Anterior communicating artery division in the endoscopic endonasal translamina terminalis approach to the third ventricle: an anatomical feasibility study

Combined pre-retrochiasmatic resection of third ventricle craniopharyngioma by endoscopic endonasal approach

BACKGROUNDS

Third ventricle craniopharyngioma (TVC) refers to the tumor originating from the tuberoinfundibular, and completely located in the third ventricle; unlike most TVCs, the retrochiasmatic-infundibulum corridor is too narrow to expose the tumor with anterior extension via an endoscopic endonasal approach.

METHODS

Retrospective analysis of two TVCs via an endoscopic endonasal combined pre-retrochiasmatic approach.

CONCLUSIONS

The tumor inside the third ventricle can be satisfactorily exposed through a combined pre-retrochiasmatic approach and be completely removed with the lowest injury of the hypothalamus and optic nerve.

Extended endoscopic endonasal approach for resecting anterior intrinsic third ventricular craniopharyngioma

Background

The surgical treatment of the extended endoscopic endonasal approach (EEEA) is a safe and effective treatment for suprasellar craniopharyngiomas. However, due to damage to the hypothalamus and third ventricle floor (TVF), EEEA is generally regarded as unsuitable in treating intrinsic third ventricle craniopharyngioma (ITVC) that is entirely within the third ventricle. Until now, there have been only a small number of reports using EEEA to treat TVC via a supra-infrachiasmatic approach. Given that the translamina terminalis (TLT) corridor was used in the transcranial subfrontal approach, EEEA via a suprachiasmatic approach may be feasible and practical to treat ITVC. In the current study, we accumulated experience applying the suprachiasmatic translamina terminalis (STLT) corridor for anterior treatment of ITVC.

Methods

From March 2016 to December 2020, 14 patients with ITVC in our center were analyzed retrospectively. All patients underwent surgery by EEEA via an STLT corridor. The multilayer reconstruction technique was adopted to achieve skull base reconstruction. Data concerning the patient’s tumor resection, vision, hypophyseal hormone, and complications were collected.

Results

Gross-total resection was achieved in 13 (92.8%) of14 patients, with achievement of near-total (90%) resection in the remaining 1 patient. Nine cases (64.3%) were papillary craniopharyngiomas, and the other 5 cases were adamantinomatous subtypes. Postoperatively, 3 patients with pituitary insufficiency received hormone replacement therapy. No permanent diabetes insipidus or hypothalamic obesity was found. All pairs showed significant improvement or stability in vision except 1 patient who encountered visual deterioration. No other neurological deficit occurred postoperatively. Observation results for the exudation of nasal tissue and the length of hospitalization were satisfactory. After a mean follow-up period of 26.2 months, tumor recurrence was not observed.

Conclusion

TLT is a minimally invasive corridor used in EEEA for treating anterior ITVC without increasing risks of visual and hormonal deficits. The multilayered reconstruction technique we used is a safe and effective method for achieving watertight closure and avoiding cerebrospinal fluid leaks and infection. The endonasal approach via STLT provides a new, safe and efficacious operative strategy that should be considered a surgical alternative in treating ITVC.

Expanded Transsphenoidal Trans-Lamina Terminalis Approach to Tumors Extending Into the Third Ventricle: Technique Notes and a Single Institute Experience

Object

The trans lamina terminalis approach (TLTA) has been described as a way to remove third ventricular tumors. The aim of this paper was to analyze the feasible outcomes of TLTA applied to tumors extending into the third ventricle in our institute.

Methods

Suprasellar tumors (n = 149) were treated by the extended endonasal approach from September 2019 to December 2020 in Beijing Tiantan Hospital. Eleven of the tumors were treated by TLTA or TLTA via the trans-chiasm-pituitary corridor (TCPC). The surgical technique notes of TLTA were described and indications and outcomes of the approach were analyzed.

Results

There were 11 patients enrolled in the study, six with papillary craniopharyngiomas, two with adamantinomatous craniopharyngiomas, one with a germinal cell tumor (GCT), one with cavernous malformation and one with chordoid glioma. Four of the patients received a radical resection by TLTA alone, while seven of them received TLTA via the TCPC. Gross total resection was achieved in eight patients (72.7%), and partial resection in three patients (27.3%). Visual function was improved in four of the 11 patients (36.4%), was unchanged in five patients (45.5%), and deteriorated in two patients (18.2%). New-onset hypopituitarism occurred in seven patients (63.3%) and new-onset diabetes insipidus occurred in two patients (18.2%). Electrocyte imbalance were observed in six patients (54.5%) at post-operative week 2. There were no surgery-related deaths or cerebrospinal fluid leaks. Postoperative intracranial infection was observed in one patient (9.1%), and during the follow-up period, tumor recurrence occurred in one patient (9.1%).

Conclusion

The expanded TLTA provides a feasible suprachiasm corridor to remove tumors extending into the third ventricle, especially for craniopharyngiomas. Sound understanding of the major strengths and limitations of this approach, as well as strategies for complication avoidance, is necessary for its safe and effective application.

Safety and effectiveness of endoscopic endonasal intracranial aneurysm clipping: a systematic review

Once considered far-fetched, endoscopic endonasal clipping (EEC) has been reported as a feasible alternative route for treating intracranial aneurysms located in the midline. Appropriately, debates regarding EEC applicability have arisen amongst the neurosurgical community. We aim to define the safety, effectiveness, and current state-of-art in the use of EEC for intracranial aneurysms. Two databases (PubMed, Cochrane) were queried for intracranial aneurysms that underwent EEC between inception and 2019. Literature review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Data regarding clinical presentation, radiological imaging, and outcome were extracted and analyzed from selected publications. Nine studies with 27 patients (8 males, 19 females), harboring 35 aneurysms (9 ruptured, 26 nonruptured), met the predetermined inclusion criteria. Patient age range is from 34 to 70 (median = 50) years old. Four aneurysms were considered not suitable for EEC during the procedure, and two aneurysms required additional treatment, leading to an overall treatment success (obliteration) rate of 86%. Complications occurred in 7 patients (26%), including CSF leakage in 5 patients (18%) and ischemic complications in 4 (15%). Among the cases reported, complications occurred more frequently in posterior circulation aneurysms in comparison with anterior circulation aneurysms (62.5 vs 10.5%). Ischemic complications occurred in 4 out of 8 posterior circulation aneurysms. Although feasible, EEC is associated with a significant risk of complications, with rates identified that are significantly higher than established open clipping or endovascular management. The current data suggest that transcranial clipping and endovascular occlusion are still the primary indication for treating intracranial aneurysms.