Radical Resection of 202 Pediatric Craniopharyngiomas with Special Reference to the Surgical Approaches and Hypothalamic Protection

Abstract

Objective: The goal of this study was to disclose the appropriate surgical approaches to radically removing pediatric craniopharyngiomas with optimal hypothalamic protection. Methods: In 202 patients undergoing primary surgery from April 1997 to December 2002, eight approaches were used to remove craniopharyngiomas in the sellar region and the third ventricle. Among the eight approaches, the transcallosal-interseptal-interforniceal approach was used in 89 cases, the unilateral transfrontal interhemispheric approach in 68 cases, the pterional approach in 20 cases, and the other five approaches in 25 cases. Active preventive and therapeutic measurements of hypothalamic dysfunction were adopted pre- and postoperatively. Results: Of the 202 cases, 184 tumors were totally or nearly totally removed (91.1%); 89 cases were resected with the transcallosal-interseptal-interforniceal approach with a total and subtotal removal rate of 92.1%, and 68 cases were removed with the unilateral transfrontal interhemispheric approach with a total and subtotal removal rate of 95.6%. Two patients died (0.9%). The major postoperative complications included diabetes insipidus in 81.7% of the cases, permanent diabetes insipidus in 11.4%, electrolyte disorder in 74.8%, and seizures in 9.4%. The 5-year survival rate was 68.2%. Conclusions: Appropriate approaches with direct tumor exposure should be determined in order to remove the craniopharyngioma as much as possible, while at the same time carefully protecting the anteroinferolateral wall of the third ventricle (hypothalamus). Active measurements to manage blood sodium disorder and seizures could help to ensure the safety of the operation.

Giant craniopharyngiomas in children: short- and long-term implications

“…Nevertheless, it has been shown that even after seemingly clean microscopic gross total resections (GTR), recurrence rates are as high as 18 to 60 % in pediatric series [6][7][8][9][10][11]. Another important factor reportedly predictive for tumor recurrence is tumor diameter greater than 4 to 5 cm [5].…”

Modified orbitozygomatic craniotomy for craniopharyngioma resection in children

“…In children, the most common operative approach is pterional. 14,27,35 Although this approach allows dissection of the sylvian fissure and access to the perisellar area, a significant amount of subfrontal retraction is often applied to allow successful resection. Removal of the orbital rim permits an increase in the angle of approach and the area of exposure without significant subfrontal retraction.…”

“…The most commonly used approach, particularly in children, is the pterional approach, which allows subfrontal and transsylvian exposure of the suprasellar/parasellar area. 14,27,35 Other approaches include the transsphenoidal approach, the BIH approach, and the transcallosal interhemispheric approach. 35 Although each of these approaches can be used for successful craniopharyngioma resection, each also has limitations in terms of exposure.…”

“…14,27,35 Other approaches include the transsphenoidal approach, the BIH approach, and the transcallosal interhemispheric approach. 35 Although each of these approaches can be used for successful craniopharyngioma resection, each also has limitations in terms of exposure. The modified orbitozygomatic craniotomy is a well-described method of addressing vascular and oncological lesions in the parasellar area; however, its use has been limited to adults for the most part.…”

Management of craniopharyngiomas: Role of conservative strategies

“…[25] Diabetes insipidus (DI), especially if accompanied by impaired thirst sensation, can result in difficult to manage fluctuations in serum sodium levels. DI occurred in 81% of patients post-operatively in the series by Zhang et al [26] The Liverpool experience suggests that even a more conservative surgery will result in DI, but with preserved thirst mechanism which makes it much easier to manage the DI. [24] The intimate adherence of this tumor to the pituitary stalk and gland often leads to pan hypopituitarism following surgery.…”