Surgical Strategy for Superior Cerebellar Peduncle Lesions: Utility of the Subtemporal Transtentorial Approach

Tumors involving the superior cerebellar peduncle (SCP) are rare and pose considerable surgical challenges due to their deep and complex location. While the supracerebellar infratentorial approach has been the most frequently described strategy, it may be insufficient for lesions extending along the entire SCP. We present 2 cases of SCP tumors to highlight the utility of the subtemporal transtentorial approach.

Case 1 was a 28-year-old woman with a hemorrhagic SCP tumor extending into the fourth ventricle. Resection was performed in 2 stages using the trans-cerebellomedullary fissure and occipital transtentorial approaches, but the central SCP remained inaccessible. In case 2, a 33-year-old man with an enlarging lesion encompassing nearly the entire SCP underwent surgery. Based on simulation and prior experience, the subtemporal transtentorial approach was selected for its potential to provide a panoramic view of the SCP.

In case 1, volumetric analysis demonstrated a resection rate of 90.1% achieved through staged approaches, with no postoperative neurological deficits. The Karnofsky Performance Status score remained at 90 at 21 months after surgery. Pathology confirmed pilocytic astrocytoma. In case 2, the subtemporal transtentorial approach enabled 79.0% resection while preserving cerebellar and cranial nerve function, with a Karnofsky Performance Status score of 100 at 18 months. Pathology revealed dysplastic cerebellar gangliocytoma (Lhermitte-Duclos disease).

The subtemporal transtentorial approach offers a direct and linear trajectory to lesions extending along the entire SCP, allowing substantial resection while minimizing functional morbidity. Although experience remains limited, this approach should be considered for surgical access to the SCP.