Neurosurg Rev (2014) 37:677–684
DOI 10.1007/s10143-014-0567-1
ORIGINAL ARTICLE
Endoscopic surgery for tumors of the pineal region via
a paramedian infratentorial supracerebellar keyhole approach
(PISKA)
Firas Thaher & Peter Kurucz & Lars Fuellbier &
Markus Bittl & Nikolai J. Hopf
Received: 31 August 2013 / Revised: 19 May 2014 / Accepted: 29 June 2014 / Published online: 10 August 2014
# Springer-Verlag Berlin Heidelberg 2014
Abstract The tumors of the pineal region represent a signif-
icant challenge in terms of patient selection and surgical
approach. Traditional surgical options were commonly used
to approach this area causing considerable surgical morbidity
and mortality. We report for the first time on a series of
endoscopic procedures for lesions of the pineal region per-
formed via an infratentorial supracerebellar keyhole approach
(PISKA) in the prone position using endoscope-assisted and
endoscope-controlled technique. A single-institution series of
11 consecutive patients (five male and six female patients [11
total cases]; mean age 21 years, range 1–75 years) treated via
the endoscope-assisted and endoscope-controlled PISKA for a
pathological entity in the pineal region was retrospectively
reviewed. The mean follow-up time was 24 months. The
endoscopic PISKA was successfully used to approach a vari-
ety of pineal lesions, including pineocytoma (three patients),
pineal cysts (four patients), germinoma, lipoma, medulloblas-
toma, and glioblastoma (one patient each). Gross total resec-
tion was achieved in ten cases and subtotal resection in one
case. The mean preoperative tumor volumes were approxi-
mately 2×2 cm. Five patients developed postoperatively tran-
sient Parinaud’s syndrome. One patient underwent surgical
revision for cerebrospinal fluid leak. There was no mortality.
Ten patients had an uneventful postoperative course with
restitutio ad integrum after a mean follow-up duration of
13.5 months. The endoscopically PISKA is a safe and effec-
tive minimally invasive approach that enables endoscopic
F. Thaher (*) : P. Kurucz : L. Fuellbier : M. Bittl : N. J. Hopf
Neurochirurgische Klinik, Katharinenhospital, Klinikum Stuttgart,
Kriegsbergstr. 60, 70174 Stuttgart, Germany
e-mail: firas.thaher@gmail.com
N. J. Hopf
Zentrum für endoskopische & minimal Invasive Neurochirurgie,
NeuroChirurgicum, Maybachstraße 50/Siemensstraße. 28,
70469 Stuttgart, Germany
treatment of different lesions of the pineal region with com-
parable results to standard microsurgical technique but less
morbidity.
Keywords Pineal tumor . Paramedian infratentorial
supracerebellar keyhole approach . Endoscopic Surgery
Introduction
Tumors of the pineal region represent only less than 1 % of all
brain tumors [22]. However, the deep location of the pineal
region surrounded by highly functional and vital structures
remains a challenging target for neurosurgeons. Wide surgical
exposure of the entire suboccipital area was commonly used
to approach this area causing considerable surgical morbidity
and mortality. Since the introduction of microsurgical tech-
niques, surgical efficiency could be significantly improved
[22, 2]. Presently, the infratentorial supracerebellar approach
is generally accepted as the standard approach that provides
adequate exposure to that region. Using standard technique,
this approach is still a time-consuming and morbidity bearing
approach. Recently, minimally invasive techniques have been
introduced also for the treatment of lesions of the pineal region
including the endoscopic transventricular route. However,
reports on endoscopic surgery for pineal region lesions using
the infratentorial supracerebellar route are very rare. Up to
now, only two reports exist from the same working group [28,
31]. This group is using a transendoscopic technique and the
sitting position. We report for the first time on a series of
endoscopic procedures for lesions of the pineal region per-
formed via an infratentorial supracerebellar keyhole approach
in the prone position using endoscope-assisted and
endoscope-controlled technique [3]. We also describe in detail
this keyhole approach defined as “paramedian infratentorial
supracerebellar keyhole approach” (PISKA).
678
Patients and methods
Eleven patients underwent surgery for pineal region tumor via
the PISKA. There were six females and five male patients
ranging from 1 to 75 years of age, with a mean age of 21 years
