Endoscopic Endonasal Transsphenoidal Surgery for Craniopharyngiomas: Pearls and Pitfalls from a Large Case Series

Introduction: Craniopharyngiomas are rare, sellar/suprasellar tumors of embryologic origin that are histologically benign but clinically aggressive presenting with neuroendocrine abnormalities, hydrocephalus, or visual disturbance with high rates of recurrence. The preferred management of craniopharyngiomas is complete surgical resection, though the surgical challenge of proximity to neurovascular structures and extension into deep-seated spaces limits this goal. Classically, open, transcranial approaches have been utilized; in recent decades, there has been increased utilization of endoscopic endonasal transsphenoidal surgery (EETS) which provides a more direct route and less brain manipulation. Characteristics of patients and tumors that might be best treated by the EETS approach have not been clearly delineated. In this project, we analyze our experience with EETS approaches to craniopharyngiomas at a high volume center to determine surgical and treatment strategies.

Methods: A complete review of a single-surgeon, single-institution case series for EETS for craniopharyngiomas from 1994 to 2019 was completed using the clinical, operative, and radiographic records within the electronic medical record. Data collected included patient demographics, radiographic findings, patient presentation, surgical intervention, adjuvant therapy, and outcomes.

Results: There were 21 patients who underwent an endoscopic endonasal transsphenoidal surgery for craniopharyngioma. Most of these patients (13/21) had gross total resection. Only 19% (4/21) had recurrence or progression of residual tumor. All patients treated with radiation therapy for residual or recurrence (6/21) had either stable or regression of their disease. Rates of intraoperative CSF leaks were expectedly high (20/21) but postoperative meningitis rates were low at 14%, and there were no incidents of new cranial nerve injury. 52% of these tumors were large (>5 cm³) and 48% extended into the third ventricle.

Conclusions: Craniopharyngiomas remain a formidable disease entity given their intricate location, proximity to critical neurovascular structures and size at presentation. Our series adds to the growing evidence that the endoscopic endonasal corridor is a safe and effective means to resect these tumors. The use of radiation therapy for residual or recurrence provides excellent disease control and should be used in combination with surgical resection when appropriate.

Fig. 1 Preop and postop sagittal MRI imaging of a craniopharyngioma resected using the endoscopic endonasal transsphenoidal approach.

Fig. 2 Preop and postop coronal MRI imaging of a craniopharyngioma resected using the endoscopic endonasal transsphenoidal approach.