Extended endoscopic endonasal transsphenoidal approach for residual or recurrent craniopharyngiomas

Clinical article

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  • 1 Department of Neurological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy; and
  • 2 Departments of Neurosurgery and
  • 3 Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Object

The management of recurrent or residual craniopharyngiomas remains controversial. Although possible, revision surgery is more challenging than primary surgery, and more often results in incomplete resection and an increased risk of death and complications. The extended (also called expanded) endoscopic endonasal transsphenoidal approach through the planum sphenoidale has been proposed over the past decade as an alternative surgical route for removal of various suprasellar tumors including craniopharyngiomas. In this study, the authors describe the feasibility and advantages of this technique in recurrent or symptomatic residual craniopharyngiomas.

Methods

Between January 2004 and June 2008, 22 patients underwent surgery via the extended endoscopic transsphenoidal approach for the treatment of recurrent or residual symptomatic craniopharyngiomas at either the University of Pittsburgh or the Universita degli Studi di Napoli. The lesions included 12 purely suprasellar craniopharyngiomas, 9 with both intra- and suprasellar extensions, and 1 arising from a remnant in the Meckel cave. To better evaluate the features of the extended endonasal approach for recurrent or residual craniopharyngiomas, each patient was assigned to 1 of 3 subgroups depending on the original surgical treatment: transcranial pterional route (13 patients), transphenoidal approach (3 patients; 2 microsurgically and 1 with the standard endoscopic technique), or extended endonasal endoscopic approach (6 patients).

Results

Total removal was achieved in 9 patients (40.9%), and in 8 patients (36.4%) near-total removal (defined as > 95% removal) was possible. Subtotal removal (> 70%) was attained in 4 patients (18.2%), and tumor removal was partial (< 50%) in only 1 case (4.5%). There were no deaths or major complications, including behavior changes. Postoperative CSF leaks developed in 2 patients in the transcranial subgroup, and 1 in the transsphenoidal subgroup (overall rate 13.6%), requiring early successful endoscopic revision surgery for the cranial base defect.

Conclusions

Most of the advantages of the endoscopic endonasal technique were noted during tumor dissection from the inferior aspect of the chiasm, the infundibulum, the third ventricle, and/or the retro- and parasellar areas. These benefits were best appreciated in patients who had originally undergone transcranial surgery, since in such cases the authors' endoscopic endonasal approach was a virgin route. However, the extended endoscopic endonasal technique can also be safely used in patients who originally underwent transsphenoidal surgery. The endoscopic endonasal technique should be considered as a therapeutic option in selected cases of recurrent or symptomatic residual craniopharyngiomas.

Abbreviations used in this paper: EEE = expanded endoscopic endonasal; GKS = Gamma Knife surgery; HBF = Hadad-Bassagasteguy flap; RT = radiation therapy; STR = subtotal resection.

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Contributor Notes

Address correspondence to: Daniel M. Prevedello, M.D., Department of Neurological Surgery, University of Pittsburgh, 200 Lothrop Street, Suite B400, Pittsburgh, Pennsylvania 15213. email: prevedellod@upmc.edu.

Please include this information when citing this paper: published online March 27, 2009; DOI: 10.3171/2009.2.JNS081026.

  • 1

    Backlund EO: Treatment of craniopharyngiomas: the multimodality approach. Pediatr Neurosurg 21:1 Suppl 8289, 1994

  • 2

    Baskin DS, & Wilson CB: Surgical management of craniopharyngiomas. A review of 74 cases. J Neurosurg 65:2227, 1986

  • 3

    Bunin GR, , Surawicz TS, , Witman PA, , Preston-Martin S, , Davis F, & Bruner JM: The descriptive epidemiology of craniopharyngioma. J Neurosurg 89:547551, 1998

    • Search Google Scholar
    • Export Citation
  • 4

    Cabezudo JM, , Vaquero J, , Areitio E, , Martinez R, , de Sola RG, & Bravo G: Craniopharyngiomas: a critical approach to treatment. J Neurosurg 55:371375, 1981

