Combined supra/infratentorial-transsinus approach to large pineal

region tumors

Ibrahim M. Ziyal, M.D., Laligam N. Sekhar, M.D., Eduardo Salas, M.D., and Wayne J. Olan, M.D.
Departments of Neurosurgery and Radiology, The George Washington University Medical Center,
Washington, D.C.

Object. The authors sought to confirm that the combined supra/infratentorial-transsinus approach offers
a safer means of resecting large pineal region tumors than other approaches currently being used. The
aforementioned method provides a wider exposure of the pineal region with less brain retraction than the
infratentorial-supracerebellar or the occipital-transtentorial approach alone and is applicable to some
large and giant tumors of this area. This combined approach was used in six patients to remove large
pineal region tumors including four tentorial meningiomas, one pineocytoma, and one epidermoid cyst.
Methods. The transverse sinus and tentorium were sectioned after review of preoperative angiographic
studies, after taking intraoperative measurements of the venous pressure in the nondominant transverse
sinus before and after clipping and while monitoring the somatosensory evoked potentials. The occipital
lobe cortex and cerebellum were retracted slightly along the tentorium. Deep veins of the galenic system,
the quadrigeminal area, and the tumor were well exposed. Before it was used for tumor resection the
approach was studied in five cadaveric head specimens, and the projection of different approaches was
compared radiologically.
The tumors were removed in a gross-total manner in all patients, and none of the major veins of the
galenic system was injured. Resuturing of the nondominant transverse sinus was performed
postoperatively in one patient. One of the six patients experienced transient visual loss, and another
suffered mild right sixth cranial nerve paresis; however, both recovered in 3 weeks. The wide exposure
of the combined approach was also confirmed on radiological and anatomical studies.
Conclusions. The combined supra/infratentorial-transsinus approach is preferred for the resection of
certain large pineal region tumors.
Key Words * pineal region tumor * surgical approach * supra/infratentorial-transsinus approach

In the past, the deep location of pineal region tumors and their relationships with important anatomical
structures have resulted in significant operative morbidity and mortality rates.[7,8,34] These unsuccessful
surgical results prompted neurosurgeons to develop safer approaches for removing pineal region tumors.
The transcallosal, occipital-transtentorial, and infratentorial-supracerebellar approaches have been
developed and used successfully in this area.[2,4,6,11,16,17,25,35] The combined
supra/infratentorial-transsinus approach for the removal of a large tentorial meningioma was reported

Unauthenticated | Downloaded 09/05/23 08:12 AM UTC

previously by Sekhar and Goel[27] in 1992, and since that time this approach has been used successfully
in six patients with giant tumors of the pineal region.
CLINICAL MATERIAL AND METHODS
Patient Population
During a 5-year period, six patients (five women and one man) underwent surgery in which the
combined supra/infratentorial-transsinus approach was used. The most frequent presenting symptoms
were headache and gait difficulty. All patients had giant (> 4.5 cm) tumors of the pineal or posterior
tentorial notch region: four tentorial meningiomas, one pineocytoma, and one epidermoid cyst (Table 1).
The new approach was selected when the tumor arose from the tentorium or extended well above and
below the tentorial notch. After performing preoperative angiographic studies, intraoperative monitoring
of venous blood flow, and measuring somatosensory evoked potentials (SSEPs), we sectioned the
nondominant transverse sinus (usually the left side).

Preoperative Studies
Magnetic resonance (MR) imaging revealed information about tumor localization and extension, and its
relation to the tentorial notch. Magnetic resonance angiography revealed the size, dominance, and
collateralization of the transverse sinuses, which are important factors in planning the combined
approach. Cerebral angiography provided information about the deep venous system, the vein of Galen,
the internal cerebral veins, the basal vein of Rosenthal, the superficial venous system, the patency of the
straight sinus, and the collateralization and enlargement of the normally present sinus (for example, the
inferior sagittal sinus). Using angiography we were able to delineate the vascularity of the lesion and its
relationship to the various arteries and veins in the area. If division of the transverse sinus was planned,
the existence of good communication between the transverse sinuses in the region of the torcular
herophili was established on preoperative studies.

