Endoscopic Endonasal Surgery for Craniopharyngiomas: A Series of 60 Patients

Risk Factors for Intracranial Infection in Surgical Patients with Suprasellar Craniopharyngiomas by an Expanded Endoscopic Endonasal Approach: A Single-Center Initial Experience

OBJECTIVE

To explore the risk factors for intracranial infection in surgical patients with suprasellar craniopharyngiomas by an expanded endoscopic endonasal approach (EEEA) in a single center.

METHODS

Forty-one patients with suprasellar craniopharyngiomaswere retrospectively recruited. EEEA was applied in all patients. All patients were evaluated for the occurrence of intracranial infection after surgery, and the risk factors of infection were further analyzed. The databases of PubMed and Web of Science were systematically reviewed to identify the rate of meningitis with suprasellar craniopharyngiomas treated with extended endoscopic endonasal transsphenoidal surgery (EETS).

RESULTS

Intracranial infection occurred in 21.95% of patients. Patients who were diagnosed as recurrent tumor presented with significant higher incidence of infection than that in the patients with first surgery (55.56% vs. 18.75%; P < 0.05). The rate of the third ventricle exposure was 88.89% in 9 infected patients, which was significantly higher than 40.63% in uninfected patients (P < 0.05). The risk factor for postsurgery infection was the exposure of third ventricle during surgery (P = 0.043; odds ratio = 10.374). The incidence of EETS meningitis varies from 0% to 30%, and the rate of cerebrospinal fluid leak varies from 0% to 58% in previous studies. Twenty three patients received gentamicin physiological saline irrigation in our study, and only 2 presented intracranial infection after surgery.

CONCLUSIONS

The rate of EETS meningitis varies from 0% to 30% according to previous studies. Opening of the third ventricle during surgery was an independent risk factor for intracranial infection in surgical patients with suprasellar craniopharyngiomas by EEEA. Gentamicin physiological saline irrigation during surgery might prevent postsurgical infection.

Development and validation of a nomogram for predicting cerebrospinal fluid leak after endoscopic craniopharyngioma resection

OBJECTIVE

To identify risk factors for cerebrospinal fluid (CSF) leak after extended endoscopic endonasal surgery for craniopharyngiomas and develop a predictive model for predicting postoperative CSF leak.

METHODS

Six hundred and sixty cases of craniopharyngioma (training cohort: n = 462; validation cohort: n = 198) were retrospectively reviewed between October 2018 and May 2024, and relevant risk factors were identified. A nomogram was built using a stepwise logistic regression method based on the Akaike information criterion. The performance of the nomogram was evaluated using area under the curve (AUC), calibration curve, and decision curve analysis.

RESULTS

The overall rate of postoperative CSF leak was 4.5%. Higher prognostic nutritional index (PNI) level (OR 0.819, 95% confidence interval [CI] 0.735-0.912; p < 0.001) and larger dural defect (OR 6.789, 95% CI 3.112-14.807; p < 0.001) were identified as independent predictors for postoperative CSF leak in multivariable logistic regression analysis. The AUCs of the nomogram were 0.870 (95% CI, 0.782-0.957; p < 0.001) and 0.842 (95% CI, 0.722-0.963; p < 0.001) in the training and validation sets, respectively. Calibration curves in the training and validation cohorts showed satisfactory agreement between predictive and actual outcomes (p = 0.608 and p = 0.564, respectively). Decision curve analysis further confirmed the clinical usefulness of the nomogram.

CONCLUSIONS

Higher PNI levels may help reduce the risk of postoperative CSF leak, while a larger dural defect size was demonstrated as an independent risk factor. We developed and validated a nomogram for predicting CSF leak after endoscopic craniopharyngioma resection, which showed strong predictive performance and could assist clinicians in formulating personalized treatment strategies.

Endoscopic transsphenoidal surgery for infradiaphragmatic craniopharyngiomas and impact of diaphragm sellae competence on hypothalamic injury

