Use of 3D-computed tomography angiography for planning the surgical removal of pineal region meningiomas using Poppen's approach: a report of ten cases and a literature review

Yunqian Li, Gang Zhao, Honglei Wang, Wanan Zhu, Limei Qu, Ye Li, Jinlu Yu, Yunqian Li, Gang Zhao, Honglei Wang, Wanan Zhu, Limei Qu, Ye Li, Jinlu Yu

Abstract

Background: There are several treatment approaches for pineal region meningiomas, such as Poppen's approach, Krause's approach and combinations of the two approaches. We present our experience with the use of 3D-computed tomography angiography for planning the surgical removal of pineal region meningiomas using a suboccipital transtentorial approach (Poppen's approach) and evaluate the role of Poppen's approach.

Methods: During the period from January 2005 to June 2010, ten patients presented to us with pineal region meningioma. MRI was routinely used to define the tumor size, position, and its relevant complications while 3D-CTA was applied to define the blood supply of the tumor and the venous complex (VC) shift before operations. Most of the meningiomas had developed at both sides of the tentorial plane and extended laterally with typical characteristics of a pineal region tumor.

Results: All tumors were completely removed surgically without any injury to the VC. Postoperative intracranial infection occurred in one case who recovered after antibiotics were given. Postoperative intraventricular hemorrhage and pneumocephalus were found in one case, but fully recovered after conservative treatment. In the nine cases of concurrent hydrocephalus, this was gradually relieved in eight patients and the single case that became aggravated was successfully treated with ventriculoperitoneal shunt. Moreover, the follow-up MRI examinations did not indicate any recurrence of the meningiomas.

Conclusion: We found that the use of Poppen's approach is strongly supported for the successful removal of pineal region meningiomas without serious complications.

Figures

Figure 1
Figure 1
Case 5: A: Sagittal sections of MRI scans showing a huge meningioma which was contrast enhanced in the pineal region. It grows below and above the tentorium. B-C: CTA images show moderate tumor (T) staining. The meningioma is supplied by the posterior branch of the cerebral artery (ellipse). VC shows downward shifting (arrow). D: An image of the opening of the cerebral falx (black arrow) and tentorium (green arrow) that exposed the tumor (T), in order to carry out the piecemeal excision. E: Postoperative contrast-enhanced sagittal MRI sections showing the surgical removal of the pineal region meningioma; the artefact of the early postoperative period can be seen. F: Histopathological section of the tumor showing an endothelial WHO grade I meningioma (HE ×200).
Figure 2
Figure 2
Case 8: A-B: Axial and sagittal sections of MRI scans showing an enhancing contrast tumor in the pineal region, below the tentorium. C: CTA image showing intense tumor staining. The tumor is supplied by the posterior cerebral and superior cerebellar arteries (arrow). D: Exposure of the tumor (T) after sectioning of the tentorium (green arrow), and cerebral falx (black arrow). E: Histopathological section of the tumor showing a vascular WHO grade I meningioma (HE, x200). F: Postoperative contrast-enhanced sagittal section of the MRI showing no residual tumor.
Figure 3
Figure 3
Case 10: A-B: Axial and sagittal sections of MRI scans that show a contrast-enhanced tumor in the pineal region below the tentorium compressing the brainstem. C: CTA did not demonstrate tumor staining or a feeding artery. D: Postoperative CT scan showing hemorrhage in the lateral ventricle and pneumocephalus. E: Histopathological section of the tumor showing a WHO grade II meningioma (HE, x200). F: Postoperative sagittal MRI section showing no residual tumor.

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