Outcomes following endoscopic, expanded endonasal resection of suprasellar craniopharyngiomas: a case series

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Object

Craniopharyngiomas are challenging tumors that most frequently occur in the sellar or suprasellar regions. Microscopic transsphenoidal resections with various extensions and variations have been performed with good results. The addition of the endoscope as well as the further expansion of the standard and extended transsphenoidal approaches has not been well evaluated for the treatment of this pathological entity.

Methods

The authors performed a retrospective review of all patients who underwent a purely endoscopic, expanded endonasal approach (EEA) for the resection of craniopharyngiomas at their institution between June 1999 and February 2006. Endocrine and ophthalmological outcomes, extent of resection, and complications were evaluated.

Results

Sixteen patients underwent endoscopic EEA for the resection of craniopharyngiomas. Five patients (31%) presented with recurrent disease. Complete resection was planned in 11 of the 16 patients. Three elderly patients with vision loss underwent planned debulking, 1 patient with vision loss and a moderate-sized tumor had express wishes for debulking, and 1 patient had a separate, third ventricular nodule that was not resected. Of those in whom complete resection was planned, 91% underwent near-total (2/11) or gross-total (8/11) resection. No patient who underwent gross-total resection suffered a recurrence. The mean follow-up period was 34 months. Of the 14 patients who presented with vision loss, 93% had improvement or complete recovery and 1 patient's condition remained stable. No patient experienced visual worsening. Eighteen percent of patients (without preexisting hypopituitarism) developed panhypopituitarism and 8% developed permanent diabetes insipidus. There were no cases of new obesity. The postoperative cere-brospinal fluid leak rate was 58%. All leaks were resolved, and there were no cases of bacterial meningitis. There was 1 vascular injury (posterior cerebral artery perforator branch) resulting in the only new neurological deficit. No patient died.

Conclusions

Endoscopic EEA for the resection of craniopharyngiomas provides acceptable results and holds the potential to improve outcomes.

Abbreviations used in this paper: CSF = cerebrospinal fluid; DI = diabetes insipidus; EEA = expanded endonasal approach; GH = growth hormone; GKS = Gamma Knife surgery; ICP = intracranial pressure; PCA = posterior cerebral artery; TSH = thyroid-stimulating hormone; VP = ventriculoperitoneal.

Article Information

Address correspondence to: Amin Kassam, M.D., Department of Neurological Surgery, Suite B-400, Presbyterian University Hospital, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213. email: kassamab@upmc.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Humphrey visual field tests. A: Preoperative study demonstrating a dense temporal defect. B: Postoperative visual field testing showing resolution of visual deficit.

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    Humphrey visual field tests. A: Preoperative study showing dense bilateral defects, greatest bitemporally. B: Postoperative study performed in the same patient demonstrating significant improvement compared with preoperative testing.

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    Preoperative (left) and postoperative (right) coronal MR images showing suprasellar, Type II (infundibular) craniopharyngioma treated using a stalk-sparing resection. The enhancement seen under the chiasm has not progressed during follow-up (see text on recurrence).

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    Contrast-enhanced T1-weighted MR images. Preoperative sagittal (A) and coronal (B) images showing a complex craniopharyngioma with suprasellar extension. Postoperative sagittal (C) and coronal (D) images showing gross-total resection.

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    Contrast-enhanced T1-weighted MR images. Preoperative sagittal (A) and coronal (B) images showing a giant, complex craniopharyngioma, with extension into the third and lateral ventricles in an elderly man with vision loss. Postoperative sagittal (C) and coronal (D) images showing debulking of this giant tumor. Debulking was chosen due to the patient's advanced age and concern over potential hypothalamic and thalamic injury with aggressive resection.

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    Coronal contrast-enhanced T1-weighted MR images. Left: Preoperative image showing a suprasellar craniopharyngioma with a separate nodule (arrow) in the lateral wall of the third ventricle. Resection of the nodule was not planned as the floor of the third ventricle appeared intact on preoperative imaging. In retrospect and with further experience, perhaps this nodule would have been accessible. Right: Postoperative image obtained in the same patient showing resection of the suprasellar tumor, with the third ventricular nodular residual lesion (arrow).

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    Bar graph illustrating CSF leakage rates early in the series compared with the last year of the series. The time periods are misleading, as only 1 case of CSF leakage occurred prior to 2003, making this comparison largely one of 2003–2004 and 2005.

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