Investigate the impact of diaphragm sellae competence on surgical outcomes and risk factors for postoperative hypothalamic injury (HI) in patients undergoing endoscopic transsphenoidal surgery (ETS) for infradiaphragmatic craniopharyngiomas (ICs). A retrospective analysis of 54 consecutive patients (2016-2023) with ICs treated by ETS was conducted. All tumors originated from the sellar region inferior to the diaphragm sellae and were classified into two subtypes in terms of diaphragm sellae competence: IC with competent diaphragm sellae (IC-CDS) and IC with incompetent diaphragm sellae (IC-IDS). Clinical features, intraoperative findings, and follow-up data were compared between subtypes. Postoperative HI was assessed using an magnetic resonance imaging-based scoring system. Fifty-four patients (29 males, 25 females) were included in this study, with 12 (22.2%) under 18 years old. Overall, 35 cases were IC-CDS, while 19 were IC-IDS. Compared with IC-CDS, patients with IC-IDS tended to have hormone hypofunction before surgery (p = 0.03). Tumor volume in IC-IDS group (9.0 ± 8.6 cm3) was also higher than that in IC-CDS group (3.3 ± 3.4 cm3, p = 0.011). Thirty-seven patients underwent standard endoscopic transsphenoidal approach (SEA) and 17 underwent an extended endoscopic transsphenoidal approach (EEA). Gross total resection (GTR) was achieved in 50 cases (92.6%). Postoperative CSF leak was observed in four patients (7.4%). Permanent diabetes insipidus (DI) occurred in 13 patients (27.7%), six in IC-CDS and seven in IC-IDS. Postoperative HI occurred in 38.9% of patients. Univariate analysis revealed that large tumor size (p = 0.014), prior hypopituitarism(p = 0.048) and IC-IDS (p < 0.001) were significantly associated with postoperative HI. Multivariate analysis revealed that IC- IDS was the sole predictor of postoperative HI. To our knowledge, this is the largest case series in the literature to describe IC resected by endoscopic surgery in a single institution. Classification based on diaphragm sellae competence highlights distinct clinical features and surgical outcomes between IC-CDS and IC-IDS subtypes. Notably, IC-IDS is an independent risk factor for postoperative HI. Preoperative identification of subtype can guide surgical strategy and potentially minimize complications.

Factors influencing postoperative visual improvement in 208 patients with tuberculum sellae meningiomas

OBJECTIVE

Tuberculum sellae meningiomas (TSMs) usually compress the optic nerve and optic chiasma, thus affecting vision. Surgery is an effective means to remove tumors and improve visual outcomes. On a larger scale, this study attempted to further explore and confirm the factors related to postoperative visual outcomes to guide the treatment of TSMs.

METHODS

Data were obtained from 208 patients with TSMs who underwent surgery at our institution between January 2010 and August 2022. Demographics, ophthalmologic examination results, imaging data, extent of resection, radiotherapy status, and surgical approaches were included in the analysis. Univariate and multivariate logistic regressions were used to assess the factors that could lead to favorable visual outcomes.

RESULTS

The median follow-up duration was 63 months, and gross total resection (GTR) was achieved in 174 (83.7%) patients. According to our multivariate logistic regression analysis, age < 60 years (odds ratio [OR] = 0.310; P = 0.007), duration of preoperative visual symptoms (DPVS) < 10 months (OR = 0.495; P = 0.039), tumor size ≤ 27 mm (OR = 0.337; P = 0.002), GTR (OR = 3.834; P = 0.006), and a tumor vertical-to-horizontal dimensional ratio < 1 (OR = 2.593; P = 0.006) were found to be significant independent predictors of favorable visual outcomes.

CONCLUSION

Age, DPVS, tumor size, GTR, and the tumor vertical-to-horizontal dimensional ratio were found to be powerful predictors of favorable visual outcomes. This study may help guide decisions regarding the treatment of TSMs.

Endoscopic Endonasal Resection of a Cavernous Malformation of the Third Ventricle: Case Report and Literature Review

BACKGROUND

 Suprasellar and third ventricle cavernous malformations (CMs) are uncommon. Conventional approaches such as interhemispheric and translamina terminalis approaches are often used to resect these lesions. Here we demonstrate the use of the endoscopic endonasal approach for a third ventricle CM.

CASE DESCRIPTION

 A 31-year-old man presented with progressive symptoms of headache and visual disturbance as well as short-term memory deficit over a 6-month period. Neurologic examination revealed bitemporal hemianopsia. Radiologic images showed a suprasellar lesion extending into the third ventricle as well as obstructive hydrocephalus. The patient was operated on using an endoscopic endonasal approach and histopathology revealed a diagnosis of CM. Transient diabetes insipidus and adrenal insufficiency were reported postoperatively.

CONCLUSION

 This report demonstrates safe resection of a third ventricle CM via the endonasal route.

Comparing Surgical Approaches for Craniopharyngioma Resection Among Adults and Children: A Meta-analysis and Systematic Review

BACKGROUND

Craniopharyngioma treatment often necessitates surgical resection. Conventional approaches, such as transcranial and transsphenoidal approaches, are predominantly used. However, a recently adopted supraorbital approach may be more efficacious. Thus, this meta-analysis and systematic review aimed to compare the efficacy of the transcranial, transsphenoidal, and supraorbital approaches for resection and treatment of craniopharyngiomas.

