Extended Endonasal Endoscopic Approach for the Resection of Craniopharyngioma-An Analysis of 40 Cases

Extended endonasal endoscopic approach for the non-pituitary lesions of the seller and suprasellar regions are not new in the field of neurosurgery. Following endoscopic approach of the pituitary adenoma surgery, the endoscopic neurosurgeon is eager to develop the skill for non-pituitary sellarsuprasellar lesions. Common sellar suprasellar lesions are pituitary adenoma, craniopharyngioma, tuberculumsellae meningioma and supra sellar germinoma. Traditional transsphenoidal approach gives exposure to the pituitary fossa, whereas extended approach provides exposure to the optic nerve, chiasm, acom complex and basal frontal lobe, mammillary body, mid brain, 3rd nerve, basilar artery, and circle of Willis and laterally to the cavernous sinuses. From November 2007 to February 2016 (over 8 years), there were 40 cases of craniopharyngioma operated by the extended endonasal endoscopic approach. Patient’s history, clinical findings, pre-operative and post-operative visual acuity, visual field and radiological data were collected and analyzed. All patients underwent endoscopic extended transsphenoidal approach with or without nasoseptal flap technique for closure. 7 patients were given lumber drain as a treatment for cerebrospinal fluid (C.S.F.) leak. Age group of the patients varied from 10 to 60 yrs. Male were 19 (47.5%), female were 21 (52.5%). Gross total removal was achieved in 22 cases out of 40 (55.00%) and subtotal in 10 (25.00%) cases. Visual acuity and field of vision improved in all cases. One case (2.5%) of craniopharyngioma had prolonged period of unconsciousness probably from hypothalamic disturbance. C.S. F. leak developed in 10 (25.00%) cases. All Patients required thyroxin and cortisol for replacement. Permanent diabetes insipidus (D.I.) developed in 10 cases (25.00%). No cases required traditional, open approaches following endoscopic resection. Three patients required permanent C.S. F diversion via a ventriculoperitoneal shunt after documentation of post-op hydrocephalus (HCP). There was one case of chemical meningitis, and two cases of confirmed bacterial infections. Craniopharyngioma can be successfully resected via a purely endoscopic, endonasal approach. Craniopharyngioma have a higher rate of perioperative hydrocephalus and postoperative C.S. F leak compared with other tumor types in the same area. Conclusion: Extended transspehnoidal approach is an excellent alternative of skull base approach for the removal of most of the craniopharyngiomas. The endoscopic endonasal route provides a good visualization, especially of the subchiasmatic and retrochiasmatic areas, as well as of the stalk–infundibulum axis, and the third ventricle chamber. It gives better visualization, improved postoperative visual outcome for less manipulation and lower complication rate than craniotomy. However C.S. F. leak and D.I. are known common complications which have to be managed promptly and appropriately. Bang. J Neurosurgery 2013; 3(1): 26-33 Introduction: Craniopharyngioma is a benign epithelial tumor of the sellar region but can have significant neurological and endocrinological consequences and may require treatment that will cause further morbidity1. As craniopharyngiomas grow, they can cause significant neurological complications, including visual loss, pituitary insufficiency, and hypothalamic damage, and recurrence. The first description of a craniopharyngioma was credited to Zenker, who made this observation in 18571.2. Following this, Mott and Barrett, in 1899, documented the occurrence of these tumors and postulated that they arose from the hypophyseal duct or Rathke’s pouch3. This was subsequently partially confirmed in 1904, when Erdheim described the tumors histologically and suggested that they arose from remnants of the Rathke duct3.4. Finally, in 1932, Cushing introduced the term “craniopharyngioma,” which has been widely used thereafter. The incidence of newly diagnosed craniopharyngioma is 0.13 to 2.0 persons per 100,000 populations per year. Distribution by age is bimodal, with the peak incidence in children at aged 5-14 years and in adults at age 50-75 years5. Craniopharyngioma accounts for 1%-3% of all brain tumors in adult, it accounts for 5%-10% of brain tumors in children. No sex predilection exists, and they equally occur in males and females5.6. The clinical presentation can include a wide range of symptoms, which depend on the location of the tumor and involvement of adjacent structures7. Headache is the most common presenting symptom, followed by endocrine deficiencies and visual disturbances. Headache is usually due to either the tumor’s mass effect or hydrocephalus (from obstruction of the foramen of Monro, third ventricle, or aqueduct of Sylvius), which occurs in 15%-30% of patients6.7. Fig.-1 (a) Fig.-1 (c) Fig.-1 (b) Extended endonasal endoscopic approach for the resection Alam S et al.