Unauthenticated | Downloaded 09/05/23 08:12 AM UTC

If the patient was diagnosed as having significant obstructive hydrocephalus preoperatively, a
ventriculoperitoneal (VP) shunt was usually placed before the tumor operation.
Anesthesia and Monitoring
Anesthesia was induced by using standard endotracheally administered thiopental and a short-acting
muscle relaxant in all patients. Furosemide and/or mannitol were administered intravenously at the start
of the operation. A precordial Doppler device was placed to detect air emboli, and a right atrial catheter
was inserted to monitor the central venous pressure and to aspirate air in the event of an embolism.
Prophylactic antibiotic drugs were administered intravenously.
The SSEPs were monitored continuously during the operation. Stimulating electrodes were placed
bilaterally at the median nerve in the wrist, and recording electrodes were placed over the appropriate
somatosensory cortex. Bilateral brainstem auditory evoked responses were similarly monitored during
the operation. Transit-time Doppler flow measurements were obtained by means of a 3-mm probe.
Operative Technique
The patient was placed in a semiprone position, which is preferred for this approach because the surgeon
can sit behind the patient (Fig. 1). We placed the side of the proposed transverse sinus section inferiorly,
which allows for gravity-aided retraction of the occipital lobe. A U-shaped incision was made, and the
skin flap and muscles were elevated as a single layer. The craniotomy was usually performed in three
pieces, and the first plate removed was the suboccipital (Fig. 2A). After separating the transverse sinus
under tangential vision, an occipital craniotomy was performed on one side up to the superior sagittal
sinus (SSS) (Fig. 2B). After separating the SSS from the bone under direct vision, we were able to
perform the occipital craniotomy on the other side more safely (Fig. 2C) because this technique avoids
injuries to the venous sinuses.

Fig. 1. Drawing showing the semiprone position, which is preferred for the combined
approach. The dashed line indicates the U-shaped incision. This position allows the surgeon

Unauthenticated | Downloaded 09/05/23 08:12 AM UTC

to sit behind the patient.

Fig. 2. Drawings showing the procedure. A: The craniotomy is usually performed in three
pieces, with the suboccipital plate removed first. B: After separating the transverse sinus
under tangential vision, an occipital craniotomy is performed on one side, up to the SSS. C:
After separating the SSS from the bone, the occipital craniotomy is performed on the other
side. D: The suboccipital dura is opened in a transverse fashion just inferior to the transverse

Unauthenticated | Downloaded 09/05/23 08:12 AM UTC

 sinus. The occipital dura is then opened parallel to the venous sinuses on the inferior side. A
20-gauge butterfly needle attached to a manometer is placed in the transverse sinus just
lateral to the torcular herophili, where test occlusion of the sinus is performed by using a
temporary clip lateral to the needle. 1, 2, 3 = order in which the plates were removed.
The suboccipital dura was opened in a transverse fashion just inferior to the transverse sinus, dividing the
occipital sinus if necessary. The cisterna magna was opened to permit relaxation of the brain through a
small dural incision. The occipital dura was then opened on the inferior side, medial to the SSS and
superior to the transverse sinus. The safety of division of the nondominant transverse sinus was then
established in the following manner: a 20-gauge butterfly needle was attached to a manometer and was
inserted into the transverse sinus just lateral to the torcular herophili, and test occlusion of the sinus
lateral to the needle was continued for 5 minutes. If the venous pressure does not rise more than 5 mm
Hg during this test, if no brain swelling is observed, and if there are no changes in the SSEPs, the
nondominant transverse sinus can be sectioned safely (Fig. 2D). In that event, the sinus was clipped with
two temporary clips and divided (Fig. 3 left). The tentorium was then cut just lateral to the straight sinus
and toward the tentorial notch area. The occipital lobe and the cerebellum were gently retracted to expose
the quadrigeminal region (Fig. 3 right).

Fig. 3. Artist's drawing of a combined supra/infratentorial-transsinus approach to a large

pineal region tumor. Left: The nondominant transverse sinus has been clipped with two
temporary clips and divided. The occipital lobe and the cerebellum are gently retracted to
expose the tentorium. Right: The tentorium is then cut just lateral to the straight sinus and
toward the tentorial notch area. The wide exposure of the tumor is seen together with
important venous structures. Int. = internal; v. = vein.
The excision of the tumor was accomplished in the usual fashion. If deep venous structures were found to
be encased, they were carefully dissected and preserved. After removal of the tumor, the transverse sinus
can be sutured with 5-0 or 6-0 prolene. If such reconstruction is preferred, a short vein graft may be
necessary because the dura containing the sinuses shrinks during the operation.
Unauthenticated | Downloaded 09/05/23 08:12 AM UTC
 Fig. 4. Case 1. Sagittal and axial T1-weighted MR images (upper) obtained after gadolinium
administration, and coronal T2-weighted MR images (lower) demonstrating a large pineal
region mass with intense homogeneous contrast enhancement and increased signal intensity
on the T2-weighted sequence.