METHODS

This study was performed following PRISMA guidelines. Analyses were performed according to study design: (1) analyses for studies comparing several surgical approaches; and (2) analyses of all included studies. Random effects meta-analysis models were used to pool odds ratios among studies comparing several approaches. Similarly, categorical meta-regression models were used to examine the effect of surgical approach as a covariate of outcome data for all studies. Statistics were performed using Comprehensive Meta-Analysis software (CMA 3.3, Biostat, Englewood, NJ) (significance set at P < 0.05).

RESULTS

Patients were well-matched for age, sex, and preoperative comorbidities between groups stratified by surgical approach. Analyses including 22 studies that compared several approaches demonstrated that the transsphenoidal group had a greater occurrence of postoperative visual improvement (P < 0.0001), lesser occurrence of visual deterioration (P < 0.0001), and lower tumor recurrence rate (P = 0.015) compared with the transcranial group. Only 2 studies compared the supraorbital approach to another approach, limiting analyses. Analyses including all studies demonstrated that the supraorbital group did not differ to either the transcranial or transsphenoidal group for any examined variables.

CONCLUSIONS

The present study suggests that the transsphenoidal approach is associated with improved clinical outcomes for craniopharyngioma resection. There are limited data regarding the supraorbital approach, warranting future investigation.

Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal approach resection of tuberculum sellae meningiomas: a single-institution study

Background

Traditionally, supratentorial craniotomy has been used to sever tuberculum sellae meningiomas (TSMs), but there has been a remarkably increasing tendency of extended endoscopic endonasal approach (EEEA) used to treat TSMs in the recent decade. Several documents have described the advantages and disadvantages of both approaches, but there is no consensus on whether one is superior to the other.

Objective

This study aimed to compare surgical outcomes between craniotomy and EEEA for TSMS treated at our institution.

Methods

From January 2015 to December 2021, a total of 84 cases of TSMs were included in this study. Cases were separated into two groups: the craniotomy group and the EEEA group. Their anamneses and surgical records were reviewed. Demographic data, presenting symptoms, tumor volume, extent of resection, visual outcomes, and follow-up data were tabulated. The Kaplan-Meier curves were constructed for the PFS for both cohorts.

Results

Complete data were available for 84 surgeries; 39 cases were treated via craniotomy, and 45 were treated via EEEA. Patient demographic data, pre-operative symptoms, and tumor characteristics were similar between the two cohorts. The extent of resection was similar between the two groups (GTR: 91.11% EEEA vs. 87.18% craniotomy; STR 8.89 vs. 12.82%, p = 0.91). There was no difference in visual outcomes between both groups (92.1 vs. 84.84%, p = 0.46). An increased rate of cranial nerve injury was noted in the craniotomy group (0 vs. 10.25%, p = 0.04). Post-operative CSF leak rate occurred in one patient in the EEEA group. The PFS curves (p = 0.52) and recurrence/progression rates (13.33 vs. 20.51%, p = 0.39) were similar between the two groups.

Conclusion

Both EEEA and craniotomy can successfully sever TSMs. The recurrence/progression rate and PFS appear to be similar between the two groups. Although there are no differences in EOR and visual outcomes between the two groups, there was a clear trend in the EEEA group to obtain a better outcome. CSF leakage was common in the EEEA cohort, whereas the rate of cranial nerve injury was found to be higher in the craniotomy cohort. We believe that our data support the conclusion that EEEA surgery is the preferred approach for the removal of TSMs.

Risk Factor and Replacement Therapy Analysis of Pre- and Postoperative Endocrine Deficiencies for Craniopharyngioma

BACKGROUND

Pituitary hormone deficiency (PHD) is one of the most common symptoms and postoperative complications of craniopharyngiomas (CPs). However, the risk factors for PHD in CPs are little known. The purpose of this study was to analyze the risk factors of pre- and postoperative PHD and to investigate replacement therapy for CP patients.

METHODS

A retrospective study of 126 patients diagnosed with CP was performed. Univariate analysis was performed using Pearson's chi-squared test or Fisher's exact test, and a multiple logistic binary regression model was used to identify the influencing factors of pre- and postoperative PHD in craniopharyngioma.

RESULTS

Children and patients with hypothalamic involvement were more likely to have preoperative PHD. Patients with suprasellar lesions had a high risk of postoperative PHD, and preoperative PHD was a risk factor for postoperative PHD.