at the time of surgery. Diagnosis was based on cranial MR
imaging in all cases. Five patients presented with long-lasting
non-specific neurological symptoms, three patients were ad-
mitted with acute hydrocephalus, which was immediately
treated by endoscopic third ventriculostomy (ETV) in two
cases and an external ventricular drainage (EVD) in the third
patient. Two patients were asymptomatic and assessed by
MRI for other reasons. One patient was referred following
neoadjuvant chemotherapy for a pineal germ cell tumor with
residual tumor tissue depicted on cranial MRI follow-up stud-
ies. Two patients had undergone previously incomplete tumor
resection in another hospital via a transventricular route in one
and a standard infratentorial supracerebellar approach in an-
other patient.
Preoperative evaluation included an extensive neurological
examination supplemented by high resolution MR imaging to
provide an accurate definition of the variations in the anatomic
and pathological structures and laboratory testing for germ
cell tumor. Exact extension of the tumor was assessed in the
preoperative imaging.
All operations were performed in the anti-Trendelenburg
prone position with the head maximally flexed (Fig. 1a) under
general anesthesia. Neuronavigation was used in selected
cases, mainly for placing the craniotomy at the exact desig-
nated localization. Motor-, sensory-, and auditory-evoked po-
tentials (MEP, SEP, AEP) were monitored routinely during
surgery. The occipital region was extensively disinfected with-
out shaving of the hair (Fig. 1b).
A 3–4 cm paramedian skin incision was performed from
just above the linea nuchae caudally. The muscles were split in
the fiber direction using monopolar cutting. A burr hole was
paced on the transverse sinus at the median limit of the
designated craniotomy. A 2×1.5 cm craniotomy was then
performed using a high-speed pneumatic drill (HiLan S:
Aesculap, Tuttlingen, Germany). The dura over the posterior
fossa was incised in a semicircular manner and flipped up-
wards towards the transverse sinus. After placing the
Fig. 1 Anti-Trendelenburg prone
position with the head maximally
flexed (a). The surgery region is
disinfected without shaving of the
hair (b)
Neurosurg Rev (2014) 37:677–684
craniotomy and opening of the dura mater, the first step is
the sufficient drainage of the CSF. This is performed always
with gently retraction of the cerebellar tonsil at one side to
open the cerebellomedullary cistern. After removal of the
CSF, the infratentorial supracerebellar route can be opened
without significant retractor pressure in a patient placed in
prone position
Endoscopes were used either as an adjunct to microsurgery,
defined as “endoscope-assisted microsurgery” (EAM) or as
the only optical tool, defined as “endoscope-controlled micro-
surgery (ECM) [12]. Endoscope-controlled technique was
used to dissect towards the pineal region via the
supracerebellar infratentorial route. A 4 mm rigid telescope
with 0° viewing angle (Minop TEAM: Aesculap, Tuttlingen,
Germany) was used with or without a fixation device
(UniTrack: Aesculap, Tuttlingen, Germany). After dissection
and finally removal of the tumor tissue, the surrounding
structures were extensively inspected with a 30° telescope
(Minop TEAM: Aesculap, Tuttlingen, Germany) including
the posterior part of the third ventricle in order to detect tumor
remnants and to ensure adequate CSF circulation.
After the removal of all instruments and paddies, the sur-
gical field was filled with artificial CSF and the dura closed
with single sutures in a watertight manner. The bone flap was
replaced and fixed with CranioFix (Aesculap, Tuttlingen,
Germany) (Fig. 2). The skin was then closed using 4.0
atraumatic sutures.
Results
EAM was performed in ten patients; in one case, the tumor
was completely resected by ECM. All patients were extubated
immediately after the procedure while still in the operating
theater. The postoperative Glasgow Outcome Scale (GOS)
scores were 5 (1–5, with 5 being the highest available score)
in ten patients and 3 in one patient. The mean postoperative
GOS score was 3.9 (range 3–5). The neuropathological ex-
amination revealed pineocytoma (n=3), pineal cysts (n=4),
and germinoma, lipoma, medulloblastoma, and glioblastoma
each in one patient. The duration of hospital stay ranged from
5 to 24 days.
Neurosurg Rev (2014) 37:677–684 679

