• Pablo Villanueva, Robert G Louis, Aaron R Cutler, Hua Wei, Danjuma Sale, Huy T Duong, Garni Barkhoudarian, and Daniel F Kelly.
• *Department of Neurosurgery, Catholic University of Chile, Santiago, Chile; ‡Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California; §Department of Neurological Surgery, University of Utah, Salt Lake City, Utah; ¶Department of Neurosurgery, Fudan University, Shanghai, China; ‖Department of Neurosurgery, Kaiser Medical Center Sacramento, Sacramento, California.
• Neurosurgery. 2015 Aug 14.

BackgroundTraditional approaches to medial temporo-occipital intra-axial brain tumors carry the risk of visual or language deficits related to brain retraction or transgression of deep fiber tracts. To reduce these risks, the microscopic supracerebellar transtentorial approach with the patient in the sitting position has been previously described for lesions in relative proximity to the tentorium.ObjectiveWe describe this approach performed with endoscopic tumor resection to allow better visualization and a more ergonomic operating position.MethodsFour consecutive patients harboring a medial temporo-occipital lesion are reported. All were operated on while in the sitting position using frameless navigation and a supracerebellar transtentorial approach. Tumor resection was performed by 2 surgeons with endoscopic visualization.ResultsPathologies included intraparenchymal metastatic melanoma, cavernous hemangioma, and ganglioglioma, as well as an intraventricular metastatic tumor. The distance from the tentorium to the lesion ranged from 1 to 4 mm. Gross total resection was achieved in 3 of the 4 patients. The patient with a metastatic melanoma had an intentional near-total resection given the tumor encasing a branch of the posterior cerebral artery. The patient with the intraventricular tumor sustained a small but symptomatic infarct of the lateral geniculate region, resulting in a visual field deficit.ConclusionThis small series suggests that the endoscopic supracerebellar transtentorial approach with the patient in the sitting position can be a safe and effective approach for removing medial temporo-occipital lesions. It allows excellent tumor visualization, eliminates the need for brain retraction, minimizes parenchymal transgression, and improves surgical ergonomics. Significant experience in endoscopy and excellent neuroanesthesia support are recommended before undertaking this approach.

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