What is the best surgical approach for Pineal Region Tumors? A systematic literature review and anatomical comparative study.

PURPOSE: Pineal region tumors pose significant surgical challenges due to their deep location and proximity to critical neurovascular structures. Despite multiple described techniques, no consensus exists on the optimal surgical approach, with the supracerebellar infratentorial (SCIT) and occipital interhemispheric transtentorial (OITA) approaches representing the most adopted corridors.

METHODS

A systematic literature review was conducted to evaluate surgical approaches for pineal region tumors and their associated complication profiles. In addition, anatomical dissections combined with a tumor simulation technique were used as illustrative tools to compare exposure patterns obtained through SCIT, SCIT with tentorial incision (SCIT + T), and OITA approaches.

RESULTS

The systematic review, comprising 27 studies and 1774 patients, identified OITA (42.21%) and SCIT (38.27%) as the most frequently employed approaches. SCIT was more commonly associated with cerebellar complications, cerebrospinal fluid leaks, meningitis, and Parinaud's syndrome (p < 0.005), whereas OITA was associated with a higher incidence of homonymous hemianopia (p = 0.0011). From an anatomical perspective, infratentorial approaches provided broader exposure of the inferior quadrants (Q1, Q2), while OITA offered greater visualization of the superior ipsilateral quadrant (Q3). The addition of a tentorial incision to SCIT facilitated visualization of supratentorial quadrants (Q3, Q4), which are otherwise less accessible through the standard infratentorial corridor. Tumor simulations further illustrated that approach selection is influenced by the tumor's relationship to the deep venous system, with supratentorial routes favoring lesions anterior to the veins and infratentorial corridors favoring posterior extension.

CONCLUSIONS

Selection between SCIT and OITA should be individualized based on tumor characteristics, venous relationships, and tentorial anatomy. Tentorial incision may expand the versatility of SCIT in selected cases.