Combined Transpetrosal Approach Research Articles

[Surgical Simulation Using a Three-Dimensional Printer].

3D printers have been applied in bone-based surgeries, including craniofacial, plastic, oral, and orthopedic surgeries. The improved capabilities of diagnostic imaging equipment and 3D printers have enabled the development of more precise models, and research on surgical simulations and training in the field of neurosurgery is increasing. This review outlines the use of 3D printers in neurosurgery at our institution in terms of modeling methods and surgical simulations. Modeling with the powder-sticking lamination method using plaster as the material allows drilling, which is a surgical procedure. Therefore, it is useful for simulating skull base tumors, such as petrosectomy in a combined transpetrosal approach or anterior clinoidectomy in an orbitozygomatic approach. The color coding of each part of the model facilitates anatomical understanding, and meshed tumor modeling allows deep translucency. As shown above, the 3D printer's modeling ingenuity allows for useful surgical simulations for each case.

Partial Labyrinth Removal Restricted to the Superior Semicircular Canal in Focal Combined Transpetrosal Approach: Description and Illustrative Cases.

The labyrinthine structures obstruct the surgical view of the deep petroclival region in the transpetrosal approach. Historically, labyrinthectomy and removal of all 3 semicircular canals, with resultant deafness, was used in patients with ipsilateral functional hearing deficits to improve access. The advent and systematization of superior and posterior semicircular canal removal (transcrusal approach) with good rates of hearing preservation has allowed a redefinition of the possibility of partial labyrinthectomy in patients without previous hearing deficits. The present manuscript is intended to describe a technical refinement of partial labyrinthectomy during focal combined petrosectomy, offering a customization of the approach through the selective removal of the superior semicircular canal for specific types of tumors. The use of the technique is demonstrated through surgical drawings, pictures, and videos. The rationale to indicate this new approach is discussed based on clinical cases. Three illustrative clinical cases (petroclival meningiomas) are demonstrated. Functional hearing on the approach side has been preserved in all of them. The focal combined transpetrosal approach associated with the superior semicircular canal resection has been a promising surgical technique in the treatment of selected petroclival tumors. It has the potential to further decrease the risks of postoperative auditory and vestibular dysfunctions associated with labyrinthectomies.

Tentorial peeling during combined petrosal approach: a cadaveric dissection.

The combined petrosal approach is an excellent method to access the petroclival region but has the inherent risk of injury to the temporal lobe and Vein of Labbé. Tentorial peeling has the potential to largely eliminate these risks during the classic combined transpetrosal approach. Anatomical dissection of three adult injected non-formalin fixed cadaveric heads was performed. Combined petrosal approach with tentorial peeling was completed. A tentorial incision just superior and parallel to the superior petrosal sinus was made to enable peeling of the tentorium into two layers, the posterior fossa tentorial leaf (PFTL), and the temporal tentorial leaf (TTL). Tentorial peeling clearly exposed the continuity betweenthe temporal dura and the TTL as well as the continuity betweenthe presigmoid dura and the PFTL.This enabled the creation of a large dural flap extending to the tentorial incisura, providing wide access to the petroclival region without any exposure of the temporal lobe and/or basal temporal veins.Techniques to create the dural flap without trochlear nerve injury were also explored. The technique of tentorial peeling into two distinct layers has the potential to reduce the morbidity associated with temporal lobe retraction and venous injury. Further cadaveric studies and surgical case series are needed to validate this important surgical nuance in transpetrosal approaches.

Combined transpetrosal approach for giant petroclival meningioma: 2-dimensional operative video.

Petroclival meningiomas are extremally challenging lesions due to their deep location and close relation to critical neurovascular structures. Several approaches have been described to achieve gross-total resection with low morbidity and mortality. In this 2-dimensional operative video, the authors show a simultaneous combined transpetrosal approach. The patient is a 44-year-old woman with an 8-month history of gait imbalance with evidence of a giant petroclival meningioma on neuroimaging. She underwent a combined middle fossa approach with anterior petrosectomy and retrosigmoid/retrolabyrinthine approach to achieve gross-total tumor resection. The postoperative course was characterized by trigeminal neuralgia, and neuroimaging showed gross-total resection of the tumor.The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21248

The mini-combined transpetrosal approach: an anatomical study and comparison with the combined transpetrosal approach.

