A Unilateral Subfrontal Basal Interhemispheric Approach to Large Craniopharyngiomas

Abstract

Objective: We report our experience with a unilateral subfrontal basal interhemispheric approach for large craniopharyngiomas that extend into the third ventricle and basal or prepontine cistern. Clinical Materials and Methods: Thirty-two patients were operated on using a unilateral subfrontal basal interhemispheric approach. We analyzed the outcomes of all patients at discharge and at 6 months postoperation and classified these patients according to the Glasgow outcome scale (GOS) score. Results: Twenty-nine (90.1%) patients gained a GOS score of 5 at discharge, and 3 patients (9.4%) gained a GOS score of 4. During the follow-up at 6 months, 31 (96.9%) patients gained a GOS score of 5, and 1 patient (3.1%) gained a GOS score of 4. Total removal of the lesion was achieved in 25 (78.1%) cases, 7 (21.2%) patients underwent subtotal resection. Preservation of the pituitary stalk was possible in 18 (56.3%) cases, severed in 12 (18.3%), and unidentified in 2 (20.7%). In our series, there were no procedure-related complications, such as frontal lobe contusion, a cerebrospinal fluid leak, or bacterial meningitis. No mortalities resulted from the approach. The olfactory nerves were preserved well. After surgery, transient panhypopituitarism developed in 22 patients (68.8%) but resolved within 2 weeks. In 6 of them there was persistent panhypopituitarism during the follow-up at 6 months. Transient diabetes insipidus developed in 23 (71.9%) patients but resolved within 1 month. Permanent postoperative diabetes insipidus was present in 9 (28.1%) patients during the follow-up at 6 months. Visual impairment was found in 10 patients before surgery; in 7 of them there was postoperative visual deterioration. Among the 7 patients, 5 had partial recovery before discharge and 3 patients had recovery during the follow-up at 6 months. Conclusions: The present results suggest that the unilateral subfrontal basal interhemispheric approach provides direct and wide exposure of large craniopharyngiomas. Anatomic preservation of the pituitary stalk, hypothalamic structure, perforating vessels, anterior communicating complex, the visual pathway, and the olfactory nerves is often possible.