RESULTS
Five patients underwent preoperative placement of a VP shunt. Preoperative embolization was performed
in three patients who had tentorial meningiomas. The nondominant transverse sinus was on the left side
in five cases and on the right side in one case (Table 1). In two patients an occipital-transtentorial
approach was attempted, and in a third an infratentorial-supracerebellar approach was initially attempted.
However, in all patients the combined approach was necessary to remove the tumor completely (Case 1,
Figs. 4-6; Case 2, Figs. 7 and 8).

Unauthenticated | Downloaded 09/05/23 08:12 AM UTC

 Fig. 5. Case 1. Venous phase of digital subtraction angiography of the right internal carotid
artery injection in lateral (left) and anteroposterior (right) projections. A marked mass effect
with downward displacement of internal cerebral veins is seen. The right transverse sinus is
clearly the dominant side.

Fig. 6. Case 1. At the 3-month follow-up review sagittal and axial T1-weighted MR images
obtained after gadolinium administration demonstrated no residual tumor. Dural
enhancement is seen along the tentorium and involves postoperative changes in the pineal
region.
One of the six patients suffered transient visual loss, and another had mild right sixth cranial nerve
paresis; both recovered in 3 weeks. One patient required replacement of the VP shunt that had been
inserted preoperatively.

Unauthenticated | Downloaded 09/05/23 08:12 AM UTC

Fig. 7. Case 2. Preoperative MR images (clockwise from top left): sagittal T1- postcontrast,
axial T1-, coronal T1- postcontrast, and sagittal T2-weighted studies demonstrating a pineal
region tumor that follows the cerebrospinal fluid signal closely on T1- and T2-weighted
sequences.

Unauthenticated | Downloaded 09/05/23 08:12 AM UTC

 Fig. 8. Case 2. Axial T2- and sagittal T1-weighted MR images obtained postoperatively
demonstrating changes in the pineal region and no residual mass.
Radiological Evaluation and Anatomical Study
The projections of the main approaches for large pineal region tumors were studied using a midsagittal
MR image. The retraction of the occipital lobe was imagined as a parallel line drawn 1.5 cm superior to
the tentorium (straight sinus), with retraction of the cerebellum as a parallel line drawn 2 cm inferiorly.
An MR image showed that the giant tentorial meningioma in our first patient (Case 1) had the maximum
diameter of 5.1 cm. The occipital-transtentorial approach had a projection revealing 65% of the tumor in
the sagittal plane (a = 3.3 cm), and the infratentorial-supracerebellar approach had a projection of 76% (b
= 3.9 cm), which was larger than the first one. The projection of the combined
supra/infratentorial-transsinus approach revealed the highest value as 100% (c = 5.1 cm), and the wide
working space provided for the surgeon was also demonstrated through this approach (Fig. 9). The
measurement of the same values in our second patient (Case 2) also showed a ratio of c > b > a (c = 4.6
cm, 100%; b = 4.1 cm, 93%; and a = 2.8 cm, 60%).

Unauthenticated | Downloaded 09/05/23 08:12 AM UTC

 Fig. 9. Schematic drawings of midsagittal images demonstrating the exposure of the various
approaches. A: The occipital-transtentorial approach with 1.5 cm of retraction on the
occipital lobe allows 65% exposure of the pineal region mass (a = 3.3 cm). B: The
infratentorial-supracerebellar approach with 2 cm of cerebellar retraction allows 76%
exposure of the pineal region mass (b = 3.9 cm). C: Combined
supra/infratentorial-transsinus approach allows 1.5 cm of occipital lobe and 2 cm of
cerebellar retraction and 100% exposure of the same pineal region mass (c = 5.1 cm). The
wide working space available to the surgeon with this approach is also demonstrated
(arrows). Dashed lines indicate tumor exposure.
The surgical anatomy of the pineal region for the combined approach was studied in five cadaveric head
specimens. We encountered no bridging veins between the transverse sinus and the inferior surface of the
occipital lobe. However, the retraction of the cerebellum may result in the sacrifice of some small
bridging veins. In all specimens we chose one side of the transverse sinus close to the torcular herophili
and sectioned it. After the slight retraction of the occipital lobe and the cerebellum, the superior approach
to the splenium of corpus callosum, the pineal gland and the third ventricle, and the lateral and inferior
approach into the quadrigeminal cistern were large enough to expose the pineal region (Fig. 10).

