Preservation of Pituitary Function after Endonasal Craniopharyngioma Surgery: Case Report and Review of the Literature

Prabhu, Vishaal; Anand, Vijay K.; Schwartz, Theodore H.

doi:10.7759/cureus.305

Cited by 7 publications

(3 citation statements)

References 17 publications

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“…The technique has been described in detail in prior publications and is mentioned briefly below. 5,7,19,27 Intraoperatively, a lumbar drain is placed and 0.25 ml of 10% fluorescein (AK-Fluor, Akorn) is given intrathecally to help with visualization of intraoperative CSF leakage during tumor removal and again following closure. 26 The middle turbinates are lateralized and a nasoseptal flap is harvested prior to posterior septectomy.…”

Section: Surgical Techniquementioning

confidence: 99%

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

Forbes

Ordóñez-Rubiano

Tomasiewicz

et al. 2019

Journal of Neurosurgery

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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.

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Section: Surgical Techniquementioning

confidence: 99%

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

Forbes

Ordóñez-Rubiano

Tomasiewicz

et al. 2019

Journal of Neurosurgery

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“…The stalk is preserved as long as possible and is only resected at the end of the operation if required to achieve GTR. 31 The superior hypophyseal arteries are preserved unless they feed a stalk infiltrated with tumor that is to be resected. If the tumor extends into the sella, the top of the pituitary gland is also removed to ensure complete resection.…”

Section: Surgerymentioning

confidence: 99%

Is the chiasm-pituitary corridor size important for achieving gross-total resection during endonasal endoscopic resection of craniopharyngiomas?

Omay

Almeida

Chen

et al. 2018

Journal of Neurosurgery

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OBJECTIVE Craniopharyngiomas arise from the pituitary stalk, and in adults they are generally located posterior to the chiasm extending up into the third ventricle. The extended endonasal approach (EEA) can provide an ideal corridor between the bottom of the optic chiasm and the top of the pituitary gland (chiasm-pituitary corridor [CPC]) for their removal. A narrow CPC in patients with a prefixed chiasm and a large tumor extending up and behind the chiasm has been considered a contraindication to EEA, with a high risk of visual deterioration and subtotal resection. METHODS A database of all patients treated in the authors' center (Weill Cornell Medical College, NewYork-Presbyterian Hospital) between July 2004 and August 2016 was reviewed. Patients with craniopharyngiomas who underwent EEA with the goal of gross-total resection (GTR) were included in the study. Patients with postfixed chiasm or limited available preoperative imaging were excluded. Using preoperative contrast-enhanced T1-weighted sagittal midline MR images, the authors calculated the CPC as well as the distance from the chiasm to the top of the tumor (CTOT). From these numbers, they calculated a ratio of the CPC to the CTOT as a measure of difficulty in removing the tumors through the EEA and called this ratio the corridor index (CI). The relationship between the CI and the ability to achieve GTR and visual outcome were measured. RESULTS Thirty-four patients were included in the study. The mean CPC was 10.1 mm (range 5.2-19.1 mm). The mean CTOT was 12.8 mm (range 0-28.3 mm). The median CI was 0.8; the CI ranged from 0.4 to infinity (for tumors with a CTOT of 0). Thirty-two patients had GTR (94.1%) and 2 had subtotal resection. The CPC value had no relationship with our ability to achieve GTR and no effect on visual or endocrine outcome. CONCLUSIONS EEA for craniopharyngioma is generally considered the first-line surgical approach. Although a narrow corridor between the top of the pituitary gland and the bottom of the chiasm may seem to be a relative contraindication to surgery for larger tumors, the authors' data do not bear this out. EEA appears to be a successful technique for the majority of midline craniopharyngiomas.

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“…Our report concerns a craniopharyngioma that is entirely above the sella, and has normal pituitary function. In our view, the endonasal approach for this tumor would have been suboptimal because of a high risk of jeopardizing all her pituitary hormones [ 10 ]. It is for this reason that we chose the main resecting route of the anterolateral pterional corridor via a one-piece orbitocranial approach.…”

Section: Discussionmentioning

confidence: 99%

Simultaneous Transventricular-Orbitocranial Resection of Large Suprasellar Craniopharyngioma as Inspired by Jackson's Maneuver from 1863

Jean

Syed

Felbaum

et al. 2016

Cureus

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Traditional skull base techniques utilizing the microscope have allowed surgeons improved safe access to deep-seated lesions. More recent technical advances with the endoscope have allowed improved visibility and access to these previously difficult-to-reach regions. Most current literature emphasizes one technique over the other. We present a unique hybrid-type approach that tackles this not-infrequent surgical dilemma. This hybrid-type surgery resulted in a new technique that is a confluence of both open microsurgery and skull base corridors with an endoscope. Furthermore, a combined ventriculoscope approach adds extended assistance with resection. We detail the utility of this technique.A patient presented with a large suprasellar lesion that was suspicious for a craniopharyngioma. Given improved survival with extent of resection, the goal of surgical intervention was maximal safe resection. The location of the tumor would have involved certain morbidity with deliberate residual if a skull base approach or endoscope-based approach was employed independently. As a result, the patient underwent a hybrid-type operation using a multi-corridor split-surgical team approach for the resection of her tumor.The patient underwent hybrid surgery via a combined open microsurgical craniotomy, endoscopic resection, and a ventriculoscope-assisted approach. The ventriculoscope access allowed for resection of the intraventricular portion of the tumor and guided the extent of resection from the microsurgical corridor. Additionally, from a separate craniotomy, the suprasellar component was resected using both standard skull base and endoscope-assisted techniques. The patient tolerated the procedure well without additional morbidity provided from the multi-corridor hybrid technique.The hybrid surgery resulted in a new multi-modality, split-surgical team approach providing maximal visualization with minimal added morbidity to resect a lesion difficult to access. This hybrid technique may be an effective piece of the surgeon’s armamentarium to provide improved patient outcomes.

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Preservation of Pituitary Function after Endonasal Craniopharyngioma Surgery: Case Report and Review of the Literature

Cited by 7 publications

References 17 publications

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

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

Is the chiasm-pituitary corridor size important for achieving gross-total resection during endonasal endoscopic resection of craniopharyngiomas?

Simultaneous Transventricular-Orbitocranial Resection of Large Suprasellar Craniopharyngioma as Inspired by Jackson's Maneuver from 1863

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