Surgical nuances for removal of retrochiasmatic craniopharyngiomas via the transbasal subfrontal translamina terminalis approach

Abstract

<jats:p>Giant craniopharyngiomas in the retrochiasmatic space are challenging tumors, given the location and surrounding vital structures. Surgical removal remains the first line of therapy and offers the best chance of cure. For tumors with extension into the retrochiasmatic space, the authors use the translamina terminalis corridor via the transbasal subfrontal approach. Although the lamina terminalis can be accessed via anterolateral approaches (pterional or orbitozygomatic), the surgical view of the optic chiasm is oblique and prevents adequate visualization of the ipsilateral wall of the third ventricle. The transbasal subfrontal approach, on the other hand, offers the major advantage of direct midline orientation and access to the third ventricle through the lamina terminalis. This provides the significant advantage of visualization of both walls of the third ventricle and hypothalamus as well as inferior midline access to the interpeduncular cistern to permit safe neurovascular dissection and total tumor removal. In this report, the authors describe the transbasal subfrontal translamina terminalis approach, with specific emphasis on technical surgical nuances in removing retrochiasmatic craniopharyngiomas. An illustrative video demonstrating the technique is also presented.</jats:p>

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

“…It is best to preserve the integrity of the membrane of Liliequist since this aids in protection of the basilar artery, posterior cerebral arteries, and P 1 perforators. 43,44 One major disadvantage with this approach is the lack of direct visualization of the undersurface of the optic nerves and chiasm (blind spot), and therefore, one cannot perform accurate dissection of tumor adhesions in this area (Fig. 5C).…”

“…The working corridor of the lamina terminalis can be better maximized by converting to a midline transcranial approach (bifrontal transbasal approach or frontobasal interhemispheric approach). 43,44 This offers the major advantage of direct midline orientation and access to the lamina terminalis with clear visualization and control of both walls of the third ventricle and the hypothalamus as well as the interpeduncular cistern (Figs. 4 and 5).…”

“…6). Although there exist several variations of midline transcranial approaches based on orbitonasal osteotomies, we favor a modified one-piece extended transbasal approach, 43,44 described below. This involves a bifrontal craniotomy that incorporates the anterior wall of the frontal sinus so that the lowest basal trajectory to the floor of the anterior fossa is achieved without removal of the supraorbital bar as a separate osteotomy.…”

“…43,44 This is essentially a bifrontal bone flap that incorporates the anterior wall of the frontal sinus so that the inferior osteotomy is flush with the contour of the anterior skull base in the coronal plane ( Fig. 4D and E).…”

“…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.…”