Unauthenticated | Downloaded 09/05/23 08:12 AM UTC

 Fig. 10. Left: Photograph showing the wide exposure of the pineal region after a combined
supra/infratentorial-transsinus approach in a cadaveric head specimen. Right: Artist's
drawing of the anatomical structures. BV = basal vein of Rosenthal; GV = vein of Galen; IC
= inferior colliculus; ICV = internal cerebral vein; IIIrd Vent. = third ventricle; PG = pineal
gland; SC = superior colliculus; Sp = splenium of the corpus callosum.
DISCUSSION
Previous Attempts to Reach the Pineal Region
Although Cushing[7] first proposed the idea of the surgical treatment of pineal lesions, he said that he
had never succeeded in exploring a pineal tumor sufficiently to justify an attempt at removing it.
Dandy[9] tried to remove pineal tumors via the transcallosal approach with the patient supine, splitting
the corpus callosum and resecting 2 to 4 cm of the splenium. The dissection was extremely difficult to
perform between the internal cerebral veins and the basal vein of Rosenthal and usually necessitated
sacrificing the internal cerebral and superior cerebellar veins. Also, an occipital lobectomy was
occasionally required.[22] Despite several complications and a mortality rate of 20%, this technique was
preferred by several authors.[12,14,18,32] The park-bench position was used in this approach, which
brought the sagittal sinus into a horizontal orientation and allowed the brain to retract with the pull of
gravity.[4]
Van Wagenen[34] used the transventricular approach in another unsuccessful attempt at removing pineal
tumors.[24,32] He tried to make a 6- to 7-cm, reversed L-shaped incision in the cortex, extending from
the posterior end of the superior temporal gyrus upward and backward, ending at the superior parietal
lobule. With another incision he reached the lateral ventricle. This approach was not preferred and has
rarely been used because of the morbidity resulting from the cortical incisions.[22]
Infratentorial-Supracerebellar Approach
The infratentorial-supracerebellar approach was introduced by Krause and improved by Stein[31] who
used microsurgical techniques. It has been reported by many authors that this approach allowed easy
orientation, did not require destruction of important structures, and provided for good visibility of the
important veins.[4,6,11,15,29-31] The sitting position was preferred so that the cerebellum could fall

Unauthenticated | Downloaded 09/05/23 08:12 AM UTC

inferiorly, thereby giving a wider surgical view without accumulation of blood in the operating field.[15]
The main disadvantage of this approach was the limited exposure of the tumors, which extended
anteriorly into the third ventricle and above the deep venous complex.[4] Large tumors extending
superiorly or inferiorly to the field of view can be brought into view by first debulking the tumor and
then grasping the tumor capsule and moving it. However, this method does not always work, especially if
the tumor is bloody. The lateral exposure of the tumor via an infratentorial-supracerebellar approach is
also restricted.
It is well known that the sitting position entails the risk of air embolism for the patient and is
uncomfortable for the surgeon.[2,15] Kobayashi, et al.,[16] described the Concorde position; a prone
position that provides for the elevation of the patient's shoulders with the head tilted to the right, away
from the surgeon. Although this position minimizes the risk of an air embolism and is more comfortable
for the surgeon, it is very disadvantageous for an assistant.[2] A modified Concorde approach with the
same disadvantage was reported by Bloomfield, et al.[4]
Occipital-Transtentorial Approach
After the description of the occipital-transtentorial approach was published,[12] some authors used it
with slight modifications.[13,23,24] The sitting,[22-25] semisitting,[4] and prone[26] positions were
usually preferred for this approach. Some authors also used a "three-quarter prone" position, concluding
that it eliminated the main disadvantages of the sitting position. There was no risk of air embolism and
the surgeon gained a better position from which to work.[2,5] The occipital lobe also fell, eliminating the
need for retraction. However, this position entailed some difficulties in orientation. During the
occipital-transtentorial approach a small part of the splenium might be sacrificed and the occipital lobe
might be retracted, which could lead to a homonymous hemianopsia. The approach to the contralateral
vein of Rosenthal was difficult.[2,4,17] The major advantages of this approach were the possibility of a
larger exposure of the lesion and its helpfulness in dissection of the lateral extension of the tumor.[4]
The infratentorial-supracerebellar approach is usually chosen for tumors located below the deep venous
complex in the pineal region. When the tumor is located above this complex or extends anteriorly into
the third ventricle, the transcallosal approach is occasionally used. When the tumor is extended above
and below this complex, the occipital-transtentorial approach is preferred. It has been suggested that the
depth of the lesion is not a factor in choosing one approach over another. The major factors affecting the
choice of approaches are the normal anatomical structures encountered in and around the tumor. These
structures may be sacrificed to expose a wider angle and gain access to the entire tumor.[4] It is obvious
that with gentle retraction the area between the undersurface of the occipital lobe and the upper surface
of the cerebellum provides the largest exposure for giant pineal region lesions. This requires division of
the transverse sinus, which should be completed at the nondominant side with the cutting of tentorium.
The advantages and disadvantages of the main approaches used for resection of pineal region tumors are
summarized in Table 2.

