Pediatric Pineal Region Tumors: Institutional Experience of Surgical Managements with Posterior Interhemispheric Trans-Tentorial Approach 

Purpose: Resecting pineal region tumors in children is often challenging. Several approaches have been proposed and practiced. A personal series of pediatric pineal region tumor resected through craniotomy with posterior interhemispheric occipital transtentorial (OT) approach are reviewed. We present the surgical techniques and pitfalls, and their results. Material and Methods Eighty patients ranging in age from 3 months to 21 years old, and treated over 3 decades were reviewed. Hydrocephalus caused the main presenting symptoms and was noted in 74 patients. It was treated prior to the craniotomy for tumor resection with endoscopic third ventriculostomy (ETV) in 33, external ventricular drainage in 26 and precraniotomy shunt in 15. Nine patients had ETV together with endoscopic biopsy. All patients had parieto-occipital craniotomy in a prone position. Through a tentorial section, a gross total resection of the tumor was attempted except for germinomas Results . The tumor pathology showed 32 germ cell tumors (GCT), 22 benign astrocytomas 13 pineal parenchymal tumors, 5 ATRTs, 3 papillary tumors and 5 others. Of GCTs, 18 were teratomas. The extent of resection consisted of 55 gross total resection, 13 subtotal resection, 10 partial and 2 biopsy with one postoperative death. Hemiparesis in 2, cerebellar ataxia in another 2 and hemiballismus in 1 were transient and improved overtime. One had permanent hemisensory loss and another patient had bilateral oculomotor palsy. Postoperative homonymous hemianopia occurred in 2 patients but subsided over a short period of time. Parinaud’s sign was noted in 24 patients, of which 16 were transient. Conclusion The posterior interhemispheric OT approach provides a safe route and comfortable access to the pineal region in children. A great majority of postoperative neurological complications are the results of direct manipulations of the midbrain at tumor resection. Identification and preservation of the tumor-brain interface is of paramount importance. GCTs other than teratomas are treated with neoadjuvant chemotherapy and may eliminate the need of craniotomy. Exophytic midbrain JPAs are amenable to resection.