Interactive image guided surgery of the pineal region

A wide variety of lesions occur in the pineal region. Of these, only 25% may benefit from surgical resection, being benign or radioresistant in nature. In the remaining 75% (malignant or radiosensitive), a conservative approach is preferred. Surgical resection of lesions arising from the pineal region has been associated with high morbidity and mortality, due to the complex microanatomy of this area. Recently computer-assisted surgery has emerged as an ideal method to safely approach many intracranial lesions. In the present study we discuss our experience in interactive image-guided surgical management of pineal mass lesions, in terms of patient selection, methodology, and surgical morbidity and mortality. From July 1992 to December 1996, 15 patients underwent interactive image guided surgical procedures. There were eight men and seven women. Age ranged from 5 to 79 years (mean 30). Preoperatively all patients underwent neuroimaging studies that included computed tomography and magnetic resonance imaging under stereotactic conditions. Surgical planning was carried out using the Neurological Surgical Planning System software developed at Wayne State University. In patients with a preoperative diagnosis of a malignant or radiosensitive lesion (n = 10), an interactive image-guided stereotactic biopsy was considered, whereas for those with benign or radioresistant lesions (n = 5) surgical excision using an infrared based system was carried out. Histological diagnosis was obtained in all patients. There was no morbidity and mortality associated with computer-assisted procedures for biopsies the diagnostic yield was 100%. For patients that underwent interactive image-guided surgery, gross total removal was accomplished in 3 and in 1 patient a subtotal resection greater than 90% was achieved. Interactive image-guided biopsy represents a safe and accurate method in the diagnosis of malignant and/or radiosensitive pineal lesions. Using this technique surgeons can simulate preoperatively the surgical trajectory, thus avoiding damage to critical and vascular structures. For patients with benign or radioresistant lesions, computer-assisted surgical excision is recommended.