Unauthenticated | Downloaded 09/05/23 08:12 AM UTC

Combined Supra/Infratentorial-Transsinus Approach
Combined approaches for different regions and lesions of the brain have been used by several
authors.[1,3,10,19-21,28,33] The combined approach accomplished via a nondominant transverse sinus
section and then a reanastomosis for a pineal region meningioma were reported by Sekhar and Goel.[27]
Since that time we have used this approach for the removal of six large pineal region tumors. The
patient's position was either semiprone or three-quarters prone and was comfortable for the surgeon and
the assistant.
Previous attempts to remove tumors in three different patients by using the infratentorial-supracerebellar
or occipital-transtentorial approach were unsuccessful. In our cases, the exposure of all lesions by using
the combined approach was greater than with the other two approaches and substantially minimized the
risks associated with retraction. The important venous structures of the galenic system were well exposed
and none of them had to be sacrificed. The quadrigeminal cistern could be visualized between the pineal
gland and cerebellum with no retraction of the cerebellum. The tentorium was a natural barrier for
protecting the occipital cortex during the retraction. In tentorial meningiomas with a good arachnoid
plane around the lesion, the total removal of the tumor was simpler.
We usually prefer to use the infratentorial-supracerebellar approach to resect tumors of the pineal region.
The main indications for the use of the combined supra/infratentorial-transsinus approach in tumors are
as follows: 1) large tumors with diameters greater than 4.5 cm; 2) tumors extending well above and
below the planes of the tentorium or tumors arising from the tentorium; 3) tumors located well below the
plane of cerebellar retraction; 4) tumors encasing important venous structures of the region; and 5)
tumors that are very vascular, requiring the surgeon to cut around the tumor initially and devascularize it

Unauthenticated | Downloaded 09/05/23 08:12 AM UTC

before performing internal debulking. Our radiological and anatomical studies and surgical experiences
also confirmed that this approach provides a wider exposure for large pineal region tumors than the other
two approaches.
CONCLUSIONS
The combined supra/infratentorial-transsinus approach provides the greatest exposure for large pineal
region tumors and requires less brain retraction than either the infratentorial-supracerebellar or the
occipital-transtentorial approach.
Acknowledgments
The authors express their gratitude to Jennifer Pryll for the medical illustrations and to Joseph Reister for
editing and preparing the manuscript.

References
1. Al-Mefty O, Fox JL, Rifai A, et al: A combined infratemporal and posterior fossa approach for the
removal of giant glomus tumors and chondrosarcomas. Surg Neurol 28:423-431, 1987
2. Ausman JI, Malik GM, Dujovny M, et al: Three-quarter prone approach to the pineal-tentorial region.
Surg Neurol 29: 298-306, 1988
3. Bailey P: Concerning technic of operation for acoustic neurinoma. Zentralbl Neurochir 4:1-5, 1939
4. Bloomfield SM, Sonntag VKH, Spetzler RF: Pineal region lesions. BNI Q 1:10-23, 1985
5. Brotchi J, Raftopoulos C, Levivier M, et al: Lésions de la région pinéale et falco-tentorielle. Abord
occipito-pariétal en trois-quarts ventral avec volet infra-sagittal. Neurochirurgie 37:410-415, 1991
6. Bruce JN, Stein BM: Surgical management of pineal region tumors. Acta Neurochir 134:130-135,
1995
7. Cushing H: Intracranial Tumors: Notes Upon a Series of 2000 Verified Cases With Surgical
Mortality Pertaining Thereto. Springfield, Ill: Charles C. Thomas, 1932, p 64
8. Dandy WE: The Brain. Hagerstown, MD: WF Prior, 1966, p 590
9. Dandy WE: An operation for the removal of pineal tumors. Surg Gynecol Obstet 33:113-119, 1921
10. Daspit CP, Spetzler RF, Pappas CTE: Combined approach for lesions involving the cerebellopontine
angle and skull base: experience with 20 cases--preliminary report. Otolaryngol Head Neck Surg
105:788-796, 1991
11. Herrmann HD, Winkler D, Westphal M: Treatment of tumours of the pineal region and posterior part
of the third ventricle. Acta Neurochir 116:137-146, 1992
12. Horrax G: Treatment of tumors of the pineal body. Experience in a series of twenty-two cases. Arch
Neurol Psychiatry 64:227-242, 1950
13. Jamieson KG: Excision of pineal tumors. J Neurosurg 35:550-553, 1971