The combined transpetrosal approach (CTPA) is a versatile technique suitable for challenging skull base pathologies. Despite the advantages provided by a wide surgical exposure, the soft tissue trauma, complex and time-consuming bony work, and cosmetic issues make it far from patient expectations. In this study, the authors describe a less invasive modification of the CTPA, the mini-combined transpetrosal approach (mini-CTPA), and perform a quantitative comparison between these two approaches. Five human specimens were used for this study. CTPA was performed on one side and mini-CTPA on the opposite side. The surgical freedom, petroclival and brainstem area of exposure, and maneuverability for 6 anatomical targets, provided by the CTPA and mini-CTPA, were calculated and statistically compared. The bony volumes corresponding to each anterior petrosectomy were also measured and compared. Three clinical cases with an operative video are also reported to illustrate the effectiveness of the approach. The question-mark skin incision done along the muscle attachments permits an optimal cosmetic result. Even though the limited incision, the smaller craniotomy, and the less extensive bone drilling of mini-CTPA provide a smaller area of surgical freedom, the areas of exposure of petroclival region and brainstem were not statistically different between the two approaches. The antero-posterior maneuverability for the oculomotor foramen (OF), Meckel's cave (MC) and the REZ of trigeminal nerve, and the supero-inferior maneuverability for OF, MC, Dorello's canal, and REZ of CN VII are significantly reduced by the smaller opening. The bony volume of anterior petrosectomy resulted similar among the approaches. The mini-CTPA is an interesting alternative to the CTPA, providing comparable surgical exposure both for petroclival region and for brainstem. Although the lesser soft tissue dissection and bony opening decrease the surgical maneuverability, the mini-CTPA may reduce surgical time, potential approach-related morbidities, and improve cosmetic and functional outcomes for the patients.

Minimal anterior and posterior combined transpetrosal approach for large petroclival meningiomas.

Petroclival meningiomas (PCMs) remain difficult to remove, and radical tumor resection continues to pose a relatively high risk of neurological morbidity in patients with these lesions because of the proximity of the tumor to neurovascular structures. The anterior and posterior combined (APC) transpetrosal approach allows resection of a large petroclival lesion with minimal retraction of the temporal lobe. However, this approach is thought to be complex and time-consuming. The authors simplified this approach by minimizing the petrosectomy and used this method for large PCMs. This retrospective study describes the surgical technique and surgical outcomes of large PCMs. Between 2014 and 2019, 23 patients (19 women and 4 men) with benign (WHO grade I) PCMs were treated using the minimal APC (MAPC) transpetrosal approach. The mean age at surgery was 54.0 years (range 37-74 years). The mean tumor diameter was 40.3 mm (range 30-74 mm). The surgical technique consisted of a temporo-suboccipital craniotomy and minimal drilling of the petrous ridge. After opening Meckel's cave and removing the lesion at the prepontine cistern, drilling of the petrous apex with superior mobilization of the trigeminal nerve was performed through the subdural space for further tumor resection around the petrous apex. Finally, the tumor was removed as much as possible. The mean preoperative and postoperative tumor volumes were 26.8 and 1.3 cm3, respectively. The mean extent of resection was 95.4% (range 62%-100%). Postoperative impairments included facial numbness in 7 patients, trochlear nerve palsy in 3 patients, mild oculomotor nerve palsy in 2 patients, and transient abducens nerve palsy in 1 patient. Preoperative Karnofsky Performance Status was improved in 13 patients, remained stable in 9 patients, and deteriorated in 1 patient. The MAPC transpetrosal approach provides sufficiently wide exposure of petroclival lesions. Maximal resection via the MAPC transpetrosal approach is a suitable surgical option for the treatment of large PCMs.

Abordaje presigmoideo transpetroso (petrosectomía parcial) combinado con abordaje subtemporal transtentorial para meningioma petroclival

Introduction: Petroclival meningiomas constitute 3 to 10% of meningiomas of the posterior fossa, they originate in the petroclival fissure, in the upper part of the clivus, petrosal apex, and medial to the trigeminal nerve. Resection of these tumors is a neurosurgical challenge. The combined partial petrosectomy approach associated with a sub-temporal approach is a technique described by various authors; however, its performance is considered highly complex. We report the case of a petroclival meningioma operated successfully in our hospital using a combined presigmoid and subtemporal transtentorial transpetrosal approach. Clinical case: 33-year-old female patient with a clinical picture of headache, nausea, and gait disturbance. Brain magnetic resonance imaging showed a large right petroclival tumor (4.2x3.9x3.8cm) that displaced the brainstem and secondary hydrocephalus. The hydrocephalus was treated with a ventricular peritoneal shunt. Then, the tumor was resected using a combined presigmoid and subtemporal transpetrosal approach, a technique that allowed adequate exposure of the tumor, achieving complete resection, without intraoperative complications. Postoperative evolution was favorable, with no sequelae. Conclusion: The combined presigmoid and transtentorial subtemporal transpetrous approach for petroclival meningiomas is an effective and feasible technique to perform in our environment. The support of technology such as Neuronavigation, the ultrasonic aspirator, intraoperative monitoring, and adequate experience in skull base surgery are fundamental factors for the success of this surgery. Keywords: Meningioma, Skull Base Neoplasms, Craniotomy, Neurosurgical Procedures. (Source: MeSH NLM)

