Endonasal endoscopic transsphenoidal resection of intrinsic third ventricular craniopharyngioma: surgical results

Abstract

OBJECTIVEIntrinsic third ventricular craniopharyngiomas (IVCs) have been reported by some authors to “pose the greatest surgical challenge” of all craniopharyngiomas (CPAs). A variety of open microsurgical approaches have historically been used for resection of these tumors. Despite increased utilization of the endoscopic endonasal approach (EEA) for resection of CPAs in recent years, many authors continue to recommend against use of the EEA for resection of IVCs. In this paper, the authors present the largest series to date utilizing the EEA to remove IVCs.METHODSThe authors reviewed a prospectively acquired database of the EEA for resection of IVCs over 14 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital. Preoperative MR images were examined independently by two neurosurgeons and a neuroradiologist to identify IVCs. Pre- and postoperative endocrinological, ophthalmological, radiographic, and other morbidities were determined from retrospective chart review and volumetric radiographic analysis.RESULTSBetween January 2006 and August 2017, 10 patients (4 men, 6 women) ranging in age from 26 to 67 years old, underwent resection of an IVC utilizing the EEA. Preoperative endocrinopathy was present in 70% and visual deterioration in 60%. Gross-total resection (GTR) was achieved in 9 (90%) of 10 patients, with achievement of near-total (98%) resection in the remaining patient. Pathology was papillary in 30%. Closure incorporated a “gasket-seal” technique with nasoseptal flap coverage and either lumbar drainage (9 patients) or a ventricular drain (1 patient). Postoperatively, complete anterior and posterior pituitary insufficiency was present in 90% and 70% of patients, respectively. In 4 patients with normal vision prior to surgery, 3 had stable vision following tumor resection. One patient noted a new, incongruous, left inferior homonymous quadrantanopsia postoperatively. In the 6 patients who presented with compromised vision, 2 reported stable vision following surgery. Each of the remaining 4 patients noted significant improvement in vision after tumor resection, with complete restoration of normal vision in 1 patient. Aside from the single case (10%) of visual deterioration referenced above, there were no instances of postoperative neurological decline. Postoperative CSF leakage occurred in 1 morbidly obese patient who required reoperation for revision of closure. After a mean follow-up of 46.8 months (range 4–131 months), tumor recurrence was observed in 2 patients (20%), one of whom was treated with radiation and the other with chemotherapy. Both of these patients had previously undergone GTR of the IVC.CONCLUSIONSThe 10 patients described in this report represent the largest number of patients with IVC treated using EEA for resection to date. EEA for resection of IVC is a safe and efficacious operative strategy that should be considered a surgical option in the treatment of this challenging subset of tumors.

Quality of life and olfactory function after suprasellar craniopharyngioma surgery—a single-center experience comparing transcranial and endoscopic endonasal approaches

“…However, this makes no sense in such small group sizes. Nevertheless, craniopharyngiomas are a rather rare disease and most series have a magnitude of size like we present in our study [7,22,25,33]. A solution for this problem would be a large multicenter study, as was done by Little et al with regard to the comparison of endoscopic versus microsurgical endonasal approaches to pituitary lesions [18].…”

Surgical management of craniopharyngiomas in adult patients: a systematic review and consensus statement on behalf of the EANS skull base section

“…-The presence of a tumor projecting through the foramen of Monro leads preference to a transcortical/trans callosal-transforaminal approach [45]. -For purely intraventricular craniopharyngiomas the endoscopic endonasal route has been described in some selected cases with encouraging results [24,52,135]. The more suitable cases are those with protrusion of the floor of the third ventricle over the suprasellar space and who already have hypopituitarism.…”

Intraventricular Craniopharyngiomas—Overcoming Their Relative Inaccessibility: Institutional Experience With a Review of Literature

“…It is, however, not suitable for large lesions, for which a transventricular approach is more appropriate ( 4 , 5 , 9 , 12 , 16 , 51 , 52 ). The risks associated with the translamina terminalis approach include a retraction injury or perforator damage involving the optic pathway, columns of fornix, supraoptic nuclei, organum vasculosum, and tuber cinereum ( 5 , 9 , 53 ).…”