Unauthenticated | Downloaded 09/05/23 08:12 AM UTC

14. Kahn EA: Surgical treatment of pineal tumor. Arch Neurol Psychiatry 38:833-842, 1937
15. Kanno T: Surgical pitfalls in pinealoma surgery. Minim Invasive Neurosurg 38:153-157, 1995
16. Kobayashi S, Sugita K, Tanaka Y, et al: Infratentorial approach to the pineal region in the prone
position: Concorde position. Technical note. J Neurosurg 58:141-143, 1983
17. Konovalov AN, Spallone A, Pitzkhelauri DI: Meningioma of the pineal region: a surgical series of 10
cases. J Neurosurg 85:586-590, 1996
18. Kunicki A: Operative experiences in 8 cases of pineal tumor. J Neurosurg 17:815-823, 1960
19. Lazar ML, Clark K: Direct surgical management of masses in the region of the vein of Galen. Surg
Neurol 2:17-21, 1974
20. Malis LI: Surgical resection of tumors of the skull base, in Wilkins RH, Rengachary SS (eds):
Neurosurgery. New York: McGraw-Hill, 1985, Vol 1, pp 1011-1021
21. Naffziger HC: Brain surgery. With special reference to exposure of the brain stem and posterior
fossa: the principle of intracranial decompression, and relief of impactions in the posterior fossa. Surg
Gynecol Obstet 46:241-248, 1928
22. Pendl G: The surgery of pineal lesions--historical perspective, in Neuwelt AE (ed): Diagnosis and
Treatment of Pineal Region Tumors. Baltimore: Williams & Wilkins, 1984, pp 139-154
23. Poppen JL: The right occipital approach to a pinealoma. J Neurosurg 25:706-710, 1966
24. Poppen JL, Marino R Jr: Pinealomas and tumors of the posterior portion of the third ventricle. J
Neurosurg 28:357-364, 1968
25. Reid WS, Clark WK: Comparison of the infratentorial and transtentorial approaches to the pineal
region. Neurosurgery 3:1-8, 1978
26. Sano K: Pineal region tumors: problems in pathology and treatment. Clin Neurosurg 30:59-91, 1983
27. Sekhar LN, Goel A: Combined supratentorial and infratentorial approach to large pineal-region
meningioma. Surg Neurol 37:197-201, 1992
28. Spetzler RF, Daspit P, Pappas CTE: The combined supra- and infratentorial approach for lesions of
the petrous and clival regions: experience with 46 cases. J Neurosurg 76:588-599, 1992
29. Stein BM: The infratentorial supracerebellar approach to pineal lesions. J Neurosurg 35:197-202,
1971
30. Stein BM: Supracerebellar-infratentorial approach to pineal tumors. Surg Neurol 11:331-337, 1979
31. Stein BM: Surgical treatment of pineal tumors. Clin Neurosurg 26:490-510, 1979
32. Suzuki J, Iwabuchi T: Surgical removal of pineal tumors. (Pinealomas and teratomas.) Experience in
a series of 19 cases. J Neurosurg 23:565-571, 1965
33. Symon L: Surgical approaches to the tentorial hiatus. Adv Tech Stand Neurosurg 9:69-112, 1982

Unauthenticated | Downloaded 09/05/23 08:12 AM UTC

34. Van Wagenen WP: A surgical approach for the removal of certain pineal tumors. Report of a case.
Surg Gynecol Obstet 53:216-220, 1931
35. Wisoff JH, Epstein F: Surgical management of symptomatic pineal cysts. J Neurosurg 77:896-900,
1992

Manuscript received August 1, 1997.

Accepted in final form January 6, 1998.
Address reprint requests to: Laligam N. Sekhar, M.D., Department of Neurological Surgery, The George
Washington University Medical Center, 2150 Pennsylvania Avenue NW, Suite 7-420, Washington, D.C.
20037.

Unauthenticated | Downloaded 09/05/23 08:12 AM UTC