35 Diagnosis Craniopharyngioma Problems and Tactics We present the case of a woman with a giant, multicystic, suprasellar, retrochiasmatic craniopharyngioma measuring 6 × 3.5 × 4 cm. The tumor extended superiorly to the ventricular system and the foramen of Monro, occupying the third ventricle primarily on the left side. Approaching this lesion with the goal of total removal requires a wide, safe exposure of all parts of the lesion and multiple avenues of access for dissection without endangering the chiasm, hypothalamus, or other neurovascular structures in the retrosellar region. We chose to combine the petrosal approach, which provides for safe dissection of the retrosellar area without endangering the hypothalamus, with the cranioorbital zygomatic approach (COZ), which allows anterior inspection, exposure, and dissection in the prechiasmatic area. Keywords Craniopharyngioma, cranioorbital zygomatic approach, petrosal approach A 52-year-old woman came to us with a history of worsening headache, decreased energy level, short-term memory difficulties, gait disturbance, and increasing visual difficulties with visual field loss. She had mild diabetes insipidus. Magnetic resonance imaging (MRI) revealed a giant sellar–suprasellar lesion displacing the optic chiasm superiorly and extending down along the upper clivus. The lesion was consistent with a large retrochiasmatic craniopharyngioma (Fig. 35–1). The patient was placed supine with the head rotated 45 degrees to the left and fixed in the Mayfield three-point headrest. A shoulder roll was placed under the right shoulder and the right frontotemporal and postauricular region was prepared and draped in the usual fashion. A curvilinear skin incision was made, extending from the root of the zygoma 1 cm anterior to the tragus behind the hairline. A posterior branch of the incision was brought back ~2 cm above the pinna and extended into the postauricular region, down to the level below the mastoid tip. The frontal portion of the skin flap was dissected free from the pericranium and temporalis muscle, and subfascial dissection of the temporalis muscle was done to preserve the frontal branches of the facial nerve. Care was taken to preserve both the pericranium and the superficial temporal artery. The zygoma and lateral orbital wall were then dissected with a periosteal elevator to allow good exposure of the zygomatic arch, which was sectioned anteriorly and posteriorly. The temporalis facia was then incised posterior to the superficial temporal artery and dissected free from the muscle posteriorly to remain in continuity with the nuchal musculature. The muscle was then dissected down to the suboccipital region to expose the mastoid and the occipital bone and was turned down in a single flap. The temporal was then stripped with the periosteal elevator and turned downward along with the zygoma. The bone flaps for both the petrosal and COZ approaches were removed as described previously.1,2
Combined Cranioorbital Zygomatic and Petrosal Approach for a Giant Retrochiasmatic Craniopharyngioma
Clinical Presentation
Surgical Technique
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