Ch. V.), superior cerebellar artery
(S. C. A.), superior (Sup. Coll.) and inferior colliculi (Inf. Coll.).
(From Yamamoto I, Rhoton AL, Peace DA: Microsurgery of the
third ventricle: Part 1, Microsurgical anatomy. Neurosurgery 8:
334356, 1981.)

Posterior transcallosal approach

The main advantage of the posterior transcallosal
approach is that the pineal region can be reached with
an irrelevant to the ventricular size as well as without a sacrifice of any important neurovascular structures besides the corpus callosum (Table 3) [17,32].
The opening of the tentorium provides the exposure to
the superior portion of the quadrigeminal region. This
approach is the shortest access to the pinral region.
However, as the galenic system and its tributaries are
encountered before the pathological structures [32].
Although a number of options in positioning are
possible in the posterior transcallosal approach, a
lateral decubitus or three-quarter prone position are
commonly used [32]. These positions provide gravity

retraction of the inferior hemisphere to assist in the

development of the parafalcine corridor. At craniotomy, the medial bone flap over the midline is desirable to expose the sagittal sinus, but the anterior flap
never reaches as far anteriorly as motor strip [33].
The dura is then reflected towards the sagittal sinus.
Although there are at times some parasagittal bridging
veins at the posterior one-third of the sagittal sinus, we
can usually go safely to the corpus callosum between
the parasagittal bridging veins and thus preserve them.
However, it is known that the division of these veins
does not significantly compromise venous drainage in
this portion of the hemisphere [32]. The parietal lobe is
gently retracted away from the falx to expose the corpus callosum. It is generally not necessary to expose
the splenium, but if necessary, either falx, tentorium
or both may be divided to gain a wide exposure of the
pineal region. After the division of the arachnoid over
the corpus callosum, the distal anterior cerebral artery
as well as the splenial branches of the posterior cerebral
artery are identified. The majority of tumors involving
the pineal region can be managed without incising the
splenium. In the case of most pineal region tumors, the
corpus callosum and the fornix become thin, and it is
relatively easy to incise the posterior part of the body
of the corpus callosum and the hippocampal commissure to reach the third ventricular cavity. During the
callosal incision, care should be taken not to divide the
splenium to prevent postoperative disconnection syndrome [33]. If the splenial section is necessary, the left
occipital region should be protected, because this carries the risk of producing an alexia without agraphia
or a right homonymous hemianopsia [32]. As in the
most pineal region tumors, the internal cerebral veins

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are situated over the tumor, and the tumor removal can
be accomplished around these veins with a variety of
microsurgical techniques. The quadrigeminal plate and
the brainstem are not well visualized in this approach
until the tumor has been removed. Therefore, the brainstem function should be carefully monitored during the
operation [33].
From these characteristics of this approach, the posterior transcallosal approach is best suited for the pineal
region tumor that appears to arise in the corpus callosum above the vein of Galen and extend into the posterior third ventricle [27].

alternative to reach the third ventricular cavity is the

incision of the thin medial wall of the lateral ventricle formed by the body and the crus of the fornix. The
internal cerebral vein, the great vein of Galen and the
medial posterior choroidal artery and its branches usually block the exposure of the quadrigeminal region.
This approach is essentially a lateral approach with a
high morbidity resulting from the cortical incision and
does not provide satisfactory exposure of the typical
midline pineal region tumor [27].
Combined supra/infratentorial-transsinus
approach to large pineal region tumors

Posterior transcortical approach

The posterior transcortical approach is only indicated
when the ventricle is dilated (Table 4) [17,27]. This
approach was first performed by Van Wagenen [13]
through an extensive parieto-temporal cortical incision.
The main disadvantages of this approach are too lateral
and too much damage of the cortex [18]. Therefore, the
other preferable approach in the posterior transcortical
approach is through the superior parietal lobule [27].
This high parietal transcortical approach is preferred
because the cortical incision avoids the visual pathway
and speech area.
This approach is usually performed with the patient
in the prone position [34]. After craniotomy of a high
parietal flap, the cortical incision is made coronally
behind the postcentral gyrus. The main advantage of
this approach is an easy identification of the junction
of the body and atrium of the lateral ventricle (Table 4)
[17]. The taenia fornicis at the trigone is opened to
expose the upper membranous layer of the roof of the
third ventricle by way of the choroidal fissure. Another
Table 4. Advantages and disadvantages of the posterior
transcortical approach
Advantages
1. Preservation of visual and speech pathways
2. Ease of landmark identification
3. Good visualization of the contralateral IIIrd ventricular
cavity
4. Ability to develop exposure of the entire IIIrd ventricular
cavity
Disadvantages
1. Requires hydrocephalus
2. Divides parietal region cortex
3. Risk of fornix damage
4. Risk of damage to the deep venous structures
5. Poor visualization of the ipsilateral IIIrd ventricular cavity
6. Poor visualization of pineal and quadrigeminal regions

Sekhar and Goel [14] first reported the combined supra/infratentorial-transsinus approach for the
removal of a large tentorial meningioma. This approach
provides the greatest exposure for the large pineal
region tumors and requires less brain retraction than
any other approaches to the pineal region [35].
The patient is placed in a semiprone position and
a U-shaped scalp incision is made. The craniotomy
is then performed in three pieces, with the suboccipital plate removed first. After separating the transverse
sinus under direct vision, an occipital craniotomy is
made on one side up to the superior sagittal sinus. After
separating the sagittal sinus from the bone, the occipital craniotomy is performed on the other side. The
occipital dura is opened in a transverse fashion just
inferior to the transverse sinus, dividing the occipital
sinus, if necessary. The occipital dura is then opened on
the inferior side, medial to the sagittal sinus and superior to the transverse sinus. The non-dominant transverse sinus and the tentorium are sectioned. A gentle
retraction of the occipital lobe as well as the cerebellum
provides an adequate view of the pineal region. The
excision of the tumor is accomplished in the usual fashion. After removal of the tumor, the transverse sinus
can be sutured, if necessary [35].
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Address for offprints: Isao Yamamoto, Department of Neurosurgery,

Yokohama City University School of Medicine, 3-9 Fukuura,
Kanazawa-ku, Yokohama 236-0004, Japan; Tel.: 045-787-2663; Fax:
045-783-6121; E-mail: yisao@med.yakohama-cu.ac.jp