Letter to the Editor: Mammillary body angle and craniopharyngioma

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To The Editor: We read with great interest the article by Pascual et al.3 (Pascual JM, Prieto R, Carrasco R, et al: Displacement of mammillary bodies by craniopharyngiomas involving the third ventricle: surgical-MRI correlation and use in topographical diagnosis. Clinical article. J Neurosurg 119:381–405, August 2013). We congratulate Prof. Pascual and his colleagues. They evaluated the diagnostic accuracy of MRI to define the precise topographical relationships between intraventricular craniopharyngiomas (CPs), the third ventricle, and the hypothalamus and provided novel methods, the type of mammillary body displacement, and the mammillary body angle (MBA), to differentiate primary third ventricular CPs and primary suprasellar CPs.

We would like to address two complementary issues with respect to the change in MBA: 1) The authors mentioned “In 69% of pseudointraventricular cases the value of the MBA was greater than 120° (obtuse angle) and only 6% of lesions belonging to this topographical category displayed an MBA less than 90°.” The exceptional case was described in a report by Dusick et al.1 In our series of CPs, there were cases in which the MBA measured less than 90° as well (Fig. 1A and B). We find the common point is that those tumors were located anterior to the pituitary stalk (preinfundibular type2), which was confirmed intraoperatively in our cases. In this condition, the third ventricle floor (TVF) is intact, the tumor compresses the third ventricle anteriorly, or the origin of force is anterior to the infundibular recess. Then the infundibulum and the TVF are pushed posteriorly, which causes the MBA to become acute (Fig. 1C). In patients with retroinfundibular pseudointraventricular CPs, the compressive force is from downward to upward, resulting in an obtuse MBA. The difference in the size of the MBA associated with preinfundibular versus retroinfundibular pseudointraventricular CPs is explained by the origin of the force that causes compression of the TVF. 2) The MBAs in secondarily third ventricular CPs were variable. This variability may be caused by the stages of tumor growth. In the early stage, upward compression may cause an obtuse MBA. In the late stage, the increased size of the tumor may cause compression in a downward direction, which results in an acute MBA.

Fig. 1.
Fig. 1.

A–B: Sagittal T1-weighted (A) and 3D-FIESTA (B) MR images from our illustrative pseudointraventricular cases in which the MBA was less than 90° (29° in A and 53° in B). The angle indicated by the white lines represents the MBA. C: Schematic illustration showing an acute MBA associated with pseudointraventricular CP. The red line represents the compressed TVF between the infundibular recess and the optic recess; the angle formed by the blue lines represents the MBA. D–E: Sagittal (D) and axial (E) 3D-FIESTA images from a case of a not strictly intraventricular CP. The TVF seemed to be torn into 2 pieces (thin black and white arrows, D) and destroyed in some place (thick black arrow, E) in MR images. The damage was confirmed intraoperatively. F: Sagittal 3D-FIESTA image from a case of a not strictly intraventricular craniopharyngioma. The TVF was damaged (thick black arrow) but the pituitary stalk was intact (thin black arrow), and these imaging findings were both verified intraoperatively. G: Sagittal 3D-FIESTA image from a case of a strictly intraventricular craniopharyngioma with intact pituitary stalk.

Previously, we reported the effectiveness of 3D-FIESTA–sequence MRI in the endoscopic expanded endonasal approach for the treatment of midline skull base lesions.4 The TVF could be better demonstrated by the 3D-FIESTA sequence than by routine MRI as well. For example, in Fig. 1D and E, which show 3D-FIESTA images obtained in one of our patients with a CP (Case 1), the infundibular recess is enlarged and filled with tumor, the TVF seems to be torn into two pieces and destroyed in places. Intraoperative views confirmed the damage of the TVF. Figure 1F and G, which are 3D-FIESTA images obtained in 2 other patients (Cases 2 and 3, respectively), demonstrate a not strictly intraventricular CP and a strictly intraventricular CP, confirmed intraoperatively in both cases. Observation of the TVF on contiguous sagittal and coronal 3D-FIESTA sequences may provide adequate information to classify the exact type of CP in most cases. An intact pituitary stalk can be found in primary intraventricular CPs even when the optic recess and infundibular recess are filled with tumor. Functional MRI of the infundibulum, tuber cinereum, mammillary bodies, and hypothalamus, although not currently feasible, may be helpful in distinguishing the type of CP and planning the surgical approach.

