The complications and outcome with three different approaches to direct surgical exploration of pineal tumors were studied in 16 consecutive patients. Among the 16 pineal tumors were three two-cell pattern germinomas, one mature teratoma, five mixed germ cell tumors, three astrocytomas, one ependymoma, one metastatic lung cancer, one hemangioblastoma, and one epithelial cyst. The parietal transcallosal approach (Dandy) was employed in eight cases. Four of these patients showed disconnection syndrome, memory and intellectual disturbances presumably due to splitting of the corpus callosum. Left sensorimotor disturbance and homonymous hemianopsia secondary to compression of the right parieto-occipital lobe were also observed in six patients postoperatively. However, these deficits tended to disappear within 1 to 2 months, especially in the younger patients. The single hemangioblastoma was totally excised via the occipital transtentorial approach (Jamieson), with complications of truncal ataxia and slurred speech. Seven tumors were removed by the infratentorial supracerebellar approach (Krause), with no complications. Thus, the infratentorial supracerebellar approach may be the safest and most effective means of removing a pineal lesion. The outcome of patients with mixed germ cell tumors (three of five died within 1 year) and astrocytomas (two of three died within 3 years) was poor, whereas that of patients with germinoma and mature teratoma was excellent. The long-term prognosis of patients with pineal tumors appeared to depend on the type of tumor, the response to irradiation, and whether or not excision was total.