Importance of appropriate surgical approach selection for radical resection of cerebellopontine angle epidermoid cysts with preservation of cranial nerve functions: our experience of 54 cases.

Although many reports state that only the lateral suboccipital retrosigmoid approach (LSO) should be used for removal of cerebellopontine angle (CPA) epidermoid cysts, it is preferable to use various surgical approaches as appropriate for each patient, for radical resection with an optimal operative field under direct visualization, and for the preservation of cranial nerve (CN) functions. In the present study, we hence focused on the importance of surgical approach selection for removal of CPA epidermoid cysts and analyzed the results of CPA epidermoid cysts after surgery in our series. Fifty-four patients who underwent surgery for CPA epidermoid cysts were retrospectively analyzed, regarding their surgical approaches, removal rates, preservation rates of CN function 1 year after surgery, and recurrence. Surgical approaches were selected for patients according to the size and extension of the tumor. Surgical approaches consisted of LSO (20 cases), anterior transpetrosal approach (ATP; 3 cases), combined transpetrosal approach (27 cases), and ATP + LSO (4 cases). Mean tumor content removal and capsule removal rates were 97.4% and 78.3%, respectively. Preservation rates of facial nerve function and useful hearing were 94.4% and 90.7%, respectively. The mean postoperative follow-up time was 62.8 months, and there were two cases of recurrence requiring reoperation about 10 years after surgery. For CPA epidermoid cyst surgeries, selection of the appropriate surgical approach for each patient and radical resection with an optimal operative field under direct visualization enable tumor removal without the need for reoperation for a long time, with preservation of CN functions.

Commentary: Tentorial Peeling: Surgical Extradural Navigation to Protect the Temporal Lobe in the Focused Combined Transpetrosal Approach.

Commentary: Tentorial Peeling: Surgical Extradural Navigation to Protect the Temporal Lobe in the Focused Combined Transpetrosal Approach.

Tentorial Peeling: Surgical Extradural Navigation to Protect the Temporal Lobe in the Focused Combined Transpetrosal Approach.

Transpetrosal approaches have been used for treatment of tumors in the petroclival region for many years. Injury to the temporal lobe, however, has been a potential drawback of the techniques described to date. To describe modifications of the transpetrosal surgical technique, which allows extradural manipulation of the temporal lobe during the focused combined transpetrosal approach. This extra layer of protection avoids mechanicalbrain retraction, direct trauma to the temporal lobe and disruption of the local venous structures. The present manuscript describes an innovative technical nuance based on the combination of the focused combined transpetrosal approach, the peeling of the dural layers of the tentorium, and the reverse peeling of the middle fossa dura mater. Ample illustrative material is provided and illustrative cases are presented. Peeling of the dural layers of the tentorium is a promising modification of the transpetrosal approach to increase the safety of the temporal lobe manipulation.

Combined Transpetrosal Approach With Preservation of Superior Petrosal Vein Drainage for a Cerebellopontine Angle Epidermoid Cyst Extending Into Meckel's Cave: 3-Dimensional Operative Video.

The combined transpetrosal approach enables wide exposure around the petroclival region by cutting the tentorium and superior petrosal sinus. We often choose this approach for removal of tumors ventral to the facial and vestibulocochlear nerves, such as petroclival meningioma and epidermoid cyst, because complete removal of the tumor under direct visualization is required to prevent its later recurrence, especially in young patients. Recent reports revealed anatomical variations of the drainage of the superior petrosal sinus, and dural incision considering preservation of the superior petrosal vein was proposed.1-3 This 3-dimensional video shows a patient with an epidermoid cyst, which was surgically treated using the combined transpetrosal approach, with consideration of the variation of the superior petrosal sinus and preservation of the drainage route of the superior petrosal vein. The video was reproduced after informed consent of the patient. The patient is a 31-yr-old woman who presented with a left cerebellopontine angle epidermoid cyst extending into Meckel's cave. The superior petrosal sinus was of the lateral type, draining only laterally into the transverse-sigmoid junction without medial connection with the cavernous sinus.1 The combined transpetrosal approach was performed with cutting of the superior petrosal sinus medial to the entry point of the superior petrosal vein, in order to preserve its drainage into the transverse-sigmoid junction. Meckel' cave was opened along its lateral margin, and tumor removal was accomplished, leaving only a minute part of the capsule strongly adhering to the neurovascular structures. The patient had no new permanent neurological deficits during follow-up. The figures in the video were modified from Matsushima et al1 by permission of the Congress of Neurological Surgeons.