From the perspective of an endonasal endoscopic approach, the not strictly intraventricular CPs could be further classified into 2 subtypes: 1) CPs involving the infundibulum with or without involving the TVF; and 2) CPs involving the TVF without involving the infundibulum. In the case of Subtype 1, the tumor and offended pituitary stalk are simultaneously exposed after opening the arachnoid membrane. In the case of Subtype 2, the tumor cannot be exposed directly after opening the arachnoid membrane but by crossing the pituitary stalk bilaterally or opening the laminal terminalis. In some cases, strictly intraventricular CPs can only be exposed after opening the lamina terminalis.

In summary, we appreciate the enlightening method proposed by Prof. Pascual and his colleagues.

Disclosure

The authors report no conflict of interest.

This article contains some figures that are displayed in color online but in black-and-white in the print edition.

References

  • 1

    Dusick JREsposito FKelly DFCohan PDeSalles ABecker DP: The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 102:8328412005

    • Search Google Scholar
    • Export Citation
  • 2

    Kassam ABGardner PASnyderman CHCarrau RLMintz AHPrevedello 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 108:7157282008

    • Search Google Scholar
    • Export Citation
  • 3

    Pascual JMPrieto RCarrasco RBarrios L: Displacement of mammillary bodies by craniopharyngiomas involving the third ventricle: surgical-MRI correlation and use in topographical diagnosis. Clinical article. J Neurosurg 119:3814052013

    • Search Google Scholar
    • Export Citation
  • 4

    Xie TZhang XBYun HHu FYu YGu Y: 3D-FIESTA MR images are useful in the evaluation of the endoscopic expanded endonasal approach for midline skull-base lesions. Acta Neurochir (Wien) 153:12182011

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    • Export Citation
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Response

We want to express our gratitude for the words of appreciation and the enthusiastic attitude toward our work shown in the letter by Drs. Ye Gu and Xiaobiao Zhang. We very much appreciate their sound insights on the topographical diagnosis of CPs after testing the validity of the MBA to define the CP–third ventricle relationships with the use of high-resolution 3D-FIESTA MRI. An accurate preoperative definition of the CP-TVF relationships cannot usually be outlined with using T1- and T2-weighted MRI sequences, even with gadolinium enhancement. Craniopharyngiomas larger than 3 cm at the time of diagnosis have typically caused such a gross distortion of or damage to the thin neural layer of the infundibulum and the tuber cinereum that the integrity of these structures becomes impossible to ascertain with standard MRI sequences. With regard to this diagnostic limitation, heavily T2-weighted and 3D-FIESTA MRI sequences have proved the most valuable tools for optimizing the accuracy of the assessment of anatomical relationships of CPs to adjacent neurovascular structures.10,13

The relative anatomical position of the hypothalamus with respect to the CP has been shown to be related to the primary position of the lesion.8 Three basic types of CP-hypothalamus relationships can be considered: 1) CPs located below an anatomically intact but upwardly displaced hypothalamus (suprasellar-extraventricular CPs); 2) CPs located at the level of the TVF, originally developing either within the infundibulum or within the tuber cinereum, whose central portion or equator is tightly attached to the remnants of the breached hypothalamus (extra-/intraventricular or not strictly intraventricular or infundibulotuberal CPs); 3) pure or strictly third ventricle CPs that expand exclusively within the third ventricle above an intact or atrophied TVF, with the hypothalamus positioned adjacent to the lower-third portion of the tumor.11 This classification takes into consideration the anatomical-functional vertical axis along the pituitary gland–pituitary stalk–hypothalamus structures. Identification of the cleavage plane between the distorted or atrophied thin layer of the TVF and the border of the CP is not usually possible preoperatively. Yet, the compact and flexible mammillary bodies remain visible on MRI, and their relative displacement with respect to the brainstem represents a valid, useful clue to define the relative position of the lesion along the vertical hypophysialhypothalamic axis.

