Transsphenoidal Surgery for Craniopharyngioma

Fig. 5.1

Preoperative MRI of type Q craniopharyngioma in a child. (a) Coronal view showing that the tumor is located beneath the diaphragma sellae and the optic chiasm is pushed upward; the bilateral cavernous sinuses are not involved. (b) Sagittal view showing that the pituitary fossa is enlarged; the pituitary gland and pituitary stalk are unrecognizable. The tumor protrudes into the anterior skull base, and the bottom of the third ventricle is pushed by the tumor

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig2_HTML.jpg — Fig. 5.2

Double nostril expanded transsphenoidal approach. The dura and pituitary sac are opened, and the tumor is visible. The tumor originates beneath the diaphragma sellae and is a Q-type tumor. (1) Pituitary sac, (2) tumor

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig3_HTML.jpg — Fig. 5.3

Separating the intra-sellar tumor from the normal pituitary; the boundary between the tumor and the pituitary gland is clear. (1) Pituitary gland, (2) tumor, (3) boundary

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig4_HTML.jpg — Fig. 5.4

Separating the tumor from the suprasellar structures. Diaphragma sellae and arachnoid remain between the tumor and suprasellar structures. (1) Diaphragma sellae on the surface of the tumor, (2) arachnoid between the tumor and optic chiasm, (3) optic nerve and optic chiasm

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig5_HTML.jpg — Fig. 5.5

The pituitary stalk is revealed. (1) Tumor, (2) pituitary stalk, (3) optic chiasm, (4) Liliequist membrane

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig6_HTML.jpg — Fig. 5.6

Detachment of the diaphragma sellae for better separation. (1) Tumor, (2) diaphragma sellae

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig7_HTML.jpg — Fig. 5.7

Separation of the tumor and the diaphragma sellae; a clear boundary is observed between the tumor and diaphragma sellae. (1) Tumor, (2) diaphragma sellae

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig8_HTML.jpg — Fig. 5.8

Detachment of the diaphragma sellae to free the pituitary stalk. (1) Pituitary stalk, (2) diaphragma sellae, (3) Liliequist membrane, (4) optic chiasm

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig9_HTML.jpg — Fig. 5.9

Structures were well protected after the tumor resection. (1) Pituitary stalk, (2) pituitary gland, (3) Liliequist membrane, (4) optic chiasm, (5) third ventricle floor

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig10_HTML.jpg — Fig. 5.10

Postoperative MRI (a, b) showing that the tumor was completely resected and that the third ventricle floor and pituitary stalk were intact

5.2.2 Comment

This is a case of Q-type craniopharyngioma in a child, and the origin was located beneath the diaphragma sellae. Therefore, the transsphenoidal approach could well treat the origin of the tumor. Although the tumor had reached the level of the third ventricle floor, diaphragma sellae and arachnoid remained between the tumor and important structures, providing a natural interface for separation.

The tumor protruded into the anterior skull base through the anterior chiasm space, and transcranial surgery could also achieve satisfactory resection through the anterior chiasm space. However, the patient’s pituitary fossa was deepened, and the transcranial approach was blocked by tuberculum sellae, which rendered it difficult to expose the tumor’s origin. Tuberculum sellae had to be removed to achieve satisfactory exposure.

5.2.3 Case 2: A Case of Q-Type Craniopharyngioma Extending to the Floor of the Third Ventricle in a Child (Figs. 5.11, 5.12, 5.13, 5.14, 5.15, 5.16, 5.17, 5.18, 5.19, 5.20, and 5.21)

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig11_HTML.jpg — Fig. 5.11

A case of Q-type craniopharyngioma involving the third ventricle floor. (a) Sagittal view showing that the pituitary fossa is enlarged and the tumor mainly extends upward to the level of the third ventricle floor. (b) Coronal view showing that part of the tumor grows into the para-sellar space

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig12_HTML.jpg — Fig. 5.12

Opening of the dura and exposure of the tumor. (1) Pituitary sac, (2) tumor

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig13_HTML.jpg — Fig. 5.13

Separation of the tumor from the pituitary gland; a clear boundary between the tumor and the pituitary gland is visible. (1) Tumor, (2) normal pituitary

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig14_HTML.jpg — Fig. 5.14

Diaphragma sellae and arachnoid cover the tumor. (1) Tumor, (2) arachnoid, (3) diaphragma sellae

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig15_HTML.jpg — Fig. 5.15

Exploration of the tumor in the para-sellar space. (1) Internal carotid artery, (2) anterior cerebral artery, (3) middle cerebral artery, (4) tumor, (5) optic chiasm

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig16_HTML.jpg — Fig. 5.16

Separation of the tumor from the third ventricle floor; the boundary between the tumor and the third ventricle floor is clear. (1) Tumor, (2) optic chiasm, (3) third ventricle floor

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig17_HTML.jpg — Fig. 5.17

Although the tumor occupies the space of the third ventricle, it is easy to separate the tumor from third ventricle floor because of the presence of a multimembrane structure. (1) Tumor, (2) third ventricle floor

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig18_HTML.jpg — Fig. 5.18

Using brain cotton as a separation tool, the tumor wall is completely pulled out from the third ventricle floor. Attention should be given to protecting the intact tumor wall and avoiding missing tumors. (1) Brain cotton, (2) tumor wall, (3) third ventricle

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig19_HTML.jpg — Fig. 5.19

After the tumor involving the third ventricle floor is pulled out, we can see that there remains pia mater between the tumor and the third ventricle floor. (1) Tumor, (2) pia mater, (3) third ventricle floor

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig20_HTML.jpg — Fig. 5.20

After the tumor is totally resected, it can be seen that the structures are well protected and that the third ventricle floor is intact. (1) Third ventricle floor, (2) pituitary stalk, (3) pituitary gland, (4) mammillary body, (5) Liliequist membrane

../images/464048_1_En_5_Chapter/464048_1_En_5_Fig21_HTML.png — Fig. 5.21

Postoperative MRI (a, b) showing that total resection was achieved

5.2.4 Comment

This is also a Q-type tumor. Compared with Case 1, the tumor in this case expanded more toward the third ventricle. Although some tumors protrude into the space of the third ventricle, there remain multiple layers of tumor and the third ventricle floor. Membrane structure was the anatomical basis for the complete preservation of the third ventricle floor in this patient. Some of the tumors are mainly cystic. When removing the tumor, it should not be separated piece by piece but in an en bloc pattern, otherwise tumor tissue will be easily missed.