Fig. 2 The dura is incised in a

semicircular manner and flipped
upwards towards the transverse
sinus (a, b)

Early postoperative MRI studies within 48 h after surgery
confirmed gross total resection of the tumor in ten patients and
subtotal resection in one patient, defined as removal of more
than 90 % of the tumor volume. The mean follow-up was
24 months. One patient with a diagnosis of glioblastoma
underwent surgery for recurrent tumor 6 months after the
initial surgery.
There was no mortality. Ten patients had an uneventful
postoperative course with restitutio ad integrum after a mean
follow-up duration of 13.5 months (range 3 to 24 months).
One patient died in succession of a severe head trauma
6 months after the surgery (case no. 1).
Five patients developed postoperatively transient
Parinaud’s syndrome. One patient underwent surgical revision
for cerebrospinal fluid leak. One patient developed postoper-
ative occlusive hydrocephalus related to postoperative swell-
ing, immediately treated by ETV. The results are summarized
in Table 1.
Illustrative cases of pure endoscopic resection of a pineal
cyst
A 14-year-old girl presented with headaches, hearing impair-
ment, and transient diplopia. MRI examination of the brain
showed a 1.3×1×1.3 cm contrast-enhancing partially cystic
lesion of the pineal region suspicions for a pineocytoma
(Fig. 3).
Indication was based on the increase of the enhancing part
of the lesion in the follow-up MRI. Surgery was performed in
a prone position via a paramedian infratentorial
supracerebellar approach, with the help of neuronavigation.
The size of the craniotomy was 1.5×2 cm and located just
inferior to the left transverse sinus about 5 mm off the midline.
Dissection of the infratentorial supracerebellar route as well as
complete removal of the lesion was done in endoscope-
controlled technique (Fig. 4). Duration of the procedure was
less than 2 h. The postoperative course was uneventful and the

Table 1 Clinical findings and outcome in patients with pineal region tumors treated via the paramedian infratentorial supracerebellar approach