    • Search Google Scholar
    • Export Citation
  • 5

    Caldarelli M, , di Rocco C, , Papacci F, & Colosimo C Jr: Management of recurrent craniopharyngioma. Acta Neurochir (Wien) 140:447454, 1998

    • Search Google Scholar
    • Export Citation
  • 6

    Cappabianca P, , Alfieri A, , Colao A, , Cavallo LM, , Fusco M, & Peca C, : Endoscopic endonasal transsphenoidal surgery in recurrent and residual pituitary adenomas: technical note. Minim Invasive Neurosurg 43:3843, 2000

    • Search Google Scholar
    • Export Citation
  • 7

    Cappabianca P, , Cavallo LM, , Esposito F, , de Divitiis O, , Messina A, & de Divitiis E: Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery. Adv Tech Stand Neurosurg 33:151199, 2008

    • Search Google Scholar
    • Export Citation
  • 8

    Cappabianca P, , Frank G, , Pasquini E, , de Divitiis O, & Calbucci F, Extended endoscopic endonasal transsphenoidal approaches to the suprasellar region, planum sphenoidale and clivus. de Divitiis E, & Cappabianca P: Endoscopic Endonasal Transsphenoidal Surgery New York, Springer, 2003. 176187

    • Search Google Scholar
    • Export Citation
  • 9

    Carmel PW, , Antunes JL, & Chang CH: Craniopharyngiomas in children. Neurosurgery 11:382389, 1982

  • 10

    Cavallo LM, , de Divitiis O, , Aydin S, , Messina A, , Esposito F, & Iaconetta G, : Extended endoscopic endonasal transsphenoidal approach to the suprasellar area: anatomic considerations—part 1. Neurosurgery 61:3 Suppl 2434, 2007

    • Search Google Scholar
    • Export Citation
  • 11

    Cavallo LM, , Messina A, , Esposito F, , de Divitiis O, , Dal Fabbro M, & de Divitiis E, : Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions. J Neurosurg 107:713720, 2007

    • Search Google Scholar
    • Export Citation
  • 12

    Choux M, , Lena G, & Genitori L: Le craniopharyngiome de l'enfant. Neurochirurgie 37:1 Suppl 1520, 1991

  • 13

    Couldwell WT, , Weiss MH, , Rabb C, , Liu JK, , Apfelbaum RI, & Fukushima T: Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases. Neurosurgery 55:539550, 2004

    • Search Google Scholar
    • Export Citation
  • 14

    de Divitiis E, , Cappabianca P, & Cavallo LM: Endoscopic transsphenoidal approach: adaptability of the procedure to different sellar lesions. Neurosurgery 51:699707, 2002

    • Search Google Scholar
    • Export Citation
  • 15

    de Divitiis E, , Cappabianca P, , Cavallo LM, , Esposito F, , de Divitiis O, & Messina A: Extended endoscopic transsphenoidal approach for extrasellar craniopharyngiomas. Neurosurgery 61:219228, 2007

    • Search Google Scholar
    • Export Citation
  • 16

    de Divitiis E, , Cavallo LM, , Cappabianca P, & Esposito F: Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: part 2. Neurosurgery 60:4659, 2007

    • Search Google Scholar
    • Export Citation
  • 17

    De Vile CJ, , Grant DB, , Kendall BE, , Neville BG, , Stanhope R, & Watkins KE, : Management of childhood craniopharyngioma: can the morbidity of radical surgery be predicted?. J Neurosurg 85:7381, 1996

    • Search Google Scholar
    • Export Citation
  • 18

    Duffner PK, , Cohen ME, & Parker MS: Prospective intellectual testing in children with brain tumors. Ann Neurol 23:575579, 1988

  • 19

    Dusick JR, , Esposito F, , Kelly DF, , Cohan P, , DeSalles A, & Becker DP, : The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 102:832841, 2005

    • Search Google Scholar
    • Export Citation
  • 20

    Ellenberg L, , McComb JG, , Siegel SE, & Stowe S: Factors affecting intellectual outcome in pediatric brain tumor patients. Neurosurgery 21:638644, 1987

