Surgical Strategy Using Extended Endoscopic Transsphenoidal Approach for Craniopharyngioma: Single-Center Experience

Craniopharyngioma is a benign brain tumor, however it is difficult to treat because of its proximity to critical structures at the base of the skull. Craniopharyngioma originates mainly in the pituitary stalk. It shows different size, shape, mode of progression. It may be associated with cyst formation, and calcification. Extended endoscopic transsphenoidal surgery (EETSS) is useful because it has wider angle of view. Our institution started EETSS for craniopharyngioma since 2012. EETSS was the first choice for suprasellar craniopharyngioma. We present our cases of suprasellar craniopharyngioma resected by purely endoscopic extended transsphenoidal approach.

Twenty-one patients (19 cases: 9–68 years old, average 48 years old, male: female = 9:10) of suprasellar craniopharyngioma (preoperative diagnosis) who underwent EETSS from April 2012 to February 2018 were included. One of them was pathologically diagnosed as xanthogranulomatosis. Six cases were recurrent cases after removal with open craniotomy. Four patients were irradiated with gamma knife. During this period, there were no cases of craniopharyngioma removed by craniotomy, and all cases were treated by endoscopic nasal surgery in our institution. Average tumor size was 28.5 mm (11–45 mm). Gross total removal (GTR) or near total removal (NTR) was achieved in 17 patients (81%). In three cases, 90% removal was achieved. Pre- and postoperative gadorinium enhanced MRI in 3 representative cases are shown in Figures (left, and center: GTR, right: 90% removal). One case had partial removal. Of the 90% of the resected cases, one pathologically had xanthogranuloma. The patient with partial removal, received a gamma knife after two times of craniotomy. There was one postoperative cerebrospinal fluid leak, but it was successfully repaired. Complications such as postoperative pneumonia occurred in one patient and subdural hematoma in one patient. Both showed complete recovery. Two patients underwent reoperation by the same route for recurrence, and four patients had small recurrence after surgery, and were treated with stereotactic radiotherapy. As regard visual function, 11 patients improved, 6 patients remained unchanged, and 3 patients deteriorated. Two of the worsening cases were cases that had not undergone intraoperative visual evoked monitoring (VEP), and the remaining one was xanthogranuloma. All but one patient returned to their normal life. In one case of xanthogranuloma, short-term memory impairment worsened. In this series, all patients needed some endocrinological compensation.

The prevention of cognitive and visual dysfunction is the major challenge during operation of craniopharyngioma. For this reason, it is necessary to observe midsagittal MRI before surgery to carefully identify the position of the optic chiasm, and mammillary bodies. The dissection between optic nerve and tumor should be performed carefully. We believe that avoiding any neurological deficit and safe gross total removal has a higher priority than preserving endocrinological function in many cases as this may be compensated medically.