Safe handling of veins in the pineal region—a mixed method study

  • Markus E. Krogager
  • Asgeir S. Jakola
  • Lars Poulsgaard
  • William Couldwell
  • Tiit Mathiesen
Original Article


Surgical experience in pineal surgery is largely confined to a few experienced surgeons and may be lost when they stop their practice. The objective of this study is to systematically preserve and analyze valuable practical knowledge of pineal region surgical venous anatomy. A survey was constructed to obtain experienced surgeons’ perception of estimated risks and individual experience following occlusion of veins during pineal surgery. Data were qualitative and analyzed with a mixed methods approach. Of the 126 invited neurosurgeons, 40 submitted completed questionnaires. General agreement existed of which veins were associated with high and low risks following occlusion. The risk of death was estimated to be high with sacrifice of the vein of Galen (83%), both internal cerebral veins (69%) and the basal veins (58%). The risk of death was estimated to be lower with the sacrifice of both superior vermian veins (13%) and one internal occipital vein (10%). Importantly, a sub-group of experienced surgeons reported substantial risk of death and consequences with the sacrifice of cerebellar bridging veins (8–13%). Our findings provide a coherent picture of surgical risk with venous sacrifice, which can inform the surgical community of systematically gathered views from aggregated surgeries of a very large cohort of patients. Extensive presurgical radiological workup and anatomical studies seemed to correlate more cautious risk estimations. Our findings increase available knowledge of risks of venous complications.


Cysts Fossa Occlusion Pineal Surgery Veins 



We thank the following neurosurgeons, who contributed with indispensable surgical knowledge and experience to the survey that formed the basis of this paper:

– Jannick Brennum, MD, Chairman of the Neurocenter, Rigshospitalet

– Lars Bøgeskov, MD, Department of Neurosurgery, Rigshospitalet

– Thomas Santarius, MD PhD, Cambridge University Hospitals NHS Trust (Addenbrooke’s)

– Marc Sindou, MD and Dumot Chloé MSc, University of Lyon

– Evandro de Oliveira, MD PhD, Adjunct Professor of Neurological Surgery at the Mayo Clinic

– Ulrich Sure, MD, Professor at University Hospital of Essen

– M. Necmettin Pamir, MD, Professor, President at Acibadem University

– Luca Regli MD, Professor and Chairman of University Hospital of Zurich

– Andreas Raabe MD, Professor, Chairman of Neurosurgery at Bern University Hospital

– Henry W. S. Schroeder, MD PhD, Dept. of Neurosurgery at the University Medicine Greifswald

– Fady T. Charbel MD, Professor and Chief at University of Illinois Hospital

– Marcos Soares Tatagiba, MD, Professor and Chief at University of Tübingen

– Veit Rohde, MD, Professor and Chief at University Medical Center Göttingen

– Jafri Malin Abdullah, MD, Professor and Chief at University of Sciences Malaysia, Department of NS

– Basant Misra, MD, Professor and Head of the Department of NS at Hinduja National Hospital

– Ioan Stefan Florian, MD PhD, Professor of the Department of NS at University of Cluj-Napoca

– Peter Nakaji, MD, Department of Neurosurgery at Barrow Neurological Institute

– Vladimir Benes, MD PhD, Professor and Chairman of the Department of NS at University Hospital Prague

– Nejat Akalan, MD PhD, Professor of the Department of Neurosurgery at Hacettepe University

– Kazuhiro Hongo, MD, Professor of the Department of Neurosurgery at Shinshu University

– Helmut Bertalanffy, MD, Professor and Director for Neurosurgery, International Neuroscience Institute Hannover

– Takanori Fukushima, MD, Professor of Neurosurgery at Duke University

– Juha Hernesemi, MD PhD, Professor emeritus in Neurosurgery at University of Helsinki

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval


Informed consent

No patients are directly involved. All questioned surgeons consented.

Supplementary material

10143_2019_1189_MOESM1_ESM.pdf (3.3 mb)
ESM 1 (PDF 3354 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of NeurosurgeryRigshospitaletCopenhagenDenmark
  2. 2.Institute of Neuroscience and PhysiologySahlgrenska AcademyGothenburgSweden
  3. 3.Department of NeurosurgerySahlgrenska University HospitalGothenburgSweden
  4. 4.Department of NeurosurgeryUniversity of UtahSalt Lake CityUSA
  5. 5.IKMUniversity of CopenhagenCopenhagenDenmark
  6. 6.Department of Clinical NeuroscienceKarolinska InstituteSolnaSweden

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