The Petrosal Approach for the Resection of Retrochiasmatic Craniopharyngiomas

Al‐Mefty, Ossama; Ayoubi, Samer; Kadri, Paulo A S

doi:10.1227/01.neu.0000326015.76692.3d

Cited by 42 publications

(34 citation statements)

References 8 publications

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“…Future prospective studies or a metaanalysis of existing series would be helpful to clarify if early radical resection could diminish the need for VP shunts and positively affect OS. Similar to the paradigm of Zucarro, 125 we do not treat hydrocephalus at presentation, 110 transpetrosal, 1 and transsphenoidal ap proaches. 16,39,56,61 However, few data exist addressing the optimal surgical approach for craniopharyngiomas in terms of EOR or functional outcomes.…”

Section: Risk Factors For Decreased Survivalmentioning

confidence: 99%

Efficacy and safety of radical resection of primary and recurrent craniopharyngiomas in 86 children

Elliott¹,

Hsieh²,

Hochm

et al. 2010

PED

157

148

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Object Optimal treatment of primary and recurrent craniopharyngiomas remains controversial. Radical resection and limited resection plus radiation therapy yield similar rates of disease control and overall survival. The data are much less clear for recurrent tumors. The authors report their experience with radical resection of both primary and recurrent craniopharyngiomas in children and compare the outcomes between the 2 groups. Methods A retrospective analysis was performed in 86 children younger than 21 years of age who underwent a total of 103 operations for craniopharyngioma between 1986 and 2008; these were performed by the senior author. The goal was resection with curative intent in all patients. Two patients were lost to follow-up and were excluded from analysis. The mean age at the time of surgery was 9.6 years, and the mean follow-up was 9.0 years. Results All 57 children with primary tumors underwent gross-total resection (GTR). A GTR was achieved in significantly fewer children with recurrent tumors (18 [62%] of 29). There were 3 perioperative deaths (3%). Tumor recurred after GTR in 14 (20%) of 71 patients. Overall survival and progression-free survival were significantly better in patients with primary tumors at time of presentation to the authors' institution. There were no significant differences in the neurological, endocrinological, visual, or functional outcomes between patients with primary and those with recurrent tumors. Factors negatively affecting overall survival and progression-free survival include subtotal resection (recurrent tumors only), tumor size ≥ 5 cm, or presence of hydrocephalus or a ventriculoperitoneal shunt. Prior radiation therapy and increasing tumor size were both risk factors for incomplete resection at reoperation. Conclusions In the hands of surgeons with experience with craniopharyngiomas, the authors believe that radical resection at presentation offers the best chance of disease control and potential cure with acceptable morbidity. While GTR does not preclude recurrence and is more difficult to achieve in recurrent tumors, especially large and previously irradiated tumors, radical resection is still possible in patients with recurrent craniopharyngiomas with morbidity similar to that of primary tumors.

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Section: Risk Factors For Decreased Survivalmentioning

confidence: 99%

Efficacy and safety of radical resection of primary and recurrent craniopharyngiomas in 86 children

Elliott¹,

Hsieh²,

Hochm

et al. 2010

PED

157

148

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“…76 Others have reported success with lateral trajectories, including pterional 95 and petrosal (presigmoid transtentorial) approaches, the latter specifically for retrochiasmatic tumors. 1 For all retroand prechiasmatic tumors, regardless of size, we prefer a modified pterional approach that incorporates a partial orbitozygomatic osteotomy and wide splitting of the sylvian fissure. It provides the shortest, most direct route to the suprasellar region, minimizes frontal and temporal lobe retraction, and allows early release of CSF from the sylvian and carotid cisterns to aid in relaxation.…”