We agree with the authors' observations about the variations in the direction of displacement of the mammillary bodies, different from those described in our paper. In fact, we had also observed such additional CP–third ventricle anatomical variants, but we tried to restrict our classification to only 4 major topographies, along the vertical axis, with the aim of highlighting the importance of the primary involvement of the hypothalamus by CPs. Hypothalamic involvement by the tumor is probably the fundamental variable that predicts both the feasibility of a complete and safe tumor resection and the success of the procedure with respect to the outcome for the patient.6,8 Preoperative definition of the CP–third ventricle relationships is not only an issue of academic value but is directly related to the degree of adherence of the lesion to hypothalamic nuclei and, consequently, the risk of hypothalamic injury should total removal of the mass be attempted. The highest rates of complications involving irreversible hypothalamic dysfunction (that is, hyperphagia, obesity, and long-term emotional and cognitive disturbances) have been observed to be directly related to the degree of anatomical disruption of the TVF displayed in postoperative MRI studies after total removal of CPs.2,5,12 Anatomical defects or breaches at the level of the infundibulum and tuber cinereum seen on postoperative coronal and sagittal MR images usually do not seem to have been caused by the surgeon but are the residual marks of lesions developing primarily within the floor of the ventricle, that is, of not strictly intraventricular or infundibulotuberal CPs.7,11 Given the high risk of hypothalamic injury posed by the latter category of CPs, this group must be differentiated preoperatively from extrapial, suprasellar lesions developing at the lower infundibulum or at the pituitary stalk, which are separated from the TVF by the arachnoid and pia mater.6,9

Gu and Zhang report in their letter cases of extraventricular CPs developing at either the anterior aspect of the pituitary stalk or at the anterior lower infundibulum, which progressively fold the infundibular recess of the TVF inward without breaking through the neural layer of tissue. The authors include these lesions within our category of pseudointraventricular CPs. Although any suprasellar CP pushing the TVF upwards, but not causing actual invasion of the third ventricle, can be defined as a pseudointraventricular lesion, the category of pseudointraventricular CPs refers, in the strict sense, to those CPs mimicking a primary intraventricular location—that is, to large lesions that have completely obliterated the third ventricle after folding the intact TVF inward. These pseudointraventricular CPs have a similar appearance to not strictly intraventricular or infundibulotuberal CPs but can be differentiated preoperatively by their effect of upward displacement on the mammillary bodies (as evidenced by an obtuse MBA), as opposed to the downward displacement (acute MBA) observed for most CPs developing at the level of the TVF itself. In addition to the vertical hypophysial-hypothalamic axis employed in our topographical classification, Gu and Zhang have introduced a second, horizontal or anteroposterior axis along the infundibulum, which differentiates between CPs developing in front of, next to, or behind the junction of the pituitary stalk with the infundibulum. Jakob Erdheim was the first author to link the origin of CPs to the nests of epithelial cells observed in normal individuals along the pars tuberalis, the tongue of pituitary glandular tissue covering the stalk and infundibulum.3 These epithelial cell nests tend to gather at two main locations within the pars tuberalis, at the point where the stalk joins the pituitary gland (lower location) and at the point where the anterior aspect of the infundibulum joins the optic chiasm (upper location). Qi et al. have described how the arachnoid sleeve enveloping the pituitary stalk becomes thicker, more compact, and more adherent to the pia mater at the recess between the ventral aspect of the chiasm and the upper anterior aspect of the upper infundibulum.9 Such a trabecular meningeal reinforcement of the chiasm-infundibulum junction would explain the type of third ventricle deformation caused by suprasellar CPs developing at the upper stalk, as it is displayed in the 3D-FIESTA sagittal images provided by Drs. Gu and Zhang. In this topographical category the preinfundibular or prestalk intraarachnoid CP progressively compresses the chiasm-infundibular recess, displacing it posteriorly, without invading the third ventricle. The infundibulum and stalk remain adhered at the posterolateral surface of the tumor capsule. The lesion indents or protrudes into the anteroinferior third ventricle without disturbing the tuber cinereum or modifying the MBA, as Gu and Zhang correctly remarked. However, the lack of infiltration or of intrinsic involvement of the hypothalamus can be easily observed on sagittal MR images, and for that reason lesions with this topography should not be included within the group of pseudointraventricular CPs, although that topographical category, as defined in our previous papers, shares with the suprasellar-extraventricular preinfundibular lesions described by Gu and Zhang the characteristic of preserving the anatomical integrity of the TVF.

