The supracerebellar approach to pineal lesions: A review of history, evolution, and outcomes

Background: The supracerebellar approach is a well-established surgical corridor for lesions of the pineal region and dorsal midbrain. Since its original description in the early 20 th century, this approach has undergone substantial refinement, including the development of paramedian, extreme lateral, and combined supra- and infratentorial variants. Advances in microsurgical techniques and visualization have improved safety and expanded its applicability. More recently, endoscopic integration has further enhanced exposure while minimizing surgical morbidity. Methods: This narrative review examines the historical evolution, technical modifications, and contemporary applications of supracerebellar approaches for pineal region pathology. A comprehensive synthesis of classical and modern literature was performed, with particular emphasis on anatomical considerations, operative nuances, patient positioning, and outcomes associated with microsurgical and endoscopic techniques. Results: Technical advancements, including refined patient positioning, microsurgical instrumentation, and endoscopic assistance, have improved visualization of deep midline structures and reduced operative morbidity. Endoscopic supracerebellar approaches offer minimally invasive alternatives with favorable clinical outcomes, particularly for midline lesions. However, limitations persist, including restricted access to laterally extending tumors and risks related to venous injury and positioning-related complications. Conclusion: The supracerebellar approach remains a cornerstone in the surgical management of pineal and dorsal midbrain lesions. Ongoing technical innovations, particularly the integration of endoscopic techniques and hybrid approaches, continue to expand its versatility and safety profile. Future advancements in visualization and instrumentation are likely to further refine this approach and improve outcomes for complex pineal region pathologies.