11 Craniopharyngiomas

10.1055/b-0035-104223

11 Craniopharyngiomas

Michael E. Sughrue and Charles Teo

11.1 Introduction

This is the only pathology-specific chapter in this book. The reason for this is that craniopharyngiomas are somewhat different, and we think about them in a different way. Most notably, certain biological features of craniopharyngiomas make operating on them different than other parasellar pathology, and we felt this deserved to be described in more detail. Additionally, craniopharyngiomas are tough problems regardless of the approach, and the neurosurgical world would certainly benefit from as many practical suggestions as possible for these patients, from as many varied sources as possible. Finally, although this book is not about endonasal skull base surgery, we felt it was also deserved to be described in some detail at some point.

This chapter is a distillation of our opinions regarding minimally invasive surgery for craniopharyngiomas, and some tips for improving outcomes in these patients.

11.2 Approach Selection

Our experience has led us to conclude that most craniopharyngiomas should be removed endonasally, regardless of size and, in most cases, of anatomy. Fig. 11.1 and Video 11.1 demonstrate a patient with a large, complex craniopharyngioma that was completely removed endonasally, with no permanent adverse neurological or hormonal sequelae, demonstrating that there are few limits to what can be achieved with these tumors using the endonasal approach. While the eyebrow approach provides excellent access to this region, and is our approach of choice in a large number of patients, the endonasal transplanar/transtubercular approach enables us to identify the pituitary stalk early during the resection and to preserve it, which is more difficult in any transcranial approach. This observation has allowed us to lower our rate of diabetes insipidus from 85% using the eyebrow to 15% through an endonasal approach. Furthermore, we have found few anatomical limitations to the extent of the endonasal approach, as we have been able to address retrodorsal and interpeduncular tumor, and have been able to dissect tumor off the pineal gland in some complex cases (see Fig. 11.1). Extreme lateral extension into the middle cranial fossa, especially very lateral to the optic nerve, may benefit from a different approach, but this is not normally necessary with these largely midline lesions.

**Fig. 11.1** **a–h** Endonasal craniopharyngioma. This case demonstrates the possibility of excellent resection of craniopharyngiomas of even significant size and complexity. This case is highlighted in Video 11.1. **(a, b)** Preoperative images demonstrating a massive craniopharyngioma. **(c, d)** Postoperative images. Note the snowman-shaped fat graft. **(e)** Intraoperative image demonstrating the pituitary stalk, which is identified and preserved very early in the resection. **(f)** The view into the third ventricle through the open third ventricular floor. The pineal region and posterior commissure can be seen in the distant background of this image. **(g)** Image demonstrating removal of the tumor bulk. **(h)** Closure technique for these defects.

Reasons to perform a craniotomy include the lack of technical support or experience to perform an endonasal approach on a lesion this difficult, severe lateral extension, or significant intraventricular extension up to or beyond the fornix. In the latter instance, an interhemispheric transcallosal approach provides access to the fornices and allows the tumor to be detached; however this is not commonly necessary. Completely intraventricular craniopharyngiomas, also rare, can be removed through a completely ventriculoscopic approach. Finally, young children and patients with poorly pneumatized sphenoid sinuses are technically difficult endonasal cases, and thus may require a craniotomy.

Only gold members can continue reading. Log In or Register to continue