Topographical classifications of CPs that use as a principal criterion the relative position of the tumor with respect to the pituitary stalk have been proposed from the surgical perspective of the endoscopic endonasal approach.4,9,14 Kassam et al. have designed a comprehensive scheme that highlights the true anatomical relationships of the tumor to the vital neurovascular structures situated at the basal brain surface, especially the undersurface of the optic chiasm, the infundibulum, and the tuber cinereum. The Type I, or preinfundibular CP of Kassam's classification, corresponds to the examples in Fig. 1A and B in Gu and Zhang's letter.4 Apart from the maintenance of an acute MBA, the importance of this topography is the absence of hypothalamic infiltration or tight CP adherence to the TVF present in this group of lesions. This category also corresponds to the “EA” pattern described by Qi et al., one example of such a pattern being shown in Fig. 5 of their paper.9 In contrast, the CP Types II (transinfundibular) and III (retroinfundibular) are tumors usually breaking through the floor into the third ventricle; therefore these two types, which displace the mammillary bodies caudally against the brainstem, are the lesions associated with the highest rate of hypothalamic disturbances and the highest risk of irreversible surgical injury to the hypothalamus.4,10

In addition to the relative location of the tumor either along the hypophysial-hypothalamic vertical axis or around the circumferential, horizontal area of the infundibulum, a third axis that indicates the depth of development of the lesion within the neural tissue can be taken into consideration to accurately define the topography of a CP. Following Erdheim's embryological theory for the origin of CPs, Ivan S. Ciric has considered that the different CP-hypothalamus relationships depend on the relative initial position of the epithelial remnants of the hypophysial duct with respect to the leptomeningeal layer (pia and arachnoid mater) covering the pituitary stalk–infundibulum-TVF complex.1 Migration of hypophysial duct epithelial cells into the floor of the diencephalic vesicle before the formation of the pia mater will cause the inclusion of such cells within the floor and the potential development of infundibulotuberal or not strictly intraventricular CPs, lesions tightly adhered to the basal hypothalamus.1,6–8 This type of CP can develop either retroinfundibularly, within the tuber cinereum, or preinfundibularly, at the junction of the infundibulum with the optic chiasm. In the latter location, CPs will become extra-intraventricular tumors (tumors that are both extra- and intraventricular) causing a breach at the junction of the optic chiasm with the infundibulum while separating the two structures. This preinfundibular variant of not strictly intraventricular CP will not cause such a severe downward displacement of the mammillary bodies as the retroinfundibular or intra–tuber cinereum type reported in our classification scheme. The lesion, usually cystic, will accommodate to the elliptical space of the third ventricle, with its solid basal apex poking through below the optic chiasm. It corresponds to the “IA2 + SA” pattern in the classification scheme by Qi et al., and one example of this pattern is shown in Fig. 6 of their paper.9 To conclude, besides a classification scheme centered in the type of third ventricle involvement by the lesion, depending on its original position along the vertical axis, different topographical variants can be described according to the origin of the lesion along the horizontal axis followed by the optic chiasm, infundibulum, and tuber cinereum, and mammillary bodies. These variants will produce specific degrees of displacement of the mammillary bodies towards particular directions, which can be better observed with the use of 3D-FIESTA MRI sequences as reported by Gu and Zhang.

