Neurosurgery

Fig. 13.5. Approaches to the pineal region and tumors of the posterior third ventricle. 1. Infratentorial, supracerebellar. 2. Suboccipital, transtentorial. 3. Posterior interhemispheric, transcallosal. 4. Anterior transcallosal, subchoroidal/transvelum interpositum. 5. Transcortical or interhemispheric transforami-nal. 6. Translamina terminalis. 7. Posterior transventricular.

Fig. 13.5. Approaches to the pineal region and tumors of the posterior third ventricle. 1. Infratentorial, supracerebellar. 2. Suboccipital, transtentorial. 3. Posterior interhemispheric, transcallosal. 4. Anterior transcallosal, subchoroidal/transvelum interpositum. 5. Transcortical or interhemispheric transforami-nal. 6. Translamina terminalis. 7. Posterior transventricular.

large tumors that have a significant lateral or supratentorial component. Supratentorial approaches have the disadvantage of requiring retraction of the occipital lobe, resulting in a hemianopsia and an obstructed view of the tumor by the deep venous system. In most cases, we prefer the infratentorial, supracerebellar approach because it allows the most direct access to these midline tumors. Typically, the deep venous anatomy is displaced superiorly, facilitating tumor resection. In the past, the sitting approach was utilized, which allows gravity to help in retracting the cerebellar hemispheres and facilitating dissection [18]. However, because of the risks of air embolism and cortical collapse, we prefer a modified "Concorde" position in which the surgeon operates over the patient's left shoulder. There is a growing appreciation of the value of aggressive tumor removal for improving the prognosis of patients; however, this is dependent on tumor type. With benign tumors, complete resection is usually curative [18]. With malignant tumors, radical debulking is thought to improve the outcome and response to adjuvant therapy [12,13,18].

All patients with malignant germ cell or pineal cell tumors require radiation therapy.

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