Endoscopic endonasal approach for craniopharyngioma: the importance of the relationship between pituitary stalk and tumor

Abstract

OBJECTIVE The endoscopic endonasal approach (EEA) is commonly used for the treatment of craniopharyngioma; therefore, it is essential to analyze outcomes in order to understand the benefits and drawbacks. The goal of this paper was to evaluate the clinical features and outcomes associated with this treatment approach. METHODS From July 2010 to March 2016, 82 adult craniopharyngioma patients underwent an EEA at the authors' institution. Of these cases, intraoperative records and immediate postoperative MR images were available for 68 patients. The patients underwent systemized endocrinological evaluation. Eighteen of 68 patients who underwent EEA for recurrence or regrowth of residual lesions after previous surgical management were excluded in the analysis of the anatomical tumor classification. The authors retrospectively analyzed preoperative clinical features and previous anatomical classifications, focusing on the relationship of the pituitary stalk and tumor, to determine predictive factors for the clinical outcome, such as the extent of resection, visual function, endocrinological function, recurrence rate, and complications. RESULTS The mean tumor size was 2.5 cm (3.1 cm for primary tumors and 1.9 cm for recurrent lesions). Gross-total resection (GTR) was achieved in 62 (91.1%) patients (48 [96.0%] patients with primary tumors and 14 [77.8%] patients with recurrent tumors). The rate of GTR was higher in the primary group than in the group with recurrence (p = 0.038). The overall pre- and postoperative visual impairment scale (VIS) scores were 40.8 and 22.1, respectively (50.9 and 14.3 in the primary group and 30.7 and 29.9 in patients with recurrence, respectively). The improvement rate in VIS score was higher in the primary group than in the recurrent group (p = 0.001). Endocrinological function was improved in 4 patients (5.9%) and deteriorated in 32 of 68 patients (47.1%). Tumor invasion into the center of the pituitary stalk affected the postoperative outcomes most significantly. Cognitive dysfunction was observed in 22 patients before surgery and improved in 20 patients (90.9%) after surgery. Hydrocephalus was found in 7 patients and resolved after surgery in all cases. CSF leakage occurred in 2 (2.9%) of 68 patients and was repaired by revision surgery in both patients. Ten patients without CSF leakage also received antibiotics for the treatment of meningitis. The infection rate was higher in the recurrent group. Postoperative endocrinological evaluation showed no deficits in 12 patients and panhypopituitarism in 55 patients. The remaining patient had growth hormone deficiency. Forty-three patients had new-onset diabetes insipidus, and 1 patient had persistent diabetes insipidus after surgery. There were 2 (2.9%) cases of recurrence during the mean 30.7-month follow-up period; one patient underwent radiosurgery and the other underwent reoperation. CONCLUSIONS The EEA resulted in excellent surgical outcomes and acceptable morbidity rates, regardless of the anatomical location of the tumor. Invasion of ...

Multi-Layer Onlay Graft Using Hydroxyapatite Cement Placement without Cerebrospinal Fluid Diversion for Endoscopic Skull Base Reconstruction

“…The pulled dural window served as a protective barrier for the surgical window from the blood coming from the sphenoid or from between the dural and skull base bone during the operation. The tumor was always dissected and removed with microsurgical techniques, and the details were not different from those in previous reports [ 14 , 36 , 38 , 54 ]. The loose approximation of bilateral dura after the removal of the tackup suture was the first step of the reconstruction process.…”

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

“…Furthermore, since a significant proportion of patients are subjected to adjuvant radiotherapy a baseline assessment enables tracking neurocognitive changes that may occur after radiation. Some authors reported no changes in neuropsychological performance after surgical procedures [78] while others describe improvement of preoperative cognitive dysfunction and memory [37]. However, reported postoperative morbidity includes cognitive dysfunction with attention deficit, impaired episodic memory, and processing speed [50,140], which were associated with microstructural alterations of the white matter tracts detected with the use of DTI [51].…”

“…Expanded endonasal approaches (EEA), through a transtubercular approach (with or without a transplanum route), allow an excellent exposure of the tumor without crossing crucial neurovascular structures [17,25,26,34,37,57,60,61,94,107]. Furthermore, the direct access through the endonasal route has the advantage of early identification of the superior hypophyseal arteries, which are important for the optic apparatus and also of early identification of the chiasm and optic nerves thus avoiding retraction not only of the nerves but also of the basal frontal lobes.…”

“…It is possibly due to this that the preservation of hypothalamic functions is superior with endoscopic EEA when compared to the transcranial approaches [4,65,189]. A direct decompression of the optic apparatus may also be performed with a direct visualization and preservation of the superior hypophyseal artery [37,164]. This may translate into a greater improvement of the postoperative visual outcome [65,103,131,182].…”

Preserve or sacrifice the stalk? Endocrinological outcomes, extent of resection, and recurrence rates following endoscopic endonasal resection of craniopharyngiomas

“…raniopharyngiomas (CPs) are benign rare tumors thought to arise from embryonic remnants of Rathke's pouch. 2,9,10,43,45 Gross-total resection (GTR) remains the gold standard treatment of CPs, although comparable control rates have been reported with subtotal resection (STR) and adjuvant radiation therapy (RT). 43 The development of the endoscopic endonasal approach (EEA) has helped to improve visualization of the sellar and suprasellar region, while eliminating the need for brain retraction and minimizing manipulation of surrounding critical neurovascular structures.…”