    • Search Google Scholar
    • Export Citation
  • 21

    Fahlbusch R, , Honegger J, , Paulus W, , Huk W, & Buchfelder M: Surgical treatment of craniopharyngiomas: experience with 168 patients. J Neurosurg 90:237250, 1999

    • Search Google Scholar
    • Export Citation
  • 22

    Fischer EG, , Welch K, , Shillito J Jr, , Winston KR, & Tarbell NJ: Craniopharyngiomas in children. Long-term effects of conservative surgical procedures combined with radiation therapy. J Neurosurg 73:534540, 1990

    • Search Google Scholar
    • Export Citation
  • 23

    Fortes FS, , Carrau RL, , Snyderman CH, , Kassam A, , Prevedello D, & Vescan A, : Transpterygoid transposition of a temporoparietal fascia flap: a new method for skull base reconstruction after endoscopic expanded endonasal approaches. Laryngoscope 117:970976, 2007

    • Search Google Scholar
    • Export Citation
  • 24

    Fortes FS, , Carrau RL, , Snyderman CH, , Prevedello D, , Vescan A, & Mintz A, : The posterior pedicle inferior turbinate flap: a new vascularized flap for skull base reconstruction. Laryngoscope 117:13291332, 2007

    • Search Google Scholar
    • Export Citation
  • 25

    Frank G, , Pasquini E, , Doglietto F, , Mazzatenta D, , Sciaretta V, & Farneti G, : The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery 59:1 Suppl ONS75ONS83, 2006

    • Search Google Scholar
    • Export Citation
  • 26

    Gardner PA, , Kassam AB, , Snyderman CH, , Carrau RL, , Mintz AH, & Grahovac S, : Outcomes following endoscopic, expanded endonasal resection of suprasellar craniopharyngiomas: a case series. J Neurosurg 109:616, 2008

    • Search Google Scholar
    • Export Citation
  • 27

    Hadad G, , Bassagasteguy L, , Carrau RL, , Mataza JC, , Kassam A, & Snyderman CH, : A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 116:18821886, 2006

    • Search Google Scholar
    • Export Citation
  • 28

    Hargrave DR: Does chemotherapy have a role in the management of craniopharyngioma?. J Pediatr Endocrinol Metab 19:1 Suppl 407412, 2006

    • Search Google Scholar
    • Export Citation
  • 29

    Harris JR, & Levene MB: Visual complications following irradiation for pituitary adenomas and craniopharyngiomas. Radiology 120:167171, 1976

    • Search Google Scholar
    • Export Citation
  • 30

    Haupt R, , Magnani C, , Pavanello M, , Caruso S, , Dama E, & Garre ML: Epidemiological aspects of craniopharyngioma. J Pediatr Endocrinol Metab 19:1 Suppl 289293, 2006

    • Search Google Scholar
    • Export Citation
  • 31

    Hetelekidis S, , Barnes PD, , Tao ML, , Fischer EG, , Schneider L, & Scott RM, : 20-year experience in childhood craniopharyngioma. Int J Radiat Oncol Biol Phys 27:189195, 1993

    • Search Google Scholar
    • Export Citation
  • 32

    Hoffman HJ: Surgical management of craniopharyngioma. Pediatr Neurosurg 21:1 Suppl 4449, 1994

  • 33

    Honegger J, , Buchfelder M, , Fahlbusch R, , Daubler B, & Dorr HG: Transsphenoidal microsurgery for craniopharyngioma. Surg Neurol 37:189196, 1992

    • Search Google Scholar
    • Export Citation
  • 34

    Hoogenhout J, , Otten BJ, , Kazem I, , Stoelinga GB, & Walder AH: Surgery and radiation therapy in the management of craniopharyngiomas. Int J Radiat Oncol Biol Phys 10:22932297, 1984

    • Search Google Scholar
    • Export Citation
  • 35

    Jane JA Jr, & Laws ER: Craniopharyngioma. Pituitary 9:323326, 2006

  • 36

    Julow J, , Lanyi F, , Hajda M, , Szeifert G, , Simkovics M, & Toth S, : Further experiences in the treatment of cystic craniopharyngeomas with yttrium 90 silicate colloid. Acta Neurochir Suppl (Wien) 42:113119, 1988