Three-Dimensional Printed Model for Surgical Simulation of Combined Transpetrosal Approach

The combined transpetrosal approach is a complicated skull base surgery with a high degree of difficulty. Herein, we made a 3-dimensional (3D) printed petrous bone with color-coded anatomic sites and evaluated its usefulness as a model to practice drilling associated with combined transpetrosal surgery. To design a 3D model of the petrous bone, we chose a representative epidermoid petroclival tumor case who underwent combined transpetrosal surgery at our hospital. A 3D image of the petrous bone embedded with color-coded anatomic sites, including cranial nerves, brainstem, and internal carotid and vertebrobasilar arteries, was created based on preoperative computed tomography scan, magnetic resonance, and digital subtraction angiography images and was then 3D printed. Thirteen neurosurgeons from our department evaluated the anatomic reproducibility and estimated distance between each anatomic site of the 3D image and model and the usefulness of the model for drilling practice. The anatomic reproducibility of both the 3D image and model was high, and the 3D model was considered good for drilling practice (P < 0.05). The error in the estimated distance between anatomic sites in the 3D model was significantly smaller than that of the 3D image (P < 0.0001). These results indicate that our 3D printed model is very useful for practice with craniotomy and petrosectomy drilling, necessary in the combined transpetrosal approach.

Intradural Combined Transpetrosal Approach for Primary Pontine Hemorrhage

The standard combined transpetrosal approach (CTPA) is fundamentally an epidural approach that has been quite successfully practiced for many decades. However, it has some disadvantages, such as cosmetic problems, difficulties with custom-tailored petrosectomy, and cerebrospinal fluid leakage, as it is a complicated epidural procedure. We describe here a case of primary pontine hemorrhage via intradural CTPA (iCTPA), which is a modified technique of CTPA and includes intradural anterior petrosectomy and partial posterior petrosectomy without mastoidectomy and skeletonization of the sigmoid sinus. A 63-year-old woman with primary pontine hemorrhage underwent surgery via iCTPA to improve postoperative functional outcomes. After the temporal craniotomy without mastoidectomy and skeletonization of the sigmoid sinus, Kawase's triangle and Trautmann's triangle were identified from the intradural space. Resection of Kawase's triangle and partial resection of Trautmann's triangle were performed to approach the frontotemporal surface of the pons. The hematoma was irrigated and totally removed after corticotomy on the pons. The postoperative symptoms of the patient improved within 2 weeks without surgical complication. The intradural approach allows for custom-tailored petrosectomy and is more straightforward than the epidural route, although it can injure the vein of Labbé. Moreover, it can also reduce cosmetic problems and cerebrospinal fluid leakage. iCTPA could provide enough working space for the frontolateral surface of pontine and petroclival lesions without the need for mastoidectomy and skeletonization of the sigmoid sinus.

The Transpetrosal-Ridge Approach: A Modification of the Combined Transpetrosal Approach

BackgroundPetroclival tumors are formidable challenges for skull base surgeons. Obtaining adequate surgical access is a paramount consideration. Although the combined transpetrosal approach provides a wide surgical corridor, it is technically challenging and, to a degree, morbid. This article describes the transpetrosal-ridge approach, which is a modification of the combined transpetrosal approach with improvements with regards to ease of execution and reduced surgical morbidity.MethodsThe key elements of the transpetrosal-ridge approach are outlined, followed by a detailed description of the steps. The head is placed in the lateral position. After skin incision and muscle elevation, a temporo-suboccipital craniotomy is performed. Middle fossa dura is elevated to the petrous ridge. A limited mastoidectomy is performed with preservation of the semicircular canals. The remaining petrous ridge is then resected and the posterior fossa dura is opened, with the opening extending through the trigeminal dural ring.ResultsSteps of the combined transpetrosal approach that do not contribute to the final surgical corridor are omitted. Extensive mastoid and petrous apex resection is avoided. Posterior fossa dural opening extending through the trigeminal dural ring is a critical step, as it detaches the superior petrosal sinus and sigmoid sinus from the petrous bone. With the retraction of the temporal lobe and the cerebellum and sigmoid sinus, a wide surgical corridor is obtained.ConclusionsThe transpetrosal-ridge approach is a modification of the combined transpetrosal approach with optimization of the operative steps while continuing to provide a wide surgical corridor to the petroclival region.