CONCLUSION

Children have a high incidence of preoperative PHD. Preoperative PHD can serve as an independent risk factor for postoperative PHD. Preoperative panhypopituitarism can serve as an indication of pituitary stalk sacrifice during surgery. The management of replacement therapy for long-term postoperative endocrine hormone deficiency in patients with craniopharyngioma should be enhanced.

Fatal Fungal Aneurysm Rupture Due to Aspergillosis after Craniopharyngioma Removal via Endoscopic Endonasal Surgery: Case Report and Comparison with Seven Reported Patients

There has been a noted increase in the incidence of intracranial aspergillosis; this is often attributed to the wider use of antibiotics, corticosteroids, and immunosuppressants. Fungal cerebral aneurysms due to aspergillosis after neurosurgery remain extremely rare; in fact, only seven cases have been reported in the literature. In this study, we present a patient with an Aspergillus aneurysm that elicited subarachnoid hemorrhage after endoscopic endonasal surgery (EES) for craniopharyngioma. A 70-year-old woman with recurrent craniopharyngioma and steroid treatment underwent uneventful EES. On the 5th postoperative day, she suffered subarachnoid hemorrhage. As per her computed tomography angiography findings, an aneurysm was detected on the left internal carotid artery (ICA). Subsequent digital subtraction angiography showed occlusion of the ICA and an irregularly shaped wall. The diagnosis was pseudoaneurysm. We then performed craniotomy to place a left high-flow bypass and to trap the pseudoaneurysm. Despite continuous intensive care, she died on the 25th postoperative day of a huge, left cerebral infarct. The final diagnosis was made at autopsy; it revealed destruction of the ICA and Aspergillus invasion of the vessel wall, confirming the presence of a true fungal aneurysm. Perioperatively, patients with potential immunosuppression must be carefully managed. Advanced age is a risk factor. As surgery via the paranasal sinuses raises the risk for aspergillosis, fungal infection must be ruled out in patients whose postoperative course is deemed concerning.

The Role of Surgical Approaches in the Multi-Modal Management of Adult Craniopharyngiomas

Craniopharyngiomas are rare, benign primary brain tumors that arise from remnants of the craniopharyngeal duct epithelium within the sellar and suprasellar region. Despite their benign biology, they may cause significant morbidity, secondary to involvement of nearby eloquent neural structures, such as the pituitary gland, hypothalamus, and optic apparatus. Historically, aggressive surgical resection was the treatment goal to minimize risk of tumor recurrence via open transcranial midline, anterolateral, and lateral approaches, but could lead to clinical sequela of visual, endocrine, and hypothalamic dysfunction. However, recent advances in the endoscopic endonasal approach over the last decade have mostly supplanted transcranial surgery as the optimal surgical approach for these tumors. With viable options for adjuvant radiation therapy, targeted medical treatment, and alternative minimally invasive surgical approaches, the management paradigm for craniopharyngiomas has shifted from aggressive open resection to more minimally invasive but maximally safe resection, emphasizing quality of life issues, particularly in regards to visual, endocrine, and hypothalamic function. This review provides an update on current multi-modal approaches for craniopharyngiomas, highlighting the modern surgical treatment paradigm for this disease entity.

Intraventricular Craniopharyngiomas-Overcoming Their Relative Inaccessibility: Institutional Experience With a Review of Literature

Introduction: Craniopharyngiomas constitute 2-4% of intracranial neoplasms. Intraventricular craniopharyngiomas (IVCrs) are the rarely encountered varieties of these lesions. Objective: The objective of the study was to study the special features in clinical presentation, imaging, management, and surgical outcome of IVCrs. Materials and Methods: This retrospective analysis included the combined experience from two tertiary care institutions. Medical records of histopathologically proven cases of IVCrs from January 1994 to June 2021 were assessed, and images were analyzed based on the criteria by Migliore et al. for inclusion of solely intraventricular lesion with the third ventricular ependyma demarcating it from the suprasellar cistern. Results: Among the 25 patients included (mean age: 35.4 years), the most common presentation included headache (n = 21, 84%), vomiting and other features of raised ICP (n = 18, 72%), visual complaints (n = 12, 48%), and endocrinopathies (n = 11, 44%). Fifteen had predominantly cystic tumors, two were purely solid, and eight were of mixed consistency. Primary open microsurgical procedures were performed in 18 (72%) patients, of which four (16%) were endoscope-assisted. Seven (28%) underwent a purely endoscopic procedure. One underwent a staged surgery with endoscopic cyst fenestration and intracystic interferon (IFN)-alpha therapy, followed by microsurgical excision. Complete excision was achieved in 10 patients, near-total in nine, and partial excision in six. Four patients underwent a ventriculoperitoneal shunt (one before the definitive procedure). At a median follow-up of 36 months (range:11-147 months), five patients developed a recurrence, and one had a stable small residue. This patient and two others with small cystic recurrences were observed. One patient was managed with radiotherapy alone. Another underwent re-surgery after a trial of radiotherapy, and the last patient developed a local recurrence, which was managed with radiotherapy; he then later developed an intraparenchymal recurrence, which was operated. Conclusion: Purely IVCrs present with raised intracranial pressure, and visual disturbances are less common. Their deep-seated location and limited surgical field-of-view makes minimally invasive endoscopic-assisted surgery most suitable for their excision. The thin-walled cystic lesions may be occasionally adherent to the ependymal wall in close vicinity to the thalamus-hypothalamus complex, making complete excision difficult. Their responsiveness to radiotherapy, often leads to a gratifying long-term outcome.

