The petrosal approach for the total removal of giant retrochiasmatic craniopharyngiomas in children

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

doi:10.3171/ped.2007.106.2.87

Cited by 44 publications

(48 citation statements)

References 32 publications

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“…8,33,34,37 Other approaches include the transcallosal or translamina terminalis approaches for intraventricular craniopharyngiomas, 25,37 and the orbitozygomatic approach, 13 endoscopic transsphenoidal approaches, and the petrosal approach for retrochiasmatic craniopharyngiomas. 1,2,6,[10][11][12]16 Accessibility of the Tumor…”

Section: Discussionmentioning

confidence: 99%

“…The frontolateral approach lacks the complications associated with the petrosal approach, such as the possibility of venous injuries and CSF leakage. 1,2,16 Other options for managing craniopharyngiomas include stereotactic aspiration and Ommaya reservoir insertion for continuous aspiration, conservative resection followed by radiosurgery, radiotherapy, and intracavitary treatment for cystic tumors with radioisotope or chemotherapeutic agents. 14,20,27,29,30 However, the long-term consequences of these methods as primary treatment are unclear, and they are not without complications.…”

Section: Approach-related Complicationsmentioning

confidence: 99%

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

Gerganov¹,

Metwali²,

Samii³

et al. 2014

JNS

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Approach-related Complicationsmentioning

confidence: 99%

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

Gerganov¹,

Metwali²,

Samii³

et al. 2014

JNS

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“…18,41 The extraventricular location of Sa-CPs adjudicates the extraaxial route, as the arachnoid membrane surrounding the tumor provides a plane of cleavage for tumor dissection. 1,2,22,26,58,64 This approach offers a high probability of preserving the integrity of the pituitary stalk and hypothalamus-hypophysis axis. The surgical removal of Sp-CPs always necessitates an intraaxial route (the translamina terminalis route as a primary or supplemental corridor) for the dissection of the tumor from the nervous tissue parenchyma of the third ventricle walls.…”

Section: Clinical Relevance Of Tumor Growth Patternsmentioning

confidence: 99%

Growth patterns of craniopharyngiomas: clinical analysis of 226 patients

Pan¹,

Qi²,

Liu³

et al. 2016

PED

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OBJECT Craniopharyngiomas (CPs) are rare epithelial tumors that are often associated with an enigmatic and unpredictable growth pattern. Understanding the growth patterns of these tumors has a direct impact on surgical planning and may enhance the safety of radical tumor removal. The aim of this study was to analyze the growth patterns and surgical treatment of CPs with a focus on the involvement of the hypothalamopituitary axis and the relationship of the tumor to the arachnoid membrane and surrounding structures. METHODS Clinical data from 226 consecutive patients with primary CP were retrospectively reviewed. Tumor location and the relationship of the tumor to the third ventricle floor and the pituitary stalk were evaluated using preoperative MRI and intraoperative findings. A topographic classification scheme was proposed based on the site of tumor origin and tumor development. The clinical relevance of this classification on patient presentation and outcomes was also analyzed. RESULTS The growth of CPs can be broadly divided into 3 groups based on the site of tumor origin and on tumor-meningeal relationships: Group I, infrasellar/infradiaphragmatic CPs (Id-CPs), which mainly occurred in children; Group II, suprasellar subarachnoid extraventricular CPs (Sa-CPs), which were mainly observed in adults and rarely occurred in children; and Group III, suprasellar subpial ventricular CPs (Sp-CPs), which commonly occurred in both adults and children. Tumors in each group may develop complex growth patterns during vertical expansion along the pituitary stalk. Tumor growth patterns were closely related to both clinical presentation and outcomes. Patients with Sp-CPs had more prevalent weight gain than patients with Id-CPs or Sa-CPs; the rates of significant weight gain were 41.7% for children and 16.7% for adults with Sp-CPs, 2.2% and 7.1% for those with Id-CPs, and 12.5% and 2.6% for those with Sa-CPs (p < 0.001). Moreover, patients with Sp-CPs had increased hypothalamic dysfunction after radical removal; 39% of patients with Sp-CPs, 14.5% with Id-CPs, and 17.4% with Sa-CPs had high-grade hypothalamic dysfunction in the first 2 postoperative years (p < 0.001). CONCLUSIONS The classification of CPs based on growth pattern may elucidate the best course of treatment for this formidable tumor. More tailored, individualized surgical strategies based on tumor growth patterns are mandatory to provide long-term tumor control and to minimize damage to hypothalamic structures. Differences in the distribution of growth patterns between children and adults imply that hierarchical comparison is necessary when investigating outcomes and survival across treatment paradigms in patients with CP.