Retrosigmoid Intradural Suprameatal Approach for Petroclival Meningioma

Background  Anterior transpetrosal approach and the combined transpetrosal approach are the major surgical approaches for petroclival meningiomas. However, anterior petrosectomy is not preferable in cases with postoperative venous drainage disorder of the sylvian vein due to anatomical variations. Here we present a case of the successful removal of petroclival meningioma by the retrosigmoid intradural suprameatal approach (RISA). Case Presentation  The patient was a 59-year-old woman with incidentally detected right petroclival meningioma. Although she had no neurological deficit, the tumor manifested with gradual growth on annual magnetic resonance imaging (MRI) during an 8-year follow-up. Three-dimensional computed tomography venography (3D–CTV) revealed sphenobasal type of the sylvian vein throughout the lateral side of the foramen ovale. Because the suprameatal tubercle was an obstacle to observe the Meckel's cave, RISA was selected for complete tumor excision. RISA could provide an excellent operative field around the Meckel's cave to confirm the remnant tumor. Postoperative MRI showed no evidence of the tumor, and the patient was discharged without any neurological deficit. Conclusion  RISA can provide a favorable operative field for petroclival meningioma, particularly for cases with high risk of postoperative complications related to the sylvian vein. The link to the video can be found at: https://youtu.be/cfci_zk0StU .

Safe maximal resection of primary cavernous sinus meningiomas via a minimal anterior and posterior combined transpetrosal approach.

OBJECTIVE Meningiomas arising from the cavernous sinus (CS) continue to be a significant technical challenge, and resection continues to carry a relatively higher risk of neurological morbidity in patients with these lesions because of the tumor's proximity to neurovascular structures. The authors report the surgical outcomes of 9 patients with primary CS meningiomas (CSMs) that were surgically treated using a minimal anterior and posterior combined (MAPC) transpetrosal approach, and they emphasize the usefulness of the approach. METHODS This retrospective study included 9 patients who underwent surgery for CSM treatment between 2015 and 2016 via the MAPC transpetrosal approach. Two patients were men and 7 were women, with a mean age of 58.5 years (39-72 years). Five patients (55.5%) had undergone previous treatment. The surgical technique consisted of a temporo-occipito-suboccipital craniotomy and exposure of the posterolateral part of the CS via the presigmoidal MAPC approach. After opening Meckel's cave and identifying the 3rd-5th cranial nerves in the prepontine cistern, Parkinson's triangle and supratrochlear triangles were opened. Finally, the tumor occupying the posterolateral part of the CS was removed. RESULTS All lesions were safely and maximally removed, with preservation of external ocular movements and preoperative Karnofsky Performance Scale scores. The mean extent of resection was 77.0% (range 58.7%-95.4%). Six patients underwent adjuvant therapy in the form of stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT) during the follow-up period; none of these patients experienced recurrence. CONCLUSION The authors conclude that the MAPC transpetrosal approach could be superior to other approaches for CSMs, as it provides direct visual access to the posterolateral portion of the CS. In their experience, this approach is an alternative and better option for safe maximal resection of CSMs.

脳幹部橋海綿状血管腫に対する経錐体到達法の有用性

Surgical resection of pontine cavernomas remains a particularly formidable challenge in the neurosurgical field because of their deep-seated and eloquent locations. We report and discuss our experience and surgical approaches in the treatment of pontine cavernomas via a transpetrosal approach. We investigated eight cases of pontine cavernomas who underwent resection via an anterior or combined transpetrosal approach at our hospital between 2008 and 2015. These eight patients comprised six men and two women with a mean age of 46.9 years. All cases presented with neurological deficits caused by hemorrhage before surgery. We used an anterior transpetrosal approach in six cases and a combined transpetrosal approach in two. Gross total resection of the tumor was achieved in all cases. No postoperative complications, viz., worsening of facial nerve palsy, ocular movement disorder, or hemiplegia were noted in any patient. It is possible to obtain a wide surgical corridor from the ventral and lateral side via an anterior or combined tranpetrosal approach for treatment of pontine cavernomas. A small cortical incision with multi-directional dissection is the best approach to avoid additional neurological deficits. We conclude that resection of pontine cavernomas via a transpetrosal approach might be superior to other approaches to minimize postoperative neurological deficits.