The predictive value of intraoperative visual evoked potential for visual outcome after extended endoscopic endonasal surgery for adult craniopharyngioma

OBJECTIVE

Due to the proximity of craniopharyngioma to the optic apparatus, one of the most common complications after surgery is visual deterioration. Intraoperative visual evoked potential (VEP), as a means of real-time visual function monitoring, has been integrated into transsphenoidal surgery for pituitary adenoma to predict postoperative visual outcome. Compared with pituitary tumor, craniopharyngioma often adheres to optic nerves, with increased risk of postoperative visual impairment. Furthermore, extended endoscopic endonasal surgery (EEES) can provide direct visualization of the surgical plane between the craniopharyngioma and the optic nerves, which contributes to analysis of the mechanism of real-time VEP changes during surgery. Therefore, VEP monitoring applied during EEES for craniopharyngioma may have more clinical value. However, only 9 patients who underwent EEES with VEP monitoring for craniopharyngioma have been sporadically reported to date. In this paper, the authors present the largest series to date analyzing the clinical value of VEP to predict postoperative visual outcome in adult patients with craniopharyngioma.

METHODS

Sixty-five adult patients who underwent EEES with intraoperative VEP monitoring for primary craniopharyngioma were retrospectively reviewed. The association between changes in VEP amplitude and postoperative visual outcome was determined. In addition, other potential prognostic factors with regard to postoperative visual outcomes were included in the analysis.

RESULTS

Gross-total resection was achieved in 59 patients (90.8%). Reproducible and stable VEP was recorded in 128 of 130 eyes (98.5%). During surgery, VEP remained stable in 108 eyes, 10 (9.3%) of which had new visual acuity (VA) and/or visual field (VF) defects after surgery. Transient VEP decrease was recorded in 15 eyes, 4 (26.7%) of which had visual deterioration. Of the 5 eyes with permanent VEP decrease, 3 (60%) experienced postoperative visual impairment. Permanent VEP decrease (OR 19.868, p = 0.007) and tight adhesion (OR 6.104, p = 0.040) were independent adverse factors for postoperative VA deterioration. Tight adhesion (OR 7.150, p = 0.002) and larger tumor volume (OR 1.066, p = 0.001) were significant risk factors for postoperative VF defects.

CONCLUSIONS

Intraoperative VEP monitoring can serve as a real-time warning to guide surgeons to avoid postoperative visual impairment. It effectively predicted VA changes in adult patients with craniopharyngioma after EEES. Tight adhesion and larger tumor volume were also strong predictors of postoperative visual impairment.

An endoscopic endonasal approach to craniopharyngioma via the infrachiasmatic corridor: a single center experience of 84 patients

OBJECT

The infrachiasmatic corridor is the most important surgical access route for craniopharyngiomas and was identified and used in clinical series. The aims of this study were to describe the characteristics that assist dissection and resection rates in endoscopic surgery of solid, cystic, and recurrent cases and their importance in the infrachiasmatic corridor in endoscopic surgery.

METHODS

One hundred operations on 84 patients with pathologically identified craniopharyngioma were included in the study. The MRI findings were evaluated, and the location of the lesions was classified as (1) infrasellar; (2) sellar; or (3) suprasellar. In the sagittal plane, we measured the longest diameter of cystic and solid components and the height of chiasm-sella. Images were assessed for the extent of resection and were classified as gross total resection. This was deemed as the absence of residual tumor and subtotal resection, which had residual tumor.

RESULTS

The infrasellar location was reported in 7/84 (8.3%) patients, the sellar location in 8/84 (9.5%), and the suprasellar location in 69/84 (82.1%) patients. The narrow and high chiasm-sella were observed in 28/69 (40.5%) and 41/69 patients (59.4%), respectively. The mean distance of the chiasm-sella was 9.46± 3.76. Gross total tumor resection was achieved in 60/84 (71.4%) and subtotal tumor resection was performed in 24/84 (28.6%) patients. The results revealed that suprasellar location (OR: 0.068; p = 0.017) and recurrent cases (OR: 0.011; p<0.001) were negative predictive factors on GTR. Increasing the experience (OR: 42,504; p = 0.001) was a positive predictor factor for GTR.