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“…The major challenge that remains is the intraoperative identification and preservation of the pituitary stalk with its feeding vessels, especially in large supradiaphragmatic craniopharyngiomas. 1,2,4,[8][9][10][11][12][13][16][17][18]20,24,33 In this article, we describe a technique that enhances tumor resection while preserving the pituitary stalk. It includes unroofing of the optic canal together with incision of the falciform ligament and drilling of the lateral part of the tuberculum sellae.…”

mentioning

confidence: 99%

“…Although patients with intrasellar craniopharyngiomas usually have hormonal disturbances at the time of presentation, in patients with supradiaphragmatic craniopharyngioma, the visual symptoms dominate. 1,2,4,[8][9][10][11][12][13][14][15][16][17][18]20,24,[32][33][34][35] The choice of operative approach for craniopharyngioma resection depends on the surgeon's preference and experience, considering the location and configuration of the tumor. Our current concept of management of craniopharyngiomas is gross-total resection via the frontolateral approach.…”

mentioning

confidence: 99%

Optic nerve mobilization to enhance the exposure of the pituitary stalk during craniopharyngioma resection: early experience

Metwali¹,

Gerganov²,

Fahlbusch³

2016

JNS

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obJectiVe Preservation of the pituitary stalk and its vasculature is a key step in good postoperative endocrinological outcome in patients with craniopharyngiomas. In this article, the authors describe the surgical technique of medial optic nerve mobilization for better inspection and preservation of the pituitary stalk. Methods This operative technique has been applied in 3 patients. Following tumor exposure via a frontolateral approach, the pituitary stalk could be seen partially hidden under the optic nerve and the optic chiasm. The subchiasmatic and opticocarotid spaces were narrow, and tumor dissection from the pituitary stalk under direct vision was not possible. The optic canal was therefore unroofed, the falciform ligament was incised, and the lateral part of the tuberculum sellae was drilled medial to the optic nerve. The optic nerve could be mobilized medially to widen the opticocarotid triangle, which enhanced visualization of and access to the pituitary stalk. Results By using the optic nerve mobilization technique, the tumor could be removed completely, and the pituitary stalk and its vasculature were preserved in all patients. In 2 patients, vision improved after surgery, while in 1 patient it remained normal, as it was before surgery. The hormonal status remained normal after surgery in 2 patients. In the patient with preoperative hormonal deficiencies, improvement occurred early after surgery and hormonal levels were normal after 3 months. No approach-related complications occurred. coNclusioNs This early experience shows that this technique is safe and could be used as a complementary step during microsurgery of craniopharyngiomas. It allows for tumor dissection from the pituitary stalk under direct vision. The pituitary stalk can thus be preserved without jeopardizing the optic nerve.

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The petrosal approach for the total removal of giant retrochiasmatic craniopharyngiomas in children

Abstract: The authors recommend this approach for patients with large or giant retrochiasmatic craniopharyngiomas.

Cited by 44 publications

References 32 publications

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

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

Growth patterns of craniopharyngiomas: clinical analysis of 226 patients

Optic nerve mobilization to enhance the exposure of the pituitary stalk during craniopharyngioma resection: early experience

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