The role of transsphenoidal surgery in the treatment of craniopharyngiomas

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Object. The optimal approach for the surgical treatment of craniopharyngiomas is still debated. In all cases involving the sella turcica, the authors have exclusively used transsphenoidal surgery (TSS), assuming that this approach is less traumatic than an intracranial one. Moreover, TSS was also performed in some cases of purely suprasellar craniopharyngiomas. In this study the surgical indications and the results obtained in all patients who had undergone TSS were analyzed.

Methods. In a series of 92 patients who underwent surgery for craniopharyngiomas, TSS was the first choice of approach in 57 cases (62%) consisting of 29 female and 28 male patients with ages ranging from 12 to 79 years (mean 35 years). The follow-up duration ranged from 2 to 20 years. A standard transsphenoidal approach was used in patients with an exclusively intrasellar (11 patients) or an intrasellar and suprasellar tumor (37 patients); in nine cases of tumors located exclusively above the sella turcica, a transsphenoidal presellar approach (seven patients) or a transsellar—transdiaphragmatic approach (two patients) was used. Total removal was performed in 36 patients (63%). All patients had good clinical results. Postoperative cerebrospinal fluid leakage occurred in 10 cases, but only one case required a surgical repair of the sella. Two patients died of late complications (3.5%). There were eight cases (14%) of tumor regrowth.

Conclusions. The authors assert that, when used in appropriately located craniopharyngiomas and by neurosurgeons with extensive experience in pituitary surgery, TSS offers excellent results with minor risks.

Article Information

Address reprint requests to: Giulio Maira, M.D., Istituto di Neurochirurgia, Università Cattolica del Sacro Cuore, Largo. A. Gemelli 8, 00168 Rome, Italy. email: gmaira@rm.unicatt.it.

© AANS, except where prohibited by US copyright law.

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    Left: Sagittal T1-weighted MR image exhibiting a tumor in contact with the planum sphenoidale. The transsphenoidal presellar approach (arrow) together with removal of bone of the tuberculum sella and planum sphenoidale was used. Right: Sagittal T1-weighted MR image demonstrating the retrochiasmatic location of the tumor and the low position of the chiasm and anterior arteries complex (upper arrow) via the transsellar—transdiaphragmatic approach (lower arrow).

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    Preoperative (left) and postoperative (right) sagittal T1-weighted Gd-enhanced MR images. The exclusively intrasellar craniopharyngioma is located behind the pituitary gland. The follow up in this case was 10 years.

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    Preoperative (left) and postoperative (right) sagittal T1-weighted Gd-enhanced MR images. The exclusively intrasellar craniopharyngioma is located above the pituitary gland. The follow up in this case was 4 years.

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    Preoperative (left) and postoperative (right) sagittal T1-weighted Gd-enhanced MR images. The intrasellar and suprasellar craniopharyngioma is located inside the pituitary gland. The follow up in this case was 4 years.

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    Upper: Sagittal T1-weighted Gd-enhanced MR image (left) and sagittal computerized tomography scan (right) demonstrating cystic intrasellar and suprasellar craniopharyngioma with a calcified capsule. Lower: Postoperative sagittal (left) and coronal (right) T1-weighted Gd-enhanced MR images. The follow up in this case was 12 years.

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    A and B: Suprasellar craniopharyngioma in contact with the planum sphenoidale. A transsphenoidal presellar approach was used to treat this tumor. Sagittal T1-weighted postcontrast MR images obtained preoperatively (the surgical route is indicated by the arrow; A) and immediately following partial resection (B). C–E: Coronal T1-weighted postcontrast MR images. One year later, a regrowth of the residual mass in the suprasellar cisterns was evident (C). A complete removal was realized using an intracranial approach (D). Six years later, we observed signs of tumor recurrence and the patient underwent a radiosurgical treatment (E).

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    Suprasellar craniopharyngioma in contact with the planum sphenoidale. A transsphenoidal presellar approach was used. Sagittal T1-weighted postcontrast MR images obtained preoperatively (left) and immediately post—partial resection (right). The follow up in this case was 2 years.

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    A transsellar—transdiaphragmatic approach was used to treat a suprasellar retrochiasmatic craniopharyngioma. Sagittal T1-weighted postcontrast MR images obtained preoperatively (left) and after subtotal resection (right). The follow up in this case was 2 years.

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