CONCLUSION

An EETS approach that uses the infrachiasmatic corridor is required for skull base lesions extending into the suprasellar area. The infrachiasmatic corridor can determine the limitations of endoscopic craniopharyngioma surgery. This corridor is a surgical safety zone for inferior approaches.

Endoscopic extended transsphenoidal surgery for newly diagnosed paediatric craniopharyngiomas

PURPOSE

Endoscopic extended transsphenoidal surgery (EETSS) has gained popularity for treatment of craniopharyngiomas. The aim of this study is to assess the outcome of endoscopic extended transsphenoidal surgery (EETSS) for newly diagnosed paediatric craniopharyngiomas.

METHODS

Patient details were obtained from a prospective database of all endoscopic transnasal operations performed by a single surgeon. Outcomes including visual function, pituitary function, body mass index (BMI), postoperative neurological deficit, extent of resection and recurrence on follow-up were obtained. Obesity was defined as BMI percentile of equal to or greater than 95%.

RESULTS

Between January 2011 and January 2020, 15 of 16 children (5-18 years old) with newly diagnosed craniopharyngiomas underwent EETSS. Four patients had a conchal-type sphenoid sinus. Gross total resection (GTR) was achieved in 4 patients and near total resection (NTR) in 5 patients. The remaining 6 had subtotal resection (STR). Postoperative radiotherapy was used in 6 patients (4 with STR, 2 with NTR). There were no postoperative deaths, strokes or CSF leaks. Normalisation of visual fields (VF) occurred in 9/13 patients with preoperative VF defects. One patient developed a new visual field defect. During a median follow-up period of 74 (8-104) months, 2 patients have required further surgery for tumour progression following initial STR, where a tumour remnant was left in situ to preserve the pituitary stalk. 6/11 patients developed new anterior pituitary dysfunction as a result of surgery and 9/12 developed new diabetes insipidus (DI). At the time of last follow-up, 14/15 children had anterior panhypopituitarism, 13/15 had DI and 1 patient developed new onset obesity. Two patients, who were obese preoperatively, were no longer obese at last follow-up.

CONCLUSIONS

EETSS can be performed as the first option in the majority of children with newly diagnosed craniopharyngioma, despite factors such as small nose, non-pneumatised sphenoid sinus, small sella or purely suprasellar tumour location. Preservation of the pituitary stalk at the expense of leaving residual tumour may not be in the best interests of the patient.

Creative and Innovative Methods and Techniques for the Challenges in the Management of Adult Craniopharyngioma

Craniopharyngioma remains a major challenge in daily clinical practice. The pathobiology of the tumor is still elusive, and there are no consensus or treatment guidelines on the optimal management strategy for this relatively rare tumor. However, recent technical and scientific advances, including genomic and radiomic profiling, innovation in surgical approaches, more precise radiotherapy protocols, targeted therapy, and restoration of lost functions all have the potential to significantly improve the outcome of patients with craniopharyngioma in the near future. Although many of these innovative tools in the new armamentarium of the clinician are still in their infancy, they could reduce craniopharyngioma-related morbidity and mortality and improve the patients' quality of life. In this article, we discuss these creative and innovative approaches that may offer solutions to the obstacles faced in treating craniopharyngioma and future possibilities in improving the care of these patients.

Treatment with endoscopic transnasal resection of hypothalamic pilocytic astrocytomas: a single-center experience

Backgrounds

Pilocytic astrocytomas (PAs) are World Health Organization (WHO) grade I tumors, which are relatively common, and are benign lesions in children. PAs could originate from the cerebellum, optic pathways, and third ventricular/hypothalamic region. Traditional various transcranial routes are used for hypothalamic PAs (HPAs). However, there are few studies on hypothalamic PAs treated through the endoscopic endonasal approach (EEA). This study reports the preliminary experience of the investigators and results with HPAs via expanded EEAs.

Methods

All patients with HPAs, undergone EEA in our hospital from 2017 to 2019, were retrospectively reviewed. The demographic data, clinical symptoms, complications, skull base reconstruction, prognosis, and endocrinological data were all recorded and analyzed in detail.

