Surgery for craniopharyngiomas extending outside the suprasellar cistern

Abstract

Objective: Craniopharyngiomas frequently grow from remnants of Rathke's pouch, located on the cisternal surface of the hypothalamic region. They can extend elsewhere in the infundibulo-hypophyseal axis. The aim of the present study was to establish the usefulness of the fronto-basal approach with a relatively small craniotomy window for the removal of tumors protruding from the sellar–suprasellar region to the third and basal cistern. Method: Thirty-one patients who were surgically treated for craniopharyngiomas extending outside the sellar–suprasellar region were evaluated. The diagnoses were established in all cases with magnetic resonance imaging and CT. The initial symptoms and signs were increased intracranial pressure in 17 patients, vision impairment or visual field defect in 15, hypopituitarism in 13, and psychological disturbances in 4 cases. All the patients were operated on by the fronto-basal interhemispheric approach, and the average follow-up period was 30 months. Results: Total removal of the lesion was achieved in 22 cases. Six patients underwent subtotal resection and 3 patients underwent partial removal due to recurrence after previous surgeries with or without radiotherapy. In the immediate postoperative period, major complications, including impairment of the cranial nerves, were not observed. One patient exhibited transient memory disturbance due to infarction of the perforator; after 3 months, this symptom was ameliorated. None of the patients died during long-term follow-up (average 30 months), however 4 of the 22 undergoing total removal and 6 of the 9 patients undergoing subtotal or partial removal suffered recurrence. Of the 10 patients with recurrence, 6 experienced a small recurrence of the lesion (average 3 months after surgery); after radiosurgery by gamma-knife, 2 of the lesions exhibited unchanged size and 4 underwent re-operation due to enlargement of the tumor in the follow-up period. Ultimately, a total of eight patients (four with recurrence and four gamma-knife-treated) underwent re-operation with gross total removal with the same approach or combined with the orbito-zygomatic approach for patients with very short optic nerves. All patients returned to a normal life. Conclusion: In our experience, the fronto-basal interhemispheric approach, even through a small craniotomy window, is a valid choice for the removal of craniopharyngiomas extending outside the sellar–suprasellar region. Using this approach, tumors can be removed without significant sequelae related to surgical technique due to easy preservation of the pituitary stalk, hypothalamic structures and perforators. This approach offers a safe and minimally invasive means of treating craniopharyngiomas.