    • Search Google Scholar
    • Export Citation
  • 37

    Kalapurakal JA, , Goldman S, , Hsieh YC, , Tomita T, & Marymont MH: Clinical outcome in children with craniopharyngioma treated with primary surgery and radiotherapy deferred until relapse. Med Pediatr Oncol 40:214218, 2003

    • Search Google Scholar
    • Export Citation
  • 38

    Kalapurakal JA, , Goldman S, , Hsieh YC, , Tomita T, & Marymont MH: Clinical outcome in children with recurrent craniopharyngioma after primary surgery. Cancer J 6:388393, 2000

    • Search Google Scholar
    • Export Citation
  • 39

    Kaptain GJ, , Vincent DA, , Sheehan JP, & Laws ER Jr: Transsphenoidal approaches for the extracapsular resection of midline suprasellar and anterior cranial base lesions. Neurosurgery 49:94101, 2001

    • Search Google Scholar
    • Export Citation
  • 40

    Kassam A, , Snyderman CH, , Mintz A, , Gardner P, & Carrau RL: Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 19:1 E3, 2005

    • Search Google Scholar
    • Export Citation
  • 41

    Kassam AB, , Gardner PA, , Snyderman CH, , Carrau RL, , Mintz AH, & Prevedello DM: Expanded endonasal approach, a fully endoscopic transnasal approach for the resection of midline suprasellar craniopharyngiomas: a new classification based on the infundibulum. J Neurosurg 108:715728, 2008

    • Search Google Scholar
    • Export Citation
  • 42

    Kassam AB, , Prevedello DM, , Thomas A, , Gardner P, , Mintz A, & Snyderman C, : Endoscopic endonasal pituitary transposition for a transdorsum sellae approach to the interpeduncular cistern. Neurosurgery 62:5774, 2008

    • Search Google Scholar
    • Export Citation
  • 43

    Kassam AB, , Thomas A, , Carrau RL, , Snyderman CH, , Vescan A, & Prevedello D, : Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 63:1 Suppl ONS44ONS53, 2008

    • Search Google Scholar
    • Export Citation
  • 44

    Kato T, , Sawamura Y, , Abe H, & Nagashima M: Transsphenoidal-transtuberculum sellae approach for supradiaphragmatic tumours: technical note. Acta Neurochir (Wien) 140:715719, 1998

    • Search Google Scholar
    • Export Citation
  • 45

    Konig A, , Ludecke DK, & Herrmann HD: Transnasal surgery in the treatment of craniopharyngiomas. Acta Neurochir (Wien) 83:17, 1986

  • 46

    Kouri JG, , Chen MY, , Watson JC, & Oldfield EH: Resection of suprasellar tumors by using a modified transsphenoidal approach. Report of four cases. J Neurosurg 92:10281035, 2000

    • Search Google Scholar
    • Export Citation
  • 47

    Laufer I, , Anand VK, & Schwartz TH: Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg 106:400406, 2007

    • Search Google Scholar
    • Export Citation
  • 48

    Laws ER Jr: Transsphenoidal microsurgery in the management of craniopharyngioma. J Neurosurg 52:661666, 1980

  • 49

    Leng LZ, , Brown S, , Anand VK, & Schwartz TH: “Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery 62:2 Suppl ONSE342ONSE343, 2008

    • Search Google Scholar
    • Export Citation
  • 50

    Lewin R, , Ruffolo E, & Saraceno C: Craniopharyngioma arising in the pharyngeal hypophysis. South Med J 77:15191523, 1984

  • 51

    Maat-Schieman ML, , Bots GT, , Thomeer RT, & Vielvoye GJ: Malignant astrocytoma following radiotherapy for craniopharyngioma. Br J Radiol 58:480482, 1985

    • Search Google Scholar
    • Export Citation
  • 52

    Maira G, , Anile C, , Rossi GF, & Colosimo C: Surgical treatment of craniopharyngiomas: an evaluation of the transsphenoidal and pterional approaches. Neurosurgery 36:715724, 1995