Results

Finally, five female patients were enrolled. The average age of patients was 28.6 ± 14.0. All patients had complaints about their menstrual disorder. One patient had severe bilateral visual impairment. Furthermore, only one patient suffered from severe headache due to acute hydrocephalus, although there were four patients with headache or dizziness. Four cases achieved gross-total resection, and one patient achieved subtotal resection. Furthermore, there was visual improvement in one patient (case 5), and postoperative worsening of vision in one patient (case 4). However, only one patient had postoperative intracranial infection. None of the patients experienced a postoperative CSF leak, and in situ bone flap (ISBF) techniques were used for two cases for skull base repair. In particular, ISBF combined with free middle turbinate mucosal flap was used for case 5. After three years of follow-up, three patients are still alive, two patients had no neurological or visual symptoms, or tumor recurrence, and one patient had severe hypothalamic dysfunction. Unfortunately, one patient died of severe postoperative hypothalamus reaction, which presented with coma, high fever, diabetes insipidus, hypernatremia and intracranial infection. The other patient died of recurrent severe pancreatitis at one year after the operation.

Conclusion

Although the data is still very limited and preliminary, EEA provides a direct approach to HPAs with acceptable prognosis in terms of tumor resection, endocrinological and visual outcomes. ISBF technique is safe and reliable for skull base reconstruction.

Endonasal endoscopic resection of suprasellar craniopharyngioma: A retrospective single-center case series

INTRODUCTION

Endoscopic endonasal approach (EEA) has recently been proposed as an option for resection of primary and recurrent suprasellar craniopharyngioma. However, surgical outcome has not yet been fully evaluated, especially in regards to recurrent cases.

METHODS

We analysed our institution (Sir Charles Gairdner University Hospital, Perth, Australia) case-series retrospectively. There were 16 patients operated through an endonasal endoscopic approach from February 2014 to February 2019 for suprasellar craniopharyngiomas. There were 14 primary, and two recurrent lesions. Extent of resection, complications, visual and endocrinological outcomes are presented.

RESULTS

Mean age of the patients was 42.9 ± 19.3 years old, with 56% female. The most common clinical symptoms were headaches (9 patients, 56%) and bi-temporal hemianopsia (9 patients, 56%), followed by unilateral optic neuropathy (5 cases, 31%), memory loss (1 case, 6%), hydrocephalus (1 case, 6%), delayed growth and puberty (1 case, 6%), and secondary amenorrhoea (1 case, 6%). Only two cases (12%) initially presented with normal visual function. Gross total resection (GTR) was achieved in 10/16 patients (62.5%), with subtotal resection (STR) in the remainder. Visual symptoms improved in 13/16 patients (81%) and remained unchanged in 3/16 patients (19%). Most common complications included new endocrinological deficit in nine patients (56%), mostly diabetes insipidus, and cerebrospinal fluid leak requiring a new intervention in three patients (19%). There was one mortality case (complicated meningitis, stroke and vasospasm). Mean follow-up time was 22.05 ± 14 months and three patients (19%) had a recurrence of the disease during this period and were referred for radiation therapy.

CONCLUSION

Endonasal endoscopic approach is a safe and effective surgical option for both primary and recurrent suprasellar craniopharyngiomas.

Reconstruction of skull base bone defects using an in situ bone flap after endoscopic endonasal transplanum-transtuberculum approaches

PURPOSE

The creation of bone flaps which can be later repositioned and fixed in situ for repairing the bone defects during the endoscopic endonasal approaches (EEAs)-similar to transcranial craniotomies-is still a challenge. We present an in situ bone flap (ISBF) closure for the repair of bone defects after endoscopic endonasal transplanum-transtuberculum approaches (EETAs).

METHODS

A retrospective analysis of consecutive patients who underwent the EETAs between January 2016 and February 2019 was performed. According to whether or not to use ISBF for skull base reconstruction, these patients were divided into the ISBF group or the non-ISBF group.

RESULTS

Of 47 patients in the ISBF group, only one patient (2.1%) developed postoperative cerebrospinal fluid (CSF) leakage, yielding a significantly lower leakage rate in the ISBF group than in the non-ISBF group (6 of 38, 15.8%, P = 0.042). Besides, when only comparing cases of hydrocephalus in the two groups, the CSF leakage rate in the ISBF group was 8.3% (1/12), which was still significantly lower than that in the non-ISBF group (62.5%, 6/8) (P = 0.018). Postoperative CSF leakages in both groups were successfully treated with lumbar drainage alone, and no cases of injury to the internal carotid arteries or optic nerves occurred in either group.

CONCLUSIONS

An ISBF closure similar to transcranial craniotomies with repositioning bone flap in situ-is feasible, safe, and reliable. The ISBF closure combining with a pedicled nasoseptal flap (PNSF) provides the cranial base surgeon with an additional repair method that has demonstrated effectiveness at facilitating a more stable and durable reconstruction and reducing CSF leaks.

