Endonasal Endoscopic Surgery of Craniopharyngiomas: A Case Series

Objects: To present the results of endoscopic endonasal surgery of craniopharyngiomas.

Methods: A retrospective review including surgical technique, extent of resection, complications and outcomes was performed. All patients were operated between 2011 and 2019 in department of neurosurgery of Kazan Interregional Clinical Diagnostic Center.

Results: Twenty-two patients with craniopharyngiomas were operated. All procedures were performed under frameless image-guidance control, purely endoscopic. There were 9 (31%) males and 13 (59%) females. Patient's age was between 20 and 76 years, with mean age of 40.5 years. In four patients (18.2%) it was a repeat surgery due to residual tumor progression in the period of 5 to 56 months postoperatively. One of them underwent initial transcranial surgery in another medical center. Gross-total resection was achieved in 12 patients (54.5%), near total in 4 (18.2%), subtotal in 5 (22.7%). In three patients after a repeat surgery a gross-total resection was achieved in one case and subtotal in three rest cases. All patients with gross-total resection have no signs of tumor recurrence at follow-up. The mean period of follow-up is 63 months. Prior to surgery 18 patients had a visual disturbance, 13 (59%) of them improved and 4 (18,2%) remained unchanged postoperatively. In one patient (4.5%) the worsening of visual function was marked. A postoperative cerebrospinal fluid (CSF) leak occurred in seven (31%) patients and was a reason of meningitis in 4 (18.2%) of them (two aseptic and two bacterial), all were cured. Six patients with cerebrospinal fluid leak underwent a surgical reconstruction of CSF-fistula (one patient twice, and one for three times), in this particular case a usage of free pericranial flap allowed get a final water-tide reconstruction. In one patient a CSF leak resolved on lumbar drain. Four (18.2%) patients developed a diabetes insipidus in one it was transient, 1 (4,5%) patient showed a panhypopituitarism, and 1 (4.5%) patient had a cerebral salt-wasting syndrome postoperatively. One patient had an acromegaly and after subtotal tumor removal receiving octreotide for growth hormone relief without residual tumor progression. In one patient a short memory loss was determined postoperatively which completely resolved 6 month later. In one patient a cognitive impairment remained at the same level postoperatively with minor improvement 1 year later. Mortality rate in series was zero.

Conclusions: Expanded endoscopic endonasal approaches allowed make a microsurgical resection of craniopharyngiomas in safe mode and with good visual control. Postoperative CSF leak remains a significant complication. Learning curve impacts on extent of tumor resection and postoperative CSF-leak frequency.