Accurate diagnosis of the topographical relationships of craniopharyngiomas (CPs) involving the third ventricle and/or hypothalamus remains a challenging issue that critically influences the prediction of risks associated with their radical surgical removal. This study evaluates the diagnostic accuracy of MRI to define the precise topographical relationships between intraventricular CPs, the third ventricle, and the hypothalamus.
An extensive retrospective review of well-described CPs reported in the MRI era between 1990 and 2009 yielded 875 lesions largely or wholly involving the third ventricle. Craniopharyngiomas with midsagittal and coronal preoperative and postoperative MRI studies, in addition to detailed descriptions of clinical and surgical findings, were selected from this database (n = 130). The position of the CP and the morphological distortions caused by the tumor on the sella turcica, suprasellar cistern, optic chiasm, pituitary stalk, and third ventricle floor, including the infundibulum, tuber cinereum, and mammillary bodies (MBs), were analyzed on both preoperative and postoperative MRI studies. These changes were correlated with the definitive CP topography and type of third ventricle involvement by the lesion, as confirmed surgically.
The mammillary body angle (MBA) is the angle formed by the intersection of a plane tangential to the base of the MBs and a plane parallel to the floor of the fourth ventricle in midsagittal MRI studies. Measurement of the MBA represented a reliable neuroradiological sign that could be used to discriminate the type of intraventricular involvement by the CP in 83% of cases in this series (n = 109). An acute MBA (< 60°) was indicative of a primary tuberal-intraventricular topography, whereas an obtuse MBA (> 90°) denoted a primary suprasellar CP position, causing either an invagination of the third ventricle (pseudointraventricular lesion) or its invasion (secondarily intraventricular lesion; p < 0.01). A multivariate model including a combination of 5 variables (the MBA, position of the hypothalamus, presence of hydrocephalus, psychiatric symptoms, and patient age) allowed an accurate definition of the CP topography preoperatively in 74%–90% of lesions, depending on the specific type of relationship between the tumor and third ventricle.
The type of mammillary body displacement caused by CPs represents a valuable clue for ascertaining the topographical relationships between these lesions and the third ventricle on preoperative MRI studies. The MBA provides a useful sign to preoperatively differentiate a primary intraventricular CP originating at the infundibulotuberal area from a primary suprasellar CP, which either invaginated or secondarily invaded the third ventricle.
Abbreviations used in this paper:CP = craniopharyngioma; MB = mammillary body; MBA = mammillary body angle; TVF = third ventricle floor.
AlénJFBotoGRLagaresAde la LamaAGómezPALobatoRD: Intratumoural bleomycin as a treatment for recurrent cystic craniopharyngioma. Case report and review of the literature. Neurocirugia (Astur)13:479–4852002
Carvi y NievasMNSchneiderHHöllerhageHGHaasE: Minimal invasive neurosurgery of infiltrative tumours extending around the sellar region: advantage of combined methods. Minim Invasive Neurosurg46:284–2882003
CinalliGSpennatoPCianciulliEFiorilloADi MaioSMaggiG: The role of transventricular neuroendoscopy in the management of craniopharyngiomas: three patient reports and review of the literature. J Pediatr Endocrinol Metab19:Suppl 1341–3542006
de VileCJGrantDBHaywardRDKendallBENevilleBGStanhopeR: Obesity in childhood craniopharyngioma: relation to post-operative hypothalamic damage shown by magnetic resonance imaging. J Clin Endocrinol Metab81:2734–27371996
InoueHKFujimakiHKohgaHOnoNHiratoMOhyeC: Basal interhemispheric supra- and/or infrachiasmal approaches via superomedial orbitotomy for hypothalamic lesions: preservation of hypothalamo-pituitary functions in combination treatment with radiosurgery. Childs Nerv Syst13:250–2561997
KassamABGardnerPASnydermanCHCarrauRLMintzAHPrevedelloDM: Expanded endonasal approach, a fully endoscopic transnasal approach for the resection of midline suprasellar craniopharyngiomas: a new classification based on the infundibulum. J Neurosurg108:715–7282008
KitanoMTanedaM: Extended transsphenoidal surgery for suprasellar craniopharyngiomas: infrachiasmatic radical resection combined with or without a suprachiasmatic translamina terminalis approach. Surg Neurol71:290–2982009
KuramotoTUchikadoHTajimaYTokutomiTShigemoriM: [Neuroendoscopic placement of the reservoir in an elderly patient with recurrenced craniopharyngioma: case report.]. No Shinkei Geka33:1207–12122005. (Jpn)
MoojJJAGoKGCysts, cyst-like tumors and other maldevelopmental tumors. VinkenPJBruynGWVechtCJ: Handbook of Clinical Neurology. Neuro-Oncolog Part II: Gliomas and Other Primary Tumors of the Brain and Spinal CordAmsterdanElsevier Science1997. 68:309–342
NishizawaSOhtaSOkiY: Spontaneous resolution of diabetes insipidus after pituitary stalk sectioning during surgery for large craniopharyngioma. Endocrinological evaluation and clinical implications for surgical strategy. Neurol Med Chir (Tokyo)46:126–1352006
PascualJMGonzález-LlanosFBarriosLRodaJM: Intraventricular craniopharyngiomas: topographical classification and surgical approach selection based on an extensive overview. Acta Neurochir (Wien)146:785–8022004
Pierre-KahnARecassensCPintoGThalassinosCChokronSSoubervielleJC: Social and psycho-intellectual outcome following radical removal of craniopharyngiomas in childhood. A prospective series. Childs Nerv Syst21:817–8242005
SaekiNMuraiHKubotaMFujimotoNIuchiTYamauraA: Heavily T2 weighted MR images of anterior optic pathways in patients with sellar and parasellar tumours - prediction of surgical anatomy. Acta Neurochir (Wien)144:25–352002
SteinerLPrasadDLindquistCKarlssonBSteinerMGamma knife surgery in vascular, neoplastic, and functional disorders of the nervous system. SchmidekHHSweetWH: Operative Neurosurgical Techniques Indications Methods and Resultsed 3PhiladelphiaWB Saunders1995. 667–694
StenoJMalácekMBízikI: Tumor-third ventricular relationships in supradiaphragmatic craniopharyngiomas: correlation of morphological, magnetic resonance imaging, and operative findings. Neurosurgery54:1051–10602004
SwaabDFCorpora mamillaria. AminoffMJBollerFSwaabDF: Handbook of Clinical Neurology. The Human Hypothalamus: Basic and Clinical Aspects. Part I: Nuclei of the Human HpypothalamusAmsterdamElsevier2003. 79:291–295
ZadaGLinNOjerholmERamkissoonSLawsER: Craniopharyngioma and other cystic epithelial lesions of the sellar region: a review of clinical, imaging, and histopathological relationships. Neurosurg Focus28:4E42010