The concept of the secondary involvement of the third ventricle by CPs, that is, the invasion of the third ventricle by lesions originally developing at a sellar or suprasellar position below an intact TVF, is a controversial issue in the literature. In a recent letter to the editor, Juraj Steno et al. pointed out the rarity of such type of lesions, while remarking on the predominance of extra-intraventricular lesions causing an initial, primary disruption of the TVF, with a symmetrical intra- and extraventricular expansion.11 In our response to their letter, we provided a detailed list of differential features that help clinicians and neuroradiologists to differentiate between CPs developing primarily at the TVF (not strictly intraventricular CPs) and CPs invading the floor from an original extraventricular position.11 A total infiltration of the pituitary stalk (90% of cases), a multilobulated shape (67%), the complete occupation of the suprasellar cistern (67%), and the presence of tumor extensions into basal cisterns (50%) and/or into the sella turcica (50%) are the morphological features associated with secondary intraventricular CPs. For their part, not strictly intraventricular CPs are characterized by their round or elliptical shape (100% of cases), lack of involvement of the sella turcica and/or basal cisterns (83%), only partial involvement of the pituitary stalk and/or the suprasellar cistern (53%), and displacement of the mammillary bodies causing an acute MBA in 100% of cases. Extraventricular lesions with secondary invasion of the third ventricle will show the most variable range of displacement of the mammillary bodies, as is properly mentioned in Gu and Zhang's letter. Craniopharyngioma variables such as the tumor's consistency and shape, its speed of growth, and, above all, the specific area of compression along the floor will all influence the mechanical resistance offered by the TVF against tumor penetration. The process of progressive atrophy and gliosis of the neural layer of the TVF will also play a role, as well as adherences of the floor and meningeal layers to the lesion. As a consequence, some CPs will cause an upward displacement of the TVF before breaking through it, showing an upward displacement of the mammillary bodies, while others will invade the floor at earlier stages of development without causing a significant displacement to the physiological acute value of the MBA.

The heavily T2-weighted and 3D-FIESTA sequences represent helpful, worthwhile MRI sequences for preoperative identification of the accurate topographical relationships between CPs and the third ventricle.11,13 Both methodologies should be employed to improve CP classification methods and to recognize preoperatively the lesions causing a primary or secondary anatomical disruption of the hypothalamus. In particular, the striking and thorough 3D-FIESTA methods used by Gu and Zhang have proved invaluable to implement the identification of the mammillary bodies and their displacements associated with specific CP topographies.

References

  • 1

    Ciric ISCozzens JW: Craniopharyngiomas: transsphenoidal method of approach—for the virtuoso only?. Clin Neurosurg 27:1691871980

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    • Export Citation
  • 2

    De Vile CJGrant DBHayward RDKendall BENeville BGStanhope R: Obesity in childhood craniopharyngioma: relation to post-operative hypothalamic damage shown by magnetic resonance imaging. J Clin Endocrinol 81:273427371996

    • Search Google Scholar
    • Export Citation
  • 3

    Erdheim J: Über Hypophysengangsgeschwülste und Hirmcholesteatome. Sitzungsb Kais Akad Wissen Math Naturw Klin 113:5377261904

  • 4

    Kassam ABGardner PASnyderman CHCarrau RLMintz AHPrevedello 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 108:7157282008

    • Search Google Scholar
    • Export Citation
  • 5

    Meuric SBrauner RTrivin CSouberbielle JCZerah MSainte-Rose C: Influence of tumor location on the presentation and evolution of craniopharyngiomas. J Neurosurg 5 Suppl103:4214262005

    • Search Google Scholar
    • Export Citation
  • 6

    Pascual JMCarrasco RPrieto RGonzalez-Llanos FAlvarez FRoda JM: Craniopharyngioma classification. J Neurosurg 109:118011832008. (Letter)