    • Search Google Scholar
    • Export Citation
  • 53

    Marks JE, , Baglan RJ, , Prassad SC, & Blank WF: Cerebral radionecrosis: incidence and risk in relation to dose, time, fractionation and volume. Int J Radiat Oncol Biol Phys 7:243252, 1981

    • Search Google Scholar
    • Export Citation
  • 54

    Minamida Y, , Mikami T, , Hashi K, & Houkin K: Surgical management of the recurrence and regrowth of craniopharyngiomas. J Neurosurg 103:224232, 2005

    • Search Google Scholar
    • Export Citation
  • 55

    Munari C, , Landre E, , Musolino A, , Turak B, , Habert MO, & Chodkiewicz JP: Long term results of stereotactic endocavitary beta irradiation of craniopharyngioma cysts. J Neurosurg Sci 33:99105, 1989

    • Search Google Scholar
    • Export Citation
  • 56

    Nelson GA, , Bastian FO, , Schlitt M, & White RL: Malignant transformation in craniopharyngioma. Neurosurgery 22:427429, 1988

  • 57

    Oliver CL, , Hackman TG, , Carrau RL, , Snyderman CH, , Kassam AB, & Prevedello DM, : Palatal flap modifications allow pedicled reconstruction of the skull base. Laryngoscope 118:21022106, 2008

    • Search Google Scholar
    • Export Citation
  • 58

    Packer RJ, , Sutton LN, , Atkins TE, , Radcliffe J, , Bunin GR, & D'Angio G, : A prospective study of cognitive function in children receiving whole-brain radiotherapy and chemotherapy: 2-year results. J Neurosurg 70:707713, 1989

    • Search Google Scholar
    • Export Citation
  • 59

    Pierre-Kahn A, , Brauner R, , Renier D, , Sainte-Rose C, , Gangemi MA, & Rappaport R, : [Treatment of craniopharyngiomas in children. Retrospective analysis of 50 cases.]. Arch Fr Pediatr 45:163167, 1988. (Fr)

    • Search Google Scholar
    • Export Citation
  • 60

    Pinheiro-Neto CD, , Prevedello DM, , Carrau RL, , Snyderman CH, , Mintz A, & Gardner P, : Improving the design of the pedicled nasoseptal flap for skull base reconstruction: a radio-anatomic study. Laryngoscope 117:15601569, 2007

    • Search Google Scholar
    • Export Citation
  • 61

    Pollock BE, , Lunsford LD, , Kondziolka D, , Levine G, & Flickinger JC: Phosphorus-32 intracavitary irradiation of cystic craniopharyngiomas: current technique and long-term results. Int J Radiat Oncol Biol Phys 33:437446, 1995

    • Search Google Scholar
    • Export Citation
  • 62

    Puget S, , Garnett M, , Wray A, , Grill J, , Habrand JL, & Bodaert N, : Pediatric craniopharyngiomas: classification and treatment according to the degree of hypothalamic involvement. J Neurosurg 106:312, 2007

    • Search Google Scholar
    • Export Citation
  • 63

    Regine WF, , Mohiuddin M, & Kramer S: Long-term results of pediatric and adult craniopharyngiomas treated with combined surgery and radiation. Radiother Oncol 27:1321, 1993

    • Search Google Scholar
    • Export Citation
  • 64

    Samii M, & Bini W: Surgical treatment of craniopharyngiomas. Zentralbl Neurochir 52:1723, 1991

  • 65

    Scott RM, , Hetelekidis S, , Barnes PD, , Goumnerova L, & Tarbell NJ: Surgery, radiation, and combination therapy in the treatment of childhood craniopharyngioma—a 20-year experience. Pediatr Neurosurg 21:1 Suppl 7581, 1994

    • Search Google Scholar
    • Export Citation
  • 66

    Sheline GE, , Wara WM, & Smith V: Therapeutic irradiation and brain injury. Int J Radiat Oncol Biol Phys 6:12151228, 1980

  • 67

    Shirane R, , Ching-Chan S, , Kusaka Y, , Jokura H, & Yoshimoto T: Surgical outcomes in 31 patients with craniopharyngiomas extending outside the suprasellar cistern: an evaluation of the frontobasal interhemispheric approach. J Neurosurg 96:704712, 2002