Case Age Histological Tumor size Residual Complications Outcome

no. (years) diagnosis (cm) tumor

1 1 Glioblastoma 2×2.3×1.5 Subtotal Transient Parinaud’s syndrome, gait Underwent surgery for recurrent
multiforme ataxia, cerebrospinal fluid leak tumor 6 months after surgery
2 35 Pineal cyst 1×1×2 Gross total Transient Parinaud’s syndrome Normal function
3 16 Pineocytoma 1×1×1 Gross total None Normal function
WHO I
4 15 Germinoma 1.6×0.7×1 Gross total Transient Parinaud’s syndrome Normal function
5 21 Pineal cyst 4×2×1.4 Gross total None Normal function
6 5 Medulloblastoma 2.5×1.7×3 Gross total Transient Parinaud’s syndrome Normal function
7 14 Pineal cyst 1.3×1×1.3 Gross total None Normal function
8 43 Pineocytoma 2.8×2.3×2.6 Gross total None Normal function
WHO I
9 26 Pineocytoma 1.4×1.3×1.8 Gross total None Normal function
WHO I
10 75 Lipoma 3×2×2 Subtotal Transient Parinaud’s syndrome, gait Normal function
ataxia, occlusive hydrocephalus
11 17 Pineal cyst 1.5×1×1.5 Gross total Transient Parinaud’s syndrome Normal function
680
Fig. 3 Preoperative axial (a) and sagittal (b) postgadolinium T1-weighted magnetic resonance imaging (MRI) scan showing a pretreatment cystic lesion
of the pineal region. c Showing postoperative sagittal postgadolinium T1-weighted MRI scan
patient recovered quickly from the operation without any new
neurological deficit. Mobilization started on the first postop-
erative day and she was discharged on the fifth postoperative
day. Postoperative MRI confirmed complete resection of the
pineal cyst and no postoperative complications (Fig. 3c). At a
3-month follow-up examination, the patient had no further
complaints.
Illustrative cases of endoscope-assisted surgery
with microscopic and endoscopic views
A 17-year-old girl presented with headaches and transient
diplopia. MRI examination of the brain showed a 2.8×2.3×
2.6 cm contrast-enhancing partially cystic lesion of the pineal
region suspicions for a pineocytoma. Dissection of the
infratentorial supracerebellar route as well as complete remov-
al of the lesion was done in endoscope-assisted technique
(Fig. 5).
Fig. 4 Intraoperative photograph showing gross total removal of the
lesion in endoscope-controlled technique
Neurosurg Rev (2014) 37:677–684
Discussion
One third of all pineal region lesions are benign tumors and
are clearly associated with excellent prognosis after surgi-
cal treatment alone [4]. There are several different histor-
ical routes for surgical management of pineal tumors in-
cluding the posterior interhemispheric transcallosal ap-
proach (PIT) which was described by Dandy in 1921 [6]
and the posterior transcortical (TC) approach by Van
Wagenen [33]. Because of the high mortality and the poor
results such as the sequel of splitting the corpus callosum
producing a partial cerebral disconnection syndrome and
incising the cortex by PT approach leading to
hemianesthesia or homonymous hemianopsia, these ap-
proaches have been used less frequently [28]. Since the
introduction of microsurgical techniques by Yasargil, two
other surgical approaches have emerged in the manage-
ment of pineal tumor: the occipital transtentorial approach
(OTT) described by Poppen in 1966 and modified by
Jamieson [25, 13] and the supracerebellar infratentorial
approach (SCIT) [8, 29, 2, 10]. One variation of SCIT is
the paramedian infratentorial supracerebellar approach,
which was described by Yaşargil [23]. Van den Berg first
described this approach also for the resection of pineal
region tumors in 1990 [32]. The choice of the surgical
approach is based on different parameters such as size,
extension of the lesion, and location/dislocation of sur-
rounding structures. Thus, the OTT seems more appropri-
ate for tumors with supratentorial extension because it
offers a good view on the tentorial notch and provides a
wide operative field with a good visualization of the deep
vein system and pineal region from above by transection
and reflection of the tentorium [17]. However, this ap-
proach appears to have limitations for lesions reaching
the contralateral quadrigeminal region [26, 18, 19] passing
the deep venous structures which are at high risk of
Neurosurg Rev (2014) 37:677–684 681

Fig. 5 Intraoperative images demonstrating microscopic and endoscopic view. Intraoperative microscopic view (a). The tumor is progressively removed
under endoscopic view (b, c)

damage [20, 34]. One of the most serious complications of
this approach is the visual impairment by retraction of the
occipital lobe, which is fortunately usually reversible [2].
The SCIT is preferable for small and medium size lesions
without lateral expansion. This approach provides a dorsal
access to the midline through a natural corridor between the
superior cerebellar surface and the tentorium allowing good
orientation. Using this route, the pineal region is located
below the vein of Galen, which gives the surgeon the oppor-
tunity to avoid direct contact with the deep venous system and
good visibility of the veins. This approach facilitates also the
dissection of the tumor from its frequently seen attachment to
the velum interpositum. Moreover, there is no manipulation
on the parietal and occipital lobe [2]. The approach, however,
is narrow through the culmen limiting the exposure of the
posterior tentorium incisura, and deep for debulking large
tumors which raise into the supratentorial space.
The here-described endoscopic paramedian infratentorial
supracerebellar keyhole approach (PISKA) is a combination
of the well-described median infratentorial supracerebellar
and paramedian [23] approach based on the location and is a
real minimally invasive approach in terms of the size and
surgical effort, with an average size of approximately 2×
2 cm. The craniotomy should be individually tailored for each
patient, depending upon the individual anatomical variations
(intra- and also extracranial) and individual pathoanatomical
situations (size of the lesion, position of the important
neurovascular structures). The basic principle is that the cra-
niotomy should be as large as necessary but as small as
possible. As a consequence of the previously mentioned as-
pects, a “standard” size of the craniotomy cannot be defined
and there is always a small variation in the size of the crani-
otomy from patient to patient.
The trajectory of the PISKA is more from a medial direc-
tion than the infratentorial supracerebellar approach. This
offers the surgeon an excellent view on the pineal region and
the quadrigeminal plate. It also provides a better view on the
caudal quadrigeminal cistern in case the lesion is extending
inferiorly. Since the surface of the cerebellum slopes down-
ward medially and laterally (from the culmen to the quadran-
gular lobe), following the tentorium, this approach requires no
or only minimal retraction of the cerebellum even in a prone
position. In addition, the more lateral approach provides a
corridor with fewer bridging veins compared to a midline
approach. As a result of that the risk of ischemia or edema is
decreased [21, 30, 11]. A further major advantage of this
approach is the avoidance of the occipital sinus, which was
found to be present in 64.5 % of examined cadavers by Das
and Hasan [7] resulting in a reduced operating time.
In our small series, there was no mortality. However, the
surgical mortality rates in most recent comparable series were
also low, at 0–2 % [5, 24, 3]. Complications were temporary

