Supracerebellar Infratentorial Paramedian Approach in Helsinki Neurosurgery: Cornerstones of a Safe and Effective Route to the Pineal Region

OBJECTIVE: The supracerebellar infratentorial (SCIT) paramedian approach in sitting position represents one of the most used surgical routes for dealing with pineal region lesions. The purpose of this study is to determine the cornerstones to perform this approach in a simple, safe, and effective way, so that it could be easily reproduced in other neurosurgical centers, particularly in those with modest resources. METHODS: We reviewed and analyzed the surgical videos of 24 pineal region lesions that were operated on through an SCIT approach between June 2012 and October 2015. The SCIT approach may be divided into 3 main steps: 1) skin-muscle incision; 2) craniotomy; and 3) dura opening and access to the pineal region. RESULTS: Complete lesion removal was accomplished in 23 cases, and subtotal removal was accomplished in 1 case. The pineal regionwas effectively and safely reached through the SCIT approach in the sitting position with a mean time of 14 minutes, using a basic set of microsurgical instruments. Cornerstones and potential delaying events were carefully recorded for each of the 3 main steps of the approach. Moreover, we present in a short video a step-by-step guide to perform the SCIT approach in a fast and safe way. CONCLUSIONS: A correct application of microsurgical principles may allow to safely and rapidly perform the SCIT approach, therefore offering an effective and relatively atraumatic route for dealing with pineal region lesions.