Microsurgical resection of extensive craniopharyngiomas using a frontolateral approach: operative technique and outcome

Abstract

Object. An extensive craniopharyngioma is a tumor that extends into multiple compartments (subarachnoid spaces) and attains a size larger than 4 cm. A wide spectrum of approaches and strategies has been used for resection of such craniopharyngiomas. In this report the authors focused on the feasibility and efficacy of microsurgical resection of extensive craniopharyngiomas using a frontolateral approach.Methods. A retrospective analysis was performed on 16 patients with extensive craniopharyngiomas who underwent operations using a frontolateral approach at one institution. The preoperative and postoperative clinical and radiological data, as well as the operative videos, were reviewed. The main focus of the review was the extent of radical tumor removal, early postoperative outcome, and approach-related complications.Results. Gross-total resection of craniopharyngioma was achieved in 14 (87.5%) of 16 cases. Early after surgery (within 3 months), 1 patient showed improvement in hormonal status, while in the remaining 15 patients it worsened. No major neurological morbidity was observed. Two patients experienced temporary psychotic disorders. Visual function improved in 6 patients and remained unchanged in 9. One patient experienced a new bitemporal hemianopsia. Three patients with features of short-term memory disturbances at presentation did show improvement after surgery. There were no deaths or significant approach-related morbidity in this patient series. Only 1 patient required revision surgery for a CSF leak.Conclusions. The safe and simple frontolateral approach provides adequate access even to extensive craniopharyngiomas and enables their complete removal with a reasonable morbidity and approach-related complication rate. (http://thejns.org/doi/abs/10.3171/2013.9.JNS122133) Key worDs • extensive craniopharyngioma • frontolateral • giant craniopharyngioma • microsurgery • outcome • oncology • skull base 559Abbreviations used in this paper: ACA = anterior cerebral artery; ACoA = anterior communicating artery; CPA = cerebellopontine an gle; GTR = gross-total resection; ICA = internal carotid artery; PCoA = posterior communicating artery. * Drs. Fahlbusch and M. Samii share senior authorship of this work.

Aggressive surgery based on an anatomical subclassification of craniopharyngiomas

“…Table 6 lists the surgical approaches utilized in previous large series. 4,6,8,10,21,24,25 We created a lesion classification that could be used to determine the most appropriate surgical approach. Lesion identification and the approach used during the resections were as follows.…”

“…However, the optimal surgical approach remains controversial. 4,6,8,10,12,21,24,25 AbbreviAtioNs GTR = gross-total resection; KPS = Karnofsky Performance Scale; NTR = near-total resection; PR = partial resection; STR = subtotal resection; VIS = visual impairment score. objeCtive Craniopharyngiomas remain a particularly formidable challenge in the neurosurgical field.…”

Microscopic versus endoscopic approaches for craniopharyngiomas: choosing the optimal surgical corridor for maximizing extent of resection and complication avoidance using a personalized, tailored approach

“…These generally include the pterional (frontotemporal), orbitozygomatic, and lateral supraorbital (frontolateral) approaches. 20,24,46,59 While all of these approaches typically use a curvilinear incision behind the hairline, the latter group of supraorbital approaches can also be performed with smaller eyebrow or eyelid incisions. 15,21,50,57 These are familiar approaches that provide a short route to the suprasellar region and are particularly useful for tumors that exhibit lateral extension into the sylvian fissure.…”

“…15,21,50,57 These are familiar approaches that provide a short route to the suprasellar region and are particularly useful for tumors that exhibit lateral extension into the sylvian fissure. Recently, Gerganov et al 24 reported excellent outcomes with an 87% rate of gross-total resection of extensive craniopharyngiomas using a more simple frontolateral craniotomy. While there are a variety of anterolateral approaches, we prefer the one-piece modified orbitozygomatic approach.…”

“…Traditional open transcranial approaches include midline approaches (transbasal subfrontal and frontobasal interhemispheric), anterolateral approaches (pterional, orbitopterional, orbitozygomatic, frontolateral, and supraorbital eyebrow), and lateral approaches (combined petrosal and subtemporal). 19,20,24,44,47,54 Alternatively, the transnasal route via the extended transsphenoidal (microsurgical) approach offers a direct trajectory to the sellar and suprasellar space for strictly midline tumors. 13,29,40,41 More recently in the last decade, the purely extended endoscopic endonasal approach (EEA) via the transplanum transtuberculum corridor has become a useful and effective route for removing craniopharyngiomas in the retrochiasmatic space extending superiorly into the third ventricle.…”