Table 2 Results of microsurgical series of pineal tumor resection

Series Year No. of cases Approaches GTR (%) Mortality (%) Permanent morbidity (%)

Bruce and Stein 1995 160 SCIT/TC/OTT 45 4 19

Chandy and Damaraja 1997 48 SCIT/OTT 55 0 NA
Kang et al. 1998 16 OTT/SCIT/TC 37.5 0 19
Shin et al. 1998 21 OTT 54 0 5
Konovalov and Pitskhelavri 2003 201 OTT/SCIT 58 10 20
Bruce 2004 81 SCIT/TC/OTT 47 1 NA
Hernesniemi et al. 2008 119 OTT/SCIT 88 0 4
Own series 2011 10 PISKA 90 0 0
682
Parinaud’s syndrome and ataxia each in one patient which had
been resolved completely in the 3-month follow-up examina-
tion. Postoperative hemorrhage, most commonly seen in ma-
lignant or vascularized tumors that have been incompletely
resected [2], could not be detected in our series. Complete
tumor removal is reported in large series to vary between 45
and 88 %. With a complete removal rate of 90 % in the present
study, we are well in line with the recent literature [3, 4, 15, 27,
10, 14, 2, 17] (see Table 2).
The PISKA is a clear realization of minimally invasive
“keyhole” neurosurgery, but of course using such a small
craniotomy there are some major limitations: limited and
predefined surgical corridor, difficult intraoperative orienta-
tion, insufficiency of available micro-instruments, and de-
creased illumination in the deep-seated fields.
The limited exposure is not the primary goal but the result
of the keyhole concept with the most important aim to avoid
approach-related traumatizations. It is realized by less need for
dura opening, less brain exposure and retraction, and less
unnecessary intracranial maneuvers such as too extensive
arachnoid dissection and mobilization of neurovascular struc-
tures of the skull base. These facts may contribute to improved
postoperative results including shorter hospitalization time
because of reduction in the risk of complications such as
bleeding or rebleeding with neurological deterioration, leak-
age of CSF, infection, scarification, and cosmetic
disturbances.
The majority of patients with pineal tumors present with
acute obstructive hydrocephalus [16]. Therefore, endoscopic
third ventriculostomy (ETV) and obtaining tissue and CSF
samples for histopathological diagnosis and tumor markers is
an option as the first step of the management. In the present
series, we performed ETVand biopsy via a single coronal burr
hole in three patients as described earlier by the senior author
(N.H.) [11].
Endoscopes were used in all patients for the removal of the
lesion. EAM was used in ten of 11 cases, meaning that at least
a small part was performed under the operating microscope,
and ECM in one case of a pineal cyst (Case no. 7). In nine of
the ten EAM cases, we achieved a total resection of the lesion.
Endoscopy helped to a great degree in achieving this by result
providing an excellent overview over the deep structures of
the pineal region and on hidden remnants around the deep
venous structures. This finding has been made also by others
[1]. Using endoscopes as the only visualization tool
(endoscope-controlled microsurgery, ECM) in the treatment
of pineal lesion has been described so far only by two groups
[9, 28, 31]. They also used the infratentorial supracerebellar
approach but in a sitting position. Sood et al. used a midline
subtorcular approach sacrificing the occipital sinus. The Phoe-
nix group used a small (1.5–2.5 cm diameter) paramedian
SCIT approach. In this study, we used a similar minimally
invasive approach as Uschold et al. that we called PISKA for
Neurosurg Rev (2014) 37:677–684
endoscopic removal of pineal lesions in prone position. We
prefer the prone position because it is less likely to experience
complications such as air embolism, cardiovascular instability,
or tension pneumocephalus. The prone position has also been
considered to be associated with less postoperative pain, nau-
sea, and hospitalization time.
Both groups started to use ventriculoscopes inserting in-
struments through the designated channels. This technique
referred as “transendoscopic surgery” certainly enables only
a very limited range of manipulations and prevents tactile
feedback. We therefore used “paraendoscopic techniques” in
which only the telescope of the endoscope is used and the
instruments are used beside the optics. This technique pro-
vides maximal dexterity by enabling the usage of standard
microsurgical instruments and bimanual dissection technique.
For the purpose of bringing light into the surgical field, the
surgical microscope can be effectively supported by the opti-
cal properties of modern endoscopes (endoscope-assisted mi-
crosurgery). The advantages of using endoscopes in PISKA
are the increased light intensity, extended viewing angle, and
clear depiction of details within the surgical field resulting in
improved surgical orientation and safety. With these proper-
ties, the endoscope is a perfect completion of the surgical
microscope allowing the best visualization through such a
small-sized craniotomy.
Conclusion
Our results demonstrate that the PISKA is a safe and effective
minimally invasive approach that enables endoscopic treat-
ment of different lesions of the pineal region with comparable
results to standard microsurgical technique but less morbidity.
Endoscopic technique improves visualization of hidden rem-
nants and deep neurovascular structures. The authors recom-
mend this approach to be performed in a prone position
associated with less postoperative malaise and using
paraendoscopic technique (EAM, ECM) in order to provide
unrestricted bimanual dissection.
Conflict of interest The authors declare that they have no conflict of
interest.
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Comments
Tadateru Fukami, Kazuhiko Nozaki, Shiga, Japan
The authors described a minimally invasive approach to the pineal
lesion, PISKA (paramedian infratentorial supracerebellar keyhole ap-
proach) in the prone position. They treated 11 consecutive patients with
lesions in the pineal region via endoscope-assisted and endoscope-
controlled procedures and achieved gross total removal of the lesion in
10 out of 11 patients and major complication or mortality was not
experienced. They should be congratulated by their elaborate techniques
combining microsurgical and endoscopic approaches through keyhole
and excellent results, but the clinical application of their approach should
be considered depending on the size, nature of the lesion, and the goal of
surgical procedures. The standard approaches to the pineal lesion are
endoscopic transventricular approach with or without third
ventriculostomy for the biopsy, microscopic occipital transtentorial ap-
proach, or infratentorial supracerebellar approach for the tumor removal
(1). The lesions in their paper are less than 2.5 cm in size in seven patients
and with cysts in four patients and seem to be hypovascular in most cases.
Their approach may not be applied to large hypervascular lesions and
solid lesions. Furthermore, only one case was treated with endoscope-
controlled procedures which may indicate the limitation of their
approach.
Recently, the clinical use of endoscopy has been expanded as a
standard main operative tool and an assist tool for the surgical microscope
and its minimal invasiveness with high effectiveness and low risks have
been apparently accepted. However, recent review papers do not support
the superiority of endoscopic surgery over conventional microsurgery.
Sheikh et al. conducted a systematic review and meta-analysis of 1,278
cases with colloid cysts and found that gross total removal rate, recurrence
rate, and reoperation rate were significantly low in endoscopic approach
in the removal of colloid cyst (2). Ammirati et al. performed PubMED
search for transsphenoidal surgery from 1990 to 2011 and collected 38
studies (24 endoscopic and 22 microscopic datasets) and found a signif-
icantly higher incidence of vascular complications in endoscopic surgery
as compared with microscopic surgery in pituitary adenoma surgery and
no significant difference in initial remission rate of hypersecretion of
functioning adenoma, complete removal rate, or CFS leak between
microscopic and endoscopic removal (3). Goudakos et al. conducted their
systematic review of 11 relevant studies of transsphenoidal pituitary
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surgery including 806 patients and found similar rates of complete tumor
excision and remission rates with less frequent diabetes insipidus and a
shorter hospital stay in endoscopic surgery (4). Komotar et al. performed
literature review about craniopharyngioma surgery and found high rates
of gross total resection, improvement of visual outcome, and CSF leak in
endoscopic surgery than microsurgical surgery (5).
The authors combined well endoscopic advantages such as wide view,
angled view, and bright operative fields to check residual tumors and
microscopic advantages such as bimanual control, stereopsis, and ade-
quate hemostasis to remove the tumor in a safer manipulation. They used
a 3–4 cm paramedian linear skin incision and a 2×1.5 cm craniotomy and
performed the sufficient drainage of the CSF by gently retraction of the
cerebellar tonsil at one side to open the cerebellomedullary cistern.
However, it may be dangerous to retract the cerebellar tonsil through
such a small craniotomy in order to cut arachnoid membrane of the
cerebellomedullary cistern. Moreover, in the event of bleeding, the oper-
ative corridor may be obstructed and a deep operative field around
quadrigeminal cistern may be severely restricted. Although PISKA itself
may provide a good operative view around the dorsal midbrain,
endoscopic-controlled procedures should be used by experienced sur-
geons who know how to avoid intra- and postoperative complications.
We should combine well the advantage of endoscopic and microscopic
approaches to achieve a minimally invasive and maximally effective
surgery in each case.
References
(1) Waleed AA, Khurram N, Waleed S. An overview of the current
surgical options for pineal region tumors. Surgical Neurology Interna-
tional 5:39. 2014
(2) Sheikh AB, Mendelson ZS, Liu JK. Endoscopic versus microsur-
gical resection of colloid cyst: a systemic review and meta-analysis of
1,278 cases. World Neurosurg 14, 2014 [Epub ahead of print]
(3) Ammirati M, Wei L, Ciric I. Short-term outcome of endoscopic
versus microscopic pituitary adenoma surgery: a systematic review and
meta-analysis. J Neurol Neurosurg Psychiatry 84:843-849, 2013
Neurosurg Rev (2014) 37:677–684
(4) Goudakos JK, Markou KD, Georgalas C. Endoscopic versus
microscopic trans-sphenoidal pituitary surgery: a systematic review and
meta-analysis. Clin Otolaryngol 36:212-220, 2011
(5) Komotar RJ, Starke RM, Paper DM, Anand VK, Schwartz TH.
Endoscopic endonasal compared with microscopic transsphenoidal and
open transcranial resection of craniopharyngioma. World Neurosurg
77:329-341, 2012
Charlie Teo, Randwick, Australia
This is a small but important series of an endoscopic approach to the
pineal region for varying pathologies. It is important because it illustrates
the metamorphosis of complex neurosurgical operations into simple
procedures simply with utilization of the latest technology and a change
in one’s surgical philosophy. The senior author is a leading figure in the
world of neuroendoscopy. Nevertheless, the indications, description of
the surgical technique, and various pearls of wisdom included in this
paper should demonstrate the clear advantage of a minimally invasive
endoscopic approach that could be duplicated by any cranial neurosur-
geon. Many of the complications associated with pineal region surgery
are directly related to the approach rather than the actual pathology itself.
Occipital lobe damage, postoperative sub-dural collections, cerebellar
venous congestion, seizures, air embolism, and quadriplegia are all ex-
amples. This endoscopic-utilizing operation would preclude many of
these potential complications.
There is one statement that I thought should be clarified. The authors
mention that “....using such a small craniotomy there are some major
limitations…”. It should be made absolutely clear that surgeons who
recommend the keyhole philosophy do not use such small openings as to
increase the risk to the patient. The “major” limitations that they discuss are
impediments that may make it more difficult for the surgeon but do not
make it riskier for the patient. If an opening is so small as to compromise
safety, then that is an “inadequate” opening NOT a “keyhole” opening.
I commend the authors on this small but important series of pineal
tumors removed effectively using a paramedian, suboccipital,
infratentorial, supracerebellar endoscopic approach.