The microsurgical management of benign pineal cysts: Helsinki experience in 60 cases

Background: Microsurgical resection represents a well-accepted management option for symptomatic benign pineal cysts. Symptoms such as a headache, hydrocephalus, and visual deficiency are typically associated with pineal cysts. However, more recent studies reported over the past years have characterized additional symptoms as a part of the clinical manifestation of this disease and represent additional indications for intervention. Methods: We present a retrospective review of patients with histologically confirmed benign pineal cysts that were operated on in our department between 1997 and 2015. A demographic analysis, evaluation of preoperative status, surgical treatment, as well as immediate and long-term clinical and radiological outcomes were conducted. Results: A total of 60 patients with benign pineal cysts underwent surgery between 1997 and 2015. Gross total resection was achieved in 58 cases. All patients except one improved in their clinical status or had made a full recovery at the time of the last follow-up. The key steps for surgical resection of pineal cysts are reported, based on an analysis of representative surgical videos. Conclusions: We describe in this paper one of the largest series of microsurgically treated pineal cysts. In our opinion, judicious microsurgery remains the most suitable technique to effectively deal with this disease.Peer reviewe

Praying Sitting Position for Pineal Region Surgery : An Efficient Variant of a Classic Position in Neurosurgery

BACKGROUND: The sitting position has lost favor among neurosurgeons partly owing to assumptions of increased complications, such as venous air embolisms and hemodynamic disturbances. Moreover, the surgeon must assume a tiring posture. We describe our protocol for the "praying position" for pineal region surgery; this variant may reduce some of the risks of the sitting position, while providing a more ergonomic surgical position. METHODS: A retrospective review of 56 pineal lesions operated on using the praying position between January 2008 and October 2015 was performed. The praying position is a steeper sitting position with the upper torso and the head bent forward and downward. The patient's head is tilted about 30 degrees making the tentorium almost horizontal, thus providing a good viewing angle. G-suit trousers or elastic bandages around the lower extremities are always used. RESULTS: Complete lesion removal was achieved in 52 cases; subtotal removal was achieved in 4. Venous air embolism associated with persistent hemodynamic changes was nonexistent in this series. When venous air embolism was suspected, an immediate reaction based on good teamwork was imperative. No cervical spine cord injury or peripheral nerve damage was reported. The microsurgical time was CONCLUSIONS: A protocolized praying position that includes proper teamwork management may provide a simple, fast, and safe approach for proper placement of the patient for pineal region surgery.Peer reviewe

Pineoblastomas : A long-term follow up study of three cases in Helsinki Neurosurgery

Background Pineoblastomas are very rare malignant lesions with a bad prognosis and high mortality during the first five years from diagnosis. Report of cases We present a retrospective review of three patients with histologically confirmed pineoblastomas consecutively operated on between 1997 and 2015. One of our patients died >14 years after surgery, and the other 2 patients are still alive and in good condition without recurrence of the disease >12 years after surgery. All of them underwent gross total resection and craniospinal radiotherapy. Individualized scheme of chemotherapy was administered in two cases. The cornerstones for the surgical resection of pineoblastomas are reported. Conclusions A proper multidisciplinary management of pineoblastomas, which associates gross total microsurgical resection of the lesion and an adjuvant therapy determined by our neurooncology team based on accurate craniospinal adjuvant radiotherapy with boost of radiation on the tumoral bed, and when needed, an adequate but aggressive medulloblastoma-like chemotherapy, may improve the overall survival of these malignant lesions.Peer reviewe

Pineal Parenchymal Tumors of Intermediate Differentiation : A long-Term Follow-Up Study in Helsinki Neurosurgery

BACKGROUND: Pineal parenchymal tumors of intermediate differentiation (PPTIDs) are rare lesions with particular features compared with other pineal parenchymal tumors. METHODS: We present a retrospective review of patients with histologically confirmed PPTIDs who were operated on in our department between 1997 and 2015. A demographic analysis and an evaluation of preoperative status, surgical treatment, as well as immediate and long-term clinical and radiologic outcomes were conducted. RESULTS: Fifteen patients with PPTIDs were operated on between 1997 and 2015. Gross total removal was achieved in 11 cases; 2 patients underwent near-total resection, 1 partial resection, and 1 received brachytherapy after an endoscopic biopsy. Nine patients required external radiation therapy (4 due to a pleomorphic histology of their lesion including pineoblastoma features in 3 of them; 3 after a subtotal resection; and 2 for tumor recurrence). No patient received chemotherapy. The survival rate of our patients was 57.1% at a mean follow-up of 137.2 +/- 77.6 months (39-248 months). CONCLUSIONS: A proper multidisciplinary management of PPTIDs based on a gross total removal of the lesion, and an adjuvant radiotherapy in selected cases, may improve the overall survival of these aggressive tumors.Peer reviewe

Pretreatment with a dual antiplatelet and anticoagulant (APAC) reduces ischemia-reperfusion injury in a mouse model of temporary middle cerebral artery occlusion-implications for neurovascular procedures

Background Several neurovascular procedures require temporary occlusion of cerebral arteries, leading to ischemia of unpredictable length, occasionally causing brain infarction. Experimental models of cerebral ischemia-reperfusion injury have established that platelet adhesion and coagulation play detrimental roles in reperfusion injury following transient cerebral ischemia. Therefore, in a model of cerebral ischemia-reperfusion injury (IRI), we investigated the therapeutic potential of a dual antiplatelet and anticoagulant (APAC) heparin proteoglycan mimetic which is able to bind to vascular injury sites. Methods Brain ischemia was induced in mice by transient occlusion of the right middle cerebral artery for 60 min. APAC, unfractionated heparin (UFH) (both at heparin equivalent doses of 0.5 mg/kg), or vehicle was intravenously administered 10 min before or 60 min after the start of ischemia. At 24 h later, mice were scored for their neurological and motor behavior, and brain damage was quantified. Results Both APAC and UFH administered before the onset of ischemia reduced brain injury. APAC and UFH pretreated mice had better neurological and motor functions (p < 0.05 and p < 0.01, respectively) and had significantly reduced cerebral infarct sizes (p < 0.01 and p < 0.001, respectively) at 24 h after transient occlusion compared with vehicle-treated mice. Importantly, no macroscopic bleeding complications were observed in either APAC- or UFH-treated animals. However, when APAC or UFH was administered 60 min after the start of ischemia, the therapeutic effect was lost, but without hemorrhaging either. Conclusions Pretreatment with APAC or UFH was safe and effective in reducing brain injury in a model of cerebral ischemia induced by transient middle cerebral artery occlusion. Further studies on the use of APAC to limit ischemic injury during temporary occlusion in neurovascular procedures are indicated.Peer reviewe