PMC6744791_01
Magnetic resonance images for patient 1. (a) Preoperative postcontrast T1 sagittal, avidly enhancing mass measuring 3.6 cm anterior-posterior (white arrow) along the tentorium, compressing the aqueduct of Sylvius. Tentorial angle is excessively steep (black arrow), which prohibits an infratentorial approach. (b) Preoperative postcontrast T1 coronal, redemonstration of hyperintense mass measuring 3 cm transverse (white arrow). (c) Preoperative postcontrast T1 axial, hyperintense mass measuring 3.5 cm cranial-caudal (white arrow). (d) Postoperative postcontrast T1 sagittal, postsurgical changes demonstrating gross total resection of pineal region mass (white arrow). (e) Postoperative postcontrast T1 coronal, postsurgical changes demonstrating gross total resection of pineal region mass (white arrow). (f) Postoperative postcontrast T1 axial, postsurgical changes demonstrating gross total resection of pineal region mass (white arrow).
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F1
Preoperative imaging showed a 3.6 cm x 3.5 cm x 3 cm enhancing lesion in the posterior incisural space with severe brainstem compression [Figure 1a-c]. The patient underwent two stages of resection: an initial left parietal-occipital transtentorial retractorless interhemispheric approach under general anesthesia with electrophysiological monitoring followed 2 days later by a right sided approach for complete tumor resection [Figure 1d-f].
(a) Surgical position keeping sagittal plane parallel to the floor. (b) Craniotomy exposing bilateral dura as well as torcula.
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F2
Gravity served to retract the parietal-occipital lobe [Figure 2].
PMC6744791_02
Magnetic resonance Images for patient 2. (a) Preoperative postcontrast T1 sagittal, homogeneously enhancing ovoid mass centered in the quadrigeminal cistern/pineal region which measures 3.5 cm anterior-posterior (white arrow), compressing the cerebral aqueduct. Tentorial angle is excessively steep (black arrow), which prohibits an infratentorial approach. (b) Preoperative postcontrast T1 coronal, homogeneously enhancing mass measuring 3.1 cm transverse (white arrow). (c) Preoperative postcontrast T1 axial, homogeneously enhancing mass measuring 3 cm cranial-caudal (white arrow). (d) Postoperative postcontrast T1 sagittal, postsurgical changes demonstrating residual tumor capsule (white arrow) attached to segments of the Vein of Galen and internal cerebral vein. (e) Postoperative postcontrast T1 coronal, postsurgical changes demonstrating gross total resection of pineal region mass (white arrow). (f) Postoperative postcontrast T1 axial, postsurgical changes demonstrating residual tumor capsule (white arrow) attached to segments of the Vein of Galen and internal cerebral vein.
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F3
Imaging revealed a 3.5 cm x 3.1 cm x 3 cm large pineal region enhancing lesion with brainstem (midbrain in the tectal plate) and cerebellar compression [Figure 3a-c]. Follow-up magnetic resonance imaging (MRI) 8 months after surgery revealed the minimal residual presence and no signs of progression [Figure 3d-f].
PMC6744791_03
Magnetic resonance images for patient 3. (a) Preoperative postcontrast T1 axial, homogeneously enhancing infratentorial paramedian lesion with high perilesional vascularity (black arrow). (b) Preoperative postcontrast T1 coronal, showing tentorial attachments. (c) Preoperative postcontrast T1 sagittal, showing a homogeneously enhancing mass with perilesional vascularity, and steep tentorial angle. (d) Postoperative (5 months) postcontrast T1 axial, demonstrating minimal tentorial enhancement and vascular clips artifact. (e) Postoperative postcontrast T1 coronal, demonstrating gross total resection and vascular clips artifact. (f) Postoperative noncontrast T1 sagittal, showing postsurgical changes.
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F4
He was found to have a 3.2 cm x 2.9 cm x 3.2 cm posterior fossa lesion arising from the inferior surface of the left tentorial leaflet, associated with cerebellar edema, effacement of the fourth ventricle, and mild hydrocephalus [Figure 4a-c]. The pathology report confirmed a WHO Grade I hemangioblastoma, and an immediate postoperative MRI and another at 5 months postsurgery confirmed gross total resection [Figure 4d-f].
PMC6744791_04
Magnetic resonance images for patient 4. (a) Preoperative postcontrast T1 axial, showing heterogeneously enhancing superior vermian lesion without hydrocephalus. (b) Preoperative postcontrast T1 coronal. (c) Preoperative postcontrast T1 sagittal, showing a heterogeneously enhancing mass with a displacement of tectal plate and steep tentorial angle. (d) Postoperative postcontrast T1 axial, demonstrating minimal surgical cavity and residual lesion. (e) Postoperative postcontrast T1 coronal, demonstrating partial resection. (f) Postoperative noncontrast T1 sagittal, demonstrating postsurgical changes.
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F5
A 47-year-old female presented with dysmetria and gait imbalance, with a history of metastatic breast cancer that was already managed at another institution with chemotherapy and whole brain radiation treatments for a superior vermian metastasis 3.1 cm x 3.0 cm x 3 cm [Figure 5a-c]. Pathology reported metastatic adenocarcinoma with prominent necrosis and we are pending to start stereotactic radiation treatment for the residual lesion [Figure 5d-f].