Surgical management of Tuberculum sellae Meningiomas: Myths, facts, and controversies

BACKGROUND

The optimal management of tuberculum sellae (TS) meningiomas, especially the surgical strategy, continues to be debated along with several controversies that persist.

METHODS

A task force was created by the EANS skull base section committee along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumors on a European perspective. To achieve this, the task force also reviewed in detail the literature in this field and had formal discussions within the group.

RESULTS

The constituted task force dealt with the practice patterns that exist with respect to pre-operative radiological investigations, ophthalmological and endocrinological assessments, optimal surgical strategies, and follow-up management.

CONCLUSION

This article represents the consensually derived opinion of the task force with respect to the surgical treatment of tuberculum sellae meningiomas. Areas of uncertainty where further clinical research is required were identified.

Gamma Knife Surgery for Residual or Recurrent Craniopharyngioma After Surgical Resection: A Multi-institutional Retrospective Study in Japan

Objective

The optimal treatment for a craniopharyngioma has been controversial. Complete resection is ideal, but it has been difficult to obtain total resection in many cases because of intimate proximity to critical structures such as the optic pathway, hypothalamus, and pituitary gland. A growing number of studies have demonstrated the utility of radiosurgery in controlling residual or recurrent craniopharyngioma. However, most of them are small series. The aim of this multi-institutional study was to clarify the efficacy and safety of Gamma Knife (Elekta, Stockholm, Sweden) surgery for patients with a craniopharyngioma.

Methods

This was a multi-institutional retrospective study by 16 medical centers of the Japan Leksell Gamma Knife Society. Data on patients with craniopharyngiomas treated with Gamma Knife Surgery (GKS) between 1991 and 2013 were obtained from individual institutional review board-approved databases at each center. A total of 242 patients with craniopharyngioma were included in this study. The mean age of the patients was 41 (range, 3 to 86) years. The median follow-up time was 61.4 months (range, 3 to 180 months). The mean radiosurgery target volume was 3.1 ml (range, 0.03-22.3 ml), and the mean marginal dose was 11.4 Gy (range, 8-20.4 Gy).

Results

Two-hundred twenty patients were alive at the time of the last follow-up visit. The three-, five-, and 10-year overall survival rates after GKS were 95.4%, 92.5%, and 82.0%, respectively. The three-, five-, and 10-year progression-free survival rates after GKS were 73.1%, 62.2%, and 42.6% respectively. The rate of radiation-induced complications was 6.2%.

Conclusion

GKS is effective for controlling the tumor growth of craniopharyngiomas with an acceptable complication rate.

Is Gross Total Resection Reasonable in Adults with Craniopharyngiomas with Hypothalamic Involvement?

OBJECTIVE

The treatment of hypothalamus-invading craniopharyngiomas, based on pediatric experience, is subtotal resection (STR) with radiotherapy. This strategy sometimes leads to uncontrollable tumor progression. In adults, with the use of endoscopic endonasal surgery (EES), does removing the hypothalamic part of the tumor-whenever possible-compromise the outcome of the patients?

METHODS

We included adults with craniopharyngioma treated by a first EES in 2008-2016 by senior neurosurgeon (E.J.). Endocrine, ophthalmologic, and hypothalamic data were retrospectively collected, including body mass index (BMI), cognitive and social status, with a systematic follow-up interview. Magnetic resonance imaging scans were graded according to Puget classification: 0, no hypothalamic involvement; 1, hypothalamic displacement; and 2, hypothalamic involvement. Grade 2 tumors were separated into gross total resection (GTR) or STR.

RESULTS

We included 22 patients aged 18-79 years. Presenting symptoms were visual (14, 64%), endocrine dysfunction (10, 45%), BMI >30 (8, 36%), and cognitive/psychiatric impairment (9, 41%). Fourteen (64%) were grade 2 craniopharyngiomas. GTR was performed in 14 (64%) patients. Postoperatively, 12/14 (86%) cases improved visually, and 20 (91%) needed hormone replacement therapy. There was no difference in BMI evolution in the GTR versus STR group, cognitive status was stable or improved in all patients except 1; 4/8 patients with STR experienced progression needing adjuvant treatment versus no patient with GTR.

CONCLUSIONS

EES GTR of grade 2 craniopharyngiomas does not cause major hypothalamic worsening, in contrast with children operated by cranial approaches. The surgeon's experience is key in deciding when to stop the dissection. Offering GTR whenever possible aims at avoiding tumor progression and radiotherapy.