Endoscopic endonasal surgery for craniopharyngiomas: surgical outcome in 64 patients

Abstract

Object The proximity of craniopharyngiomas to vital neurovascular structures and their high recurrence rates make them one of the most challenging and controversial management dilemmas in neurosurgery. Endoscopic endonasal surgery (EES) has recently been introduced as a treatment option for both pediatric and adult craniopharyngiomas. The object of the present study was to present the results of EES and analyze outcome in both the pediatric and the adult age groups. Methods The authors retrospectively reviewed the records of patients with craniopharyngioma who had undergone EES in the period from June 1999 to April 2011. Results Sixty-four patients, 47 adults and 17 children, were eligible for this study. Forty-seven patients had presented with primary craniopharyngiomas and 17 with recurrent tumors. The mean age in the adult group was 51 years (range 28–82 years); in the pediatric group, 9 years (range 4–18 years). Overall, the gross-total resection rate was 37.5% (24 patients); near-total resection (> 95% of tumor removed) was 34.4% (22 patients); subtotal resection (≥ 80% of tumor removed) 21.9% (14 patients); and partial resection (< 80% of tumor removed) 6.2% (4 patients). In 9 patients, EES had been combined with radiation therapy (with radiosurgery in 6 cases) as the initial treatment. Among the 40 patients (62.5%) who had presented with pituitary insufficiency, pituitary function remained unchanged in 19 (47.5%), improved or normalized in 8 (20%), and worsened in 13 (32.5%). In the 24 patients who had presented with normal pituitary function, new pituitary deficit occurred in 14 (58.3%). Nineteen patients (29.7%) suffered from diabetes insipidus at presentation, and the condition developed in 21 patients (46.7%) after treatment. Forty-four patients (68.8%) had presented with impaired vision. In 38 (86.4%) of them, vision improved or even normalized after surgery; in 5, it remained unchanged; and in 1, it temporarily worsened. One patient without preoperative visual problems showed temporary visual deterioration after treatment. Permanent visual deterioration occurred in no one after surgery. The mean follow-up was 38 months (range 1–135 months). Tumor recurrence after EES was discovered in 22 patients (34.4%) and was treated with repeat surgery (6 patients), radiosurgery (1 patient), combined repeat surgery and radiation therapy (8 patients), interferon (1 patient), or observation (6 patients). Surgical complications included 15 cases (23.4%) with CSF leakage that was treated with surgical reexploration (13 patients) and/or lumbar drain placement (9 patients). This leak rate was decreased to 10.6% in recent years after the introduction of the vascularized nasoseptal flap. Five cases (7.8%) of meningitis were found and treated with antibiotics without further complications. Postoperative hydrocephalus occurred in 7 patients (12.7%) and was treated with ventriculoperitoneal shunt placement. Five patients experienced transient cranial nerve palsies. There was no operative mortality. Conclusions With the goal of gross-total or maximum possible safe resection, EES can be used for the treatment of every craniopharyngioma, regardless of its location, size, and extension (excluding purely intraventricular tumors), and can provide acceptable results comparable to those for traditional craniotomies. Endoscopic endonasal surgery is not limited to adults and actually shows higher resection rates in the pediatric population.

Endoscopic endonasal surgery for olfactory groove meningiomas: outcomes and limitations in 50 patients

“…And, although the innovation of the vascularized nasoseptal reconstruction technique has dramatically decreased the CSF leak rates in other pathological entities, the extensive skull base defect after olfactory groove meningioma surgery remains a reconstruction challenge. 19,[25][26][27][28]43 Our technique has changed since this series to include a 3-layer technique as described by Eloy et al 14 In addition, the more recent use of the wider and longer extracranial pericranial flap has shown no failure so far (our unpublished data, 2014), and it may represent the ideal available technique to avoid CSF leakage following EES for olfactory groove meningioma. Further advances and innovative materials for skull base reconstruction are needed and expected to minimize this complication.…”

Endoscopic endonasal versus open transcranial resection of craniopharyngiomas: a case-matched single-institution analysis

“…Though some institutions now advocate the use of endoscopy for the treatment of every craniopharyngioma, we still believe in the reservation of transcranial staging for tumors with significant middle fossa, ambient, or third ventricular roof disease. 20 Considerations or relative contraindications also include a poorly pneumatized sphenoid sinus, sinus pathology precluding endoscopy or inability to raise a vascularized flap, and a narrow intercarotid distance. 4 While a prospective trial is unlikely, further long-term data will elucidate any oncological outcome differences in this challenging disease.…”

Microscopic versus endoscopic approaches for craniopharyngiomas: choosing the optimal surgical corridor for maximizing extent of resection and complication avoidance using a personalized, tailored approach

“…13,32 However, with advances in endoscopic endonasal skull base surgery and expanded techniques, a pure EEA has gained increased acceptance for removing more extensive craniopharyngiomas associated with a normal-sized sella and suprasellar tumors of supradiaphragmatic origin. 5,6,12,14,22,23,33,[35][36][37][42][43][44][45][46][47][48] The pure EEA has a major advantage when removing retrochiasmatic craniopharyngiomas with suprasellar third ventricular extension since it provides direct visualization of the undersurface of the optic nerves, chiasm, and hypothalamus. The prior aforementioned blind spots underneath the optic chiasm encountered with an approach from above (transbasal interhemispheric or pterional/orbitozygomatic approach) can be well visualized with an EEA from below.…”

“…13,29,40,41 More recently in the last decade, the purely extended endoscopic endonasal approach (EEA) via the transplanum transtuberculum corridor has become a useful and effective route for removing craniopharyngiomas in the retrochiasmatic space extending superiorly into the third ventricle. 5,[7][8][9][10]22,23,31,33,[35][36][37]42,45 Lastly, purely intraventricular craniopharyngiomas situated in the third ventricle and/or lateral ventricles may be better accessed with transcortical or transcallosal intraventricular approaches.…”