Arterial vascularization of the pineal gland

The Minimally Invasive Lateral Occipital Infracortical Supra-/Transtentorial Approach in Surgery of Lesions of the Pineal Region: A Possible Alternative to the Standard Approaches

OBJECTIVE

The pineal region is an anatomical region that is difficult to access surgically, especially when it comes to removing neoplasms. Four main surgical approaches to this region are used as standards nowadays: infratentorial supracerebellar, occipital supra-/transtentorial, interhemispheric, and transventricular approaches. All methods have both advantages and disadvantages and are associated to any extent with intra- and postoperative risks. We have developed a lateral minimally invasive occipital infracortical supra-/transtentorial (OICST) approach, which retains the advantages of the standard occipital transtentorial approach while improving tumor exposure and minimizing its disadvantages.

METHODS

We describe 7 consecutive cases of successful complete removals of pineal tumor formations of various quality and size (3 pineal cysts, 2 pineocytomas, 1 meningioma, 1 medulloblastoma) using the OICST approach developed by us. Preoperative 3-dimensional and virtual reality-modeling and the use of a special retractor also contributed to reducing the size of the surgical approach.

RESULTS

All patients underwent surgery for removal of a lesion in the pineal region and suffered from no new and permanent neurological deficits postoperatively. The mean size of the craniotomies was 2.3 × 1.85 cm. The minimally invasive approach developed by us carries the advantages of the standard occipital transtentorial approach, but minimizes its disadvantages. The main disadvantage of the standard occipital approach is excessive retraction of the occipital lobe, which is frequently associated with visual neurological deficits. Also, with occipital approach, the Rosenthal vein lying along the surgical corridor is frequently not good visible since the tumor is approached from its tip rather than side which limits the overview of the surgical field and can pose a risk. Damage to this vein can cause infarction of the basal ganglia. By approaching the pineal region from more laterally the size of the craniotomy can significantly be reduced, excessive retraction of the occipital lobe can be avoided and the risk of damage to large deep veins can be minimized. The cosmetic outcome with a small skin incision of only about 3 cm is also a very good side effect of this minimally invasive technique.

CONCLUSIONS

The minimally invasive lateral OICST approach described by us can be successfully used in the surgery of pineal neoplasms. Reducing the size of the craniotomy does not limit the possibility of complete removal of tumors of various sizes and tissue consistency, and also minimizes the risks of both intra- and postoperative complications.

CSF generation by pineal gland results in a robust melatonin circadian rhythm in the third ventricle as an unique light/dark signal

Pineal gland is an important organ for the regulation of the bio-clock in all vertebrate species. Its major secretory product is melatonin which is considered as the chemical expression of darkness due to its circadian peak exclusively at night. Pineal melatonin can be either released into the blood stream or directly enter into the CSF of the third ventricle via the pineal recess. We have hypothesized that rather than the peripheral circulatory melatonin circadian rhythm serving as the light/dark signal, it is the melatonin rhythm in CSF of the third ventricle that serves this purpose. This is due to the fact that melatonin circadian rhythm in the CSF is more robust in terms of its extremely high concentration and its precise on/off peaks. Thus, extrapineal-generated melatonin or diet-derived melatonin which enters blood would not interfere with the bio-clock function of vertebrates. In addition, based on the relationship of the pineal gland to the CSF and the vascular structure of this gland, we also hypothesize that pineal gland is an essential player for CSF production. We feel it participates in both the formation and reabsorption of CSF. The mechanisms associated with these processes are reviewed and discussed in this brief review.