Bypass Revascularization Applied to the Posterior Cerebral Artery

The application of bypass procedures to the posterior cerebral artery (PCA) in combination with proximal clipping or trapping is a useful option for the treatment of complex posterior circulation aneurysms, especially those of the PCA. Because of its course around the midbrain through various cisterns, different approaches are required to access the PCA. The presented study analyzes a retrospective case series of bypass procedures to the PCA to investigate the relevant treatment strategies and their outcomes. Seven patients with bypass procedures to the PCA bypass were analyzed. The location of the aneurysms, approaches, site of anastomosis, bypass patency, pre- and postoperative modified Rankin Scale scores, and transient and permanent morbidity were assessed. Analyzed patients were treated for intracranial aneurysm located on the P2 (n= 3) or P3 (n= 2) of the PCA, bilateral vertebral artery dissecting aneurysm (n= 1) or internal carotid artery-posterior communicating artery aneurysm (n= 1). The following approaches were used: anterior temporal approach (n= 2), anterior temporal approach combined with subtemporal approach (n= 2), combined transpetrosal approach (n= 1), posterior interhemispheric approach (n= 1), and posterior interhemispheric approach with subtemporal approach (n= 1). All bypasses were patent. Permanent morbidity occurred in 2 patients via cognitive dysfunction (n= 1) and hemiparesis (n= 1). Bypass revascularization of the PCA territory is effective for the treatment of complex vascular lesions affecting the posterior circulation. To address the various surgical segments of the PCA, different approaches are required. Combined approaches allow access to the PCA proximal and distal from the lesion.

A neurosurgical simulation of skull base tumors using a 3D printed rapid prototyping model containing mesh structures.

Deep regions are not visible in three-dimensional (3D) printed rapid prototyping (RP) models prepared from opaque materials, which is not the case with translucent images. The objectives of this study were to develop an RP model in which a skull base tumor was simulated using mesh, and to investigate its usefulness for surgical simulations by evaluating the visibility of its deep regions. A 3D printer that employs binder jetting and is mainly used to prepare plaster models was used. RP models containing a solid tumor, no tumor, and a mesh tumor were prepared based on computed tomography, magnetic resonance imaging, and angiographic data for four cases of petroclival tumor. Twelve neurosurgeons graded the three types of RP model into the following four categories: 'clearly visible,' 'visible,' 'difficult to see,' and 'invisible,' based on the visibility of the internal carotid artery, basilar artery, and brain stem through a craniotomy performed via the combined transpetrosal approach. In addition, the 3D positional relationships between these structures and the tumor were assessed. The internal carotid artery, basilar artery, and brain stem and the positional relationships of these structures with the tumor were significantly more visible in the RP models with mesh tumors than in the RP models with solid or no tumors. The deep regions of PR models containing mesh skull base tumors were easy to visualize. This 3D printing-based method might be applicable to various surgical simulations.

Surgical Management of Craniopharyngioma with Large Calcification

Background: Craniopharyngiomas with large diameter and major calcification are a particularly formidable challenge for radical resection. We report our surgical treatment and outcome of calcified and large craniopharyngiomas. Methods: From 1986 to 2013, 78 cases of craniopharyngiomas were resected at OCU hospital. There were 31 cases with 10% or more of calcification of tumor volume and 8 cases with 50% or more of calcification of tumor volume. In this study, we analyzed these eight cases retrospectively. Median age was 38.4 years (range 5-71 years). Four cases had been already received previous operation or radiotherapy at previous other hospitals. Five lesions underwent multistaged surgery for radical resection. Combined transpetrosal approach was selected in six cases, orbitozygomatic approach was selected in four cases, interhemispheric approach was selected in two cases, and extended transsphenoidal approach was selected in one case. During initial part of tumor resection, diamond drill or CUSA was used with the aim of division of calcification, and we resected tumor piece by piece. Results: Radical resection was performed in all cases. Visual function was improved in five cases and remained in three cases. Although one of eight patients died due to uncontrollable tumor progression, other patients show good functional outcome and good tumor control. Conclusions: Our policy of treatment of craniopharyngiomas is radical tumor resection even in cases with large calcification.