PMC9990807_01
Brain magnetic resonance imaging (MRI). Preoperative axial (a), sagittal (b), and frontal (c) contrast T1-weighted image and axial (d), sagittal (e), and frontal (f) T2-weighted images demonstrates a large (43 x 36 x 35 mm) and homogenously enhancing tumor in the pineal region, occluding the aqueduct, and results in the hydrocephalus.
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F1
Contrast brain MRI showed a large smooth, oval, well circumscribed mass (43 x 36 x 35 mm) in the pineal region, mass effect, and ventricular enlargement [Figures 1a-f].
(a) Patient positioning in the operating room. (b) CT 3D reconstruction of the patient's head with a black arrow indicating the midline occipital incision (dashed line). (c) Postoperative CT 3D reconstruction demonstrating craniotomy extension (dashed black arrow).
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The patient was in the three-quarter prone position with the neck flexed and the torso elevated about 30  [Figure 2a]. A midline skin incision was made in the occipital region, and an occipital bone flap was fashioned [Figures 2b and c].
Intraoperative view. (a) Surgical corridor via supracerebellar infratentorial approach. (b and c) The pineal region tumor visualization. (d) Identifying the Vein of Galen. (e) Surgical corridor via right occipital interhemispheric approach. (f) visualization of the superior part of the tumor. (OPMI PENTERO 900 x6).
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First, the supracerebellar infratentorial approach was performed [Figure 3a], and a gray-yellow mass that grows in the capsule was identified in the pineal region [Figures 3b and c]. During the tumor removal, the vein of Galen and the pineal gland were identified and preserved [Figure 3d]. The U-shaped dural opening over the transverse sinus is done on the right side of the sagittal sinus [Figure 3e]. The right occipital lobe was carefully retracted, and the superior part of the tumor was dissected from the medial part of the occipital lobes and the spleen of the corpus callosum and removed [Figure 3f].
A histological specimen from the tumor resection demonstrates transitional meningioma, WHO Grade 1, ICD-O code 9537/0. Hematoxylin and eosin (x200). A pathological examination was carried out using an Axioskop 40 microscope by Carl Zeiss (Germany) and a panoramic MIDI scanning microscope, with a total magnification of x200. The hematoxylin and eosin stained slides demonstrated meningothelial cells with bundles of elongated cells that form collagen and reticulin fibers. The nuclei are oval, round, spindle-shaped, and monomorphic.
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The histopathologic diagnosis was transitional meningioma (WHO Grade 1, ICD-O code 9537/0) [Figure 4].
Postoperative axial contrast T1-weighted (a), sagittal T2-weighted (b), and CE-FLAIR coronal (c) MRI scans showing tumor removal through a combined supracerebellar infratentorial and occipital interhemispheric approach and the surgical corridor.
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A control brain MRI with contrast-enhancement [Figure 5], performed 3 months after the surgery, shows total tumor removal and hydrocephalus regression due to the restoration of cerebrospinal fluid flow.