Surgical Treatment of Third Ventricle Craniopharyngiomas in Adults

Although the endoscopic endonasal approach (EEA) allows to effectively treat the vast majority of craniopharyngiomas (Cphs) with satisfactory results, the most effective management of those with third ventricle extension remains open and could be debated. The aim of this study is the analysis of the outcome of the different surgical approaches for third ventricle Cphs in adult patients, in order to assess the correct indications for EEA and for the other routes.

Our institutional surgical database, encompassing a timespan from 1998 to 2023, was retrospectively reviewed. All the surgically treated craniopharyngiomas with third ventricle extension were included in the case series and analyzed. The type of treatment, the preoperative and postoperative clinical and neuroradiological features were gathered and analyzed. The long-term outcome was evaluated with magnetic resonance imaging (MRI), endocrinological and ophtalmological evaluation at 3 months and then yearly.

In the analyzed timespan, 146 Cphs in adult patients were treated in our center. Of these, 60 (41.1%) cases involved the 3rd ventricle (30 males, 50%, mean age: 53, range: 18–83). Endoscopic endonasal approach was performed in 46 cases (76.7%), craniotomy in 10 (16.7%) and endoscopic transventricular in 4 (6.7%). Gross-total resection was achieved in 91.3% of cases operated though EEA and in 70% with craniotomy. Cystic drainage with symptoms resolution was achieved in all cases treated through an endoscopic transventricular. Improvement of visual deficits was observed in 72.5% of 40 cases with preoperative visual impairment. Histological analysis revealed a papillary Cph in 24 cases (40%) and an adamantinomatous Cph in 36 cases (60%). No perioperative mortality was observed.

Neuroradiological assessment of tumor relationship with diencephalic and optic structures represents a crucial parameter for the surgical approach selection. In our experience, EEA was preferred for tubero-infundubular cases, which displace circumferentially the hypothalamus and antero-superiorly the chiasm. Conversely, for purely endoventricular forms, particularly associated to hydrocephalus, a transcranial transcallosal or pterional trans-lamina terminals approach was preferentially chosen. Elderly patients or with multiple comorbidities and poor Karnofsky score were treated with a transventricular endoscopic cyst drainage to resolve the symptoms, eventually followed by radiotherapy.

Publication History

Article published online:
07 February 2025