    • Search Google Scholar
    • Export Citation
  • 68

    Spaziante R, & de Divitiis E: Drainage techniques for cystic craniopharyngiomas. Neurosurg Quart 7:183208, 1997

  • 69

    Spaziante R, , de Divitiis E, , Irace C, , Cappabianca P, & Caputi F: Management of primary or recurring grossly cystic craniopharyngiomas by means of draining systems. Topic review and 6 case reports. Acta Neurochir (Wien) 97:95106, 1989

    • Search Google Scholar
    • Export Citation
  • 70

    Sung DI, , Chang CH, , Harisiadis L, & Carmel PW: Treatment results of craniopharyngiomas. Cancer 47:847852, 1981

  • 71

    Symon L, & Sprich W: Radical excision of craniopharyngioma. Results in 20 patients. J Neurosurg 62:174181, 1985

  • 72

    Thomsett MJ, , Conte FA, , Kaplan SL, & Grumbach MM: Endocrine and neurologic outcome in childhood craniopharyngioma: review of effect of treatment in 42 patients. J Pediatr 97:728735, 1980

    • Search Google Scholar
    • Export Citation
  • 73

    Tomita T, & Bowman RM: Craniopharyngiomas in children: surgical experience at Children's Memorial Hospital. Childs Nerv Syst 21:729746, 2005

    • Search Google Scholar
    • Export Citation
  • 74

    Ushio Y, , Arita N, , Yoshimine T, , Nagatani M, & Mogami H: Glioblastoma after radiotherapy for craniopharyngioma: case report. Neurosurgery 21:3338, 1987

    • Search Google Scholar
    • Export Citation
  • 75

    Van Effenterre R, & Boch AL: Craniopharyngioma in adults and children: a study of 122 surgical cases. J Neurosurg 97:311, 2002

  • 76

    Villani RM, , Tomei G, , Bello L, , Sganzerla E, , Ambrosi B, & Re T, : Long-term results of treatment for craniopharyngioma in children. Childs Nerv Syst 13:397405, 1997

    • Search Google Scholar
    • Export Citation
  • 77

    Weiner HL, , Wisoff JH, , Rosenberg ME, , Kupersmith MJ, , Cohen H, & Zagzag D, : Craniopharyngiomas: a clinicopathological analysis of factors predictive of recurrence and functional outcome. Neurosurgery 35:10011011, 1994

    • Search Google Scholar
    • Export Citation
  • 78

    Weiss M, , Sutton L, , Marcial V, , Fowble B, , Packer R, & Zimmerman R, : The role of radiation therapy in the management of childhood craniopharyngioma. Int J Radiat Oncol Biol Phys 17:13131321, 1989

    • Search Google Scholar
    • Export Citation
  • 79

    Wen BC, , Hussey DH, , Staples J, , Hitchon PW, , Jani SK, & Vigliotti AP, : A comparison of the roles of surgery and radiation therapy in the management of craniopharyngiomas. Int J Radiat Oncol Biol Phys 16:1724, 1989

    • Search Google Scholar
    • Export Citation
  • 80

    Wisoff JH: Surgical management of recurrent craniopharyngiomas. Pediatr Neurosurg 21:1 Suppl 108113, 1994

  • 81

    Yaşargil MG, , Curcic M, , Kis M, , Siegenthaler G, , Teddy PJ, & Roth P: Total removal of craniopharyngiomas. Approaches and long-term results in 144 patients. J Neurosurg 73:311, 1990

    • Search Google Scholar
    • Export Citation
  • 82

    Zanation AM, , Snyderman CH, , Carrau RL, , Kassam AB, , Gardner PA, & Prevedello DM: Minimally invasive endoscopic pericranial flap: A new method for endonasal skull base reconstruction. Laryngoscope 119:1318, 2009

    • Search Google Scholar
    • Export Citation
  • 83

    Zuccaro G: Radical resection of craniopharyngioma. Childs Nerv Syst 21:679690, 2005

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