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    • Export Citation
  • 7

    Pascual JMPrieto RCarrasco R: Infundibulo-tuberal or not strictly intraventricular craniopharyngioma: evidence for a major topographical category. Acta Neurochir (Wien) 153:240324252011

    • Search Google Scholar
    • Export Citation
  • 8

    Pascual JMPrieto RCastro Duforny IGil Simoes RCarrasco R: Hypothalamus-referenced classification for craniopharyngiomas: evidence provided by the endoscopic endonasal approach. Neurosurg Rev 36:3373392012. (Letter)

    • Search Google Scholar
    • Export Citation
  • 9

    Qi SLu YPan JZhang XLong HFan J: Anatomic relations of the arachnoidea around the pituitary stalk: relevance for surgical removal of craniopharyngiomas. Acta Neurochir (Wien) 153:7857962011

    • Search Google Scholar
    • Export Citation
  • 10

    Saeki NMurai HKubota MFujimoto NIuchi TYamaura A: Heavily T2 weighted MR images of anterior optic pathways in patients with sellar and parasellar tumours—prediction of surgical anatomy. Acta Neurochir (Wien) 144:25352002

    • Search Google Scholar
    • Export Citation
  • 11

    Steno JBízik ISteno AMatejcík V: Craniopharyngiomas and the hypothalamus. J Neurosurg 119:164616532013. (Letter)

  • 12

    Van Gompel JNippoldt TBHiggins DMMeyer FB: Magnetic resonance imaging-graded hypothalamic compression in surgically treated adult craniopharyngiomas determining postoperative obesity. Neurosurg Focus 28:4E32010

    • Search Google Scholar
    • Export Citation
  • 13

    Xie TZhang XBYun HHu FYu YGu Y: 3D-FIESTA MR images are useful in the evaluation of the endoscopic expanded endonasal approach for midline skull-base lesions. Acta Neurochir (Wien) 153:12182011

    • Search Google Scholar
    • Export Citation
  • 14

    Zhang YQWang CCMa ZY: Pediatric craniopharyngiomas: clinicomorphological study of 189 cases. Pediatr Neurosurg 36:80842002

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Article Information

Contributor Notes

Please include this information when citing this paper: published online February 14, 2014; DOI: 10.3171/2013.11.JNS132343.
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    A–B: Sagittal T1-weighted (A) and 3D-FIESTA (B) MR images from our illustrative pseudointraventricular cases in which the MBA was less than 90° (29° in A and 53° in B). The angle indicated by the white lines represents the MBA. C: Schematic illustration showing an acute MBA associated with pseudointraventricular CP. The red line represents the compressed TVF between the infundibular recess and the optic recess; the angle formed by the blue lines represents the MBA. D–E: Sagittal (D) and axial (E) 3D-FIESTA images from a case of a not strictly intraventricular CP. The TVF seemed to be torn into 2 pieces (thin black and white arrows, D) and destroyed in some place (thick black arrow, E) in MR images. The damage was confirmed intraoperatively. F: Sagittal 3D-FIESTA image from a case of a not strictly intraventricular craniopharyngioma. The TVF was damaged (thick black arrow) but the pituitary stalk was intact (thin black arrow), and these imaging findings were both verified intraoperatively. G: Sagittal 3D-FIESTA image from a case of a strictly intraventricular craniopharyngioma with intact pituitary stalk.

References
  • 1

    Dusick JREsposito FKelly DFCohan PDeSalles ABecker DP: The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 102:8328412005

    • Search Google Scholar
    • Export Citation
  • 2

    Kassam ABGardner PASnyderman CHCarrau RLMintz AHPrevedello 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 108:7157282008

    • Search Google Scholar
    • Export Citation
  • 3

    Pascual JMPrieto RCarrasco RBarrios L: Displacement of mammillary bodies by craniopharyngiomas involving the third ventricle: surgical-MRI correlation and use in topographical diagnosis. Clinical article. J Neurosurg 119:3814052013

    • Search Google Scholar
    • Export Citation
  • 4

    Xie TZhang XBYun HHu FYu YGu Y: 3D-FIESTA MR images are useful in the evaluation of the endoscopic expanded endonasal approach for midline skull-base lesions. Acta Neurochir (Wien) 153:12182011

    • Search Google Scholar
    • Export Citation
  • 1

    Ciric ISCozzens JW: Craniopharyngiomas: transsphenoidal method of approach—for the virtuoso only?. Clin Neurosurg 27:1691871980

    • Search Google Scholar
    • Export Citation
  • 2

    De Vile CJGrant DBHayward RDKendall BENeville BGStanhope R: Obesity in childhood craniopharyngioma: relation to post-operative hypothalamic damage shown by magnetic resonance imaging. J Clin Endocrinol 81:273427371996

    • Search Google Scholar
    • Export Citation
  • 3

    Erdheim J: Über Hypophysengangsgeschwülste und Hirmcholesteatome. Sitzungsb Kais Akad Wissen Math Naturw Klin 113:5377261904

  • 4

    Kassam ABGardner PASnyderman CHCarrau RLMintz AHPrevedello 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 108:7157282008

    • Search Google Scholar
    • Export Citation
  • 5

    Meuric SBrauner RTrivin CSouberbielle JCZerah MSainte-Rose C: Influence of tumor location on the presentation and evolution of craniopharyngiomas. J Neurosurg 5 Suppl103:4214262005

    • Search Google Scholar
    • Export Citation
  • 6

    Pascual JMCarrasco RPrieto RGonzalez-Llanos FAlvarez FRoda JM: Craniopharyngioma classification. J Neurosurg 109:118011832008. (Letter)

    • Search Google Scholar
    • Export Citation
  • 7

    Pascual JMPrieto RCarrasco R: Infundibulo-tuberal or not strictly intraventricular craniopharyngioma: evidence for a major topographical category. Acta Neurochir (Wien) 153:240324252011

    • Search Google Scholar
    • Export Citation
  • 8

    Pascual JMPrieto RCastro Duforny IGil Simoes RCarrasco R: Hypothalamus-referenced classification for craniopharyngiomas: evidence provided by the endoscopic endonasal approach. Neurosurg Rev 36:3373392012. (Letter)

    • Search Google Scholar
    • Export Citation
  • 9

    Qi SLu YPan JZhang XLong HFan J: Anatomic relations of the arachnoidea around the pituitary stalk: relevance for surgical removal of craniopharyngiomas. Acta Neurochir (Wien) 153:7857962011

    • Search Google Scholar
    • Export Citation
  • 10

    Saeki NMurai HKubota MFujimoto NIuchi TYamaura A: Heavily T2 weighted MR images of anterior optic pathways in patients with sellar and parasellar tumours—prediction of surgical anatomy. Acta Neurochir (Wien) 144:25352002

    • Search Google Scholar
    • Export Citation
  • 11

    Steno JBízik ISteno AMatejcík V: Craniopharyngiomas and the hypothalamus. J Neurosurg 119:164616532013. (Letter)

  • 12

    Van Gompel JNippoldt TBHiggins DMMeyer FB: Magnetic resonance imaging-graded hypothalamic compression in surgically treated adult craniopharyngiomas determining postoperative obesity. Neurosurg Focus 28:4E32010

    • Search Google Scholar
    • Export Citation
  • 13

    Xie TZhang XBYun HHu FYu YGu Y: 3D-FIESTA MR images are useful in the evaluation of the endoscopic expanded endonasal approach for midline skull-base lesions. Acta Neurochir (Wien) 153:12182011

    • Search Google Scholar
    • Export Citation
  • 14

    Zhang YQWang CCMa ZY: Pediatric craniopharyngiomas: clinicomorphological study of 189 cases. Pediatr Neurosurg 36:80842002

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