Posterior petrosal approach for retrochiasmatic craniopharyngioma

Abstract

Craniophyringiomas are histologically benign tumors arising from embryonic epithelial cells of the craniopharyngeal duct. They are locally aggressive and their location in the sellar/supra-sellar region is associated with a high rate of recurrence and morbidity. It is generally recognized that surgical resection is the first treatment option. Craniopharyngiomas located in the retrochiasmatic area are among the most challenging to treat. They grow superiorly pushing floor of third ventricle, and posteriorly in the prepontine and interpeduncular cisterns. Different skull base approaches have been utilized to tackle tumors in this location. In this video we illustrate the surgical steps and nuances for resection of a large retrochiasmatic craniopharyngioma in a 25 YO RHF who presented with progressive headaches and visual decline. On neurological examination she was found to have bi-temporal hemianopia. An MRI scan of the brain showed a 4.5 × 3.2 × 4.3 cm mixed solid and cystic suprasellar mass with obstructive hydrocephalus located behind the optic chiasm. A brain CTA showed no displacement of the anterior communicating artery confirming the retrochiasmatic location of the tumor. The preoperative endocrine work up showed central hypothyroidism and low cortisol levels. Postoperatively the patient was extubated in the operating room, she had intact extra-ocular movements. She developed Diabetes insipidus and oculomotor nerve palsy on postoperative day 3. Her third nerve palsy recovered when she was seen 3 weeks postoperatively. The histopathology showed an adamantinomatous craniopharyngioma. The posterior petrosal approach should be considered in treating patients with Retrochiasmatic Craniopharyngiomas. The consent was obtained.