Refining pineal gland tumor resection with bilateral occipital transtentorial approach: Technical insights

Pineal gland tumors are infrequent malignancies that predominantly manifest in children, comprising a mere 3-11% of all pediatric brain cancers and <1% of adult brain tumors. Pineal resection can be accessed through various approaches, most commonly the supracerebral infratentorial approach and the occipital transtentorial (OT) approach. Bilateral OT approach (BiOTA) on pineal gland complete resection allowed exposure and, therefore safer complete resection of the contralateral lesion, though the use is rarely reported before this case report.

The patient was positioned in a prone/Concorde position, with the operator alternating between the right and left sides. A lumbar cerebrospinal fluid drain was installed between the L3 and L4 vertebrae to induce brain relaxation. A linear midline incision was made, followed by occipital craniectomy using multiple burr holes to create a kite shape, and then, the bone flap was removed, and the dura mater was opened. The BiOTA was performed by first addressing the right side and then the left, completing the procedure by closing both sides of the tentorium.

Using BiOTA, we successfully achieved total removal of the tumor without postoperative visual disturbance, a common issue frequently reported with the use of the OT approach.

The BiOTA is suitable for large pineal tumors with disturbed complete visualization of the tumors by cerebral falx that needed total resection.