Update on the Surgical Management of Craniopharyngiomas
Table 1: Operative Approaches Advantages
Anterior Midline Trans-sphenoidal
Subfrontal Decreased risk of visual injury Straight frontal trajectory;
can access third ventricle through lamina terminalis
Anterolateral Pterional
Access to suprasellar cistern, even with pre-fixed chiasm
Orbitozygomatic
Disadvantages Difficult in children with a
non-pneumatised sinus; higher risk of CSF leak
Potential violation of frontal sinus; technically more difficult with a pre-fixed chiasm
Grade III and IV tumours
Indications Grade I and II tumours
Limited view of contralateral opticocarotid Can be used for intrasellar, suprasellar, triangle and contralateral retrocarotid
space; posterior third ventricle obscured by