Section: Treatment Options For Giant Craniopharyngiomasmentioning

confidence: 99%

Surgical management of giant pediatric craniopharyngiomas

Elliott¹,

Wisoff

2010

PED

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Object Prior work by the authors' group and reports of other authors suggest worse functional outcomes and decreased survival in children with larger craniopharyngiomas. The purpose of this study was to assess the oncological, endocrinological, and functional outcomes in children who underwent radical resection of giant craniopharyngiomas (defined as 5 cm or greater in largest diameter). Methods Between 1986 and 2006, 26 children under the age of 18 (14 boys, 12 girls; mean age 10.5 years) underwent radical resection of giant craniopharyngiomas performed by the senior author. Data were retrospectively collected to assess the outcome of surgical treatment. Results Twenty (77%) of 26 patients underwent gross-total resection (GTR) confirmed by intraoperative inspection and postoperative imaging. All primary tumors (17 of 17) and 3 (33%) of 9 recurrent tumors were treated with GTR. There was no operative mortality, and 18 of 26 patients (69%) were alive at a mean follow-up of 8.9 years (median 9.3 years). Disease control was achieved in 21 (84%) of the 25 patients followed up for more than 6 months and was more successful in patients who underwent GTR (95%) than in those who underwent STR (50%, p = 0.03). New-onset diabetes insipidus (DI) occurred in 63.2% of patients (73% of patients had DI postoperatively). New or worsened deficits in visual acuity and visual fields occurred in 16% and 28%, respectively, of the 25 patients for whom postoperative visual data were available. Five patients (19%) experienced significant, permanent neurological deficits, and 5 (19%) had mild to moderate deficits. New or worsened hypothalamic disturbance occurred in 35% and 22% of patients, respectively, but obesity developed in only 15%. Conclusions In this retrospective series, radical resection of giant craniopharyngiomas in children was found to lead to excellent rates of disease control with acceptable or good functional outcomes but slightly higher rates of neurological complications compared with rates in patients with smaller tumors. Radical resection is less successful in recurrent tumors that reach very large sizes, especially previously irradiated tumors, with resultant diminished survival.

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“…[1][2][3]9,13,27,28,30,31,33,34,36 At the mere expense of meticulous bone work to preserve the labyrinth and skeletonize the sigmoid sinus, this approach affords a wide exposure, minimizing operative distance and brain retraction, and affording multiple working angles to the neurosurgical target and adjacent vascular anatomy. [1][2][3]9,13 These advantages are only fully realized by the division of the tentorium and superior petrosal sinus and mobilization of a completely skeletonized sigmoid sinus. This contrasts with early work in the otolaryngology literature in which the exposure was limited superiorly by the tentorium and posteriorly by the sigmoid sinus.…”

Section: Neurosurg Focus 33 (2):e7 2012mentioning

confidence: 99%

“…This presigmoid, retrolabyrinthine approach has served as the backbone in the approach to innumerable neoplastic and vascular lesions over the past 3 decades. [1][2][3]9,27,28,30,31,33,34,36 The Posterior Petrosal Approach…”

Section: Evolution To the Modern Posterior Petrosal Approachmentioning

confidence: 99%

Evolution of the posterior petrosal approach

Gross¹,

Tavanaiepour²,

Du³

et al. 2012

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In this article, the authors review the history of the posterior petrosal approach. The early foundation of the retrolabyrinthine lateral petrosectomy has its roots in the otolaryngology literature. These early approaches were limited in exposure by the tentorium superiorly and the sigmoid sinus posteriorly. Although the concept of a transtentorial approach was originally combined with a complete labyrinthectomy, Hakuba and colleagues described the expansive exposure afforded by sectioning the tentorium and superior petrosal sinus and mobilizing a skeletonized sigmoid sinus. This maneuver serves as the key step in allowing for the full, combined supra- and infratentorial exposure that the posterior petrosal approach provides. In contrast to Hakuba et al.'s approach, which used a partial labyrinthectomy, modern approaches often preserve the entire labyrinth (retrolabyrinthine approach). For added exposure, the latter can be combined with the anterior petrosal approach, allowing for the preservation of hearing and an enhanced view of the surgical target. The authors review the evolution of the petrosal approach and highlight its applicability.

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The Petrosal Approach for the Resection of Retrochiasmatic Craniopharyngiomas

Cited by 42 publications

References 8 publications

Efficacy and safety of radical resection of primary and recurrent craniopharyngiomas in 86 children

Efficacy and safety of radical resection of primary and recurrent craniopharyngiomas in 86 children

Surgical management of giant pediatric craniopharyngiomas

Evolution of the posterior petrosal approach

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