What are the main vessels to avoid sacrificing during a supracerebellar infratentorial approach for pineal tumors?

From the Guidelines

The main vessels to avoid sacrificing during a supracerebellar infratentorial approach for pineal tumors are the internal cerebral veins, basal veins of Rosenthal, and the vein of Galen. When performing this surgical approach, it is critical to preserve these key venous structures to prevent potentially severe complications, as highlighted in the recent consensus on management of pineal parenchymal tumors 1. Some key considerations for this approach include:

• The relationship of the lesion with the deep venous network, including the internal cerebral veins, basal veins of Rosenthal, and the vein of Galen, which informs the choice of surgical approach 1.
• The angle of the straight sinus and the height of the tumor along the vertical axis created by the splenium, which are crucial factors in determining the optimal surgical corridor 1.
• The importance of gross tumor removal, which is usually the only treatment required in lower-grade pineal lesions, and is preferred for patients with certain types of pineal tumors 1. Additionally, be aware of and preserve smaller bridging veins in the operative corridor when possible. Use of neuronavigation, careful preoperative imaging review, and meticulous microsurgical technique are essential for identifying and protecting these vital vascular structures during tumor resection. Key vessels to preserve during this approach include:

1. Vein of Galen: This large cerebral vein drains blood from deep brain structures and plays a critical role in cerebral venous drainage.
2. Internal cerebral veins: These paired veins drain the deep white matter of the cerebral hemispheres and are essential for maintaining normal cerebral function.
3. Basal veins of Rosenthal: These veins are also critical for cerebral venous drainage and must be preserved to prevent complications. Sacrificing these vessels can lead to venous infarction, hemorrhage, or severe edema in critical brain regions, emphasizing the need for careful dissection and retraction of surrounding tissue while maintaining the integrity of these vessels throughout the procedure 1.

From the Research

Main Vessels to Avoid Sacrificing

The main vessels to avoid sacrificing during a supracerebellar infratentorial approach for pineal tumors include:

• The cerebellomesencephalic vein (CMV) 2
• The Galenic draining system, including the vein of Galen and its tributaries 3
• The thick bridging veins of the tentorial surface of the cerebellum, especially the hemispheric bridging veins 3, 4
• The vermian and hemispheric bridging veins between the superior surface of the cerebellum and the tentorium 4

Key Considerations

Key considerations for preserving these vessels include:

• Using a purely endoscopic supracerebellar infratentorial approach to enhance the safety and effectiveness of the surgery 2
• Shifting the approach off-midline to reduce the need for venous sacrifice at the level of the tentorial sinuses and the tributaries of the vein of Galen 5
• Minimizing retraction of the cerebellum during surgery to avoid adverse effects caused by both direct cerebellar compression and disturbance of the venous circulation 3
• Having adequate knowledge of the anatomy of the bridging veins, particularly the hemispheric bridging veins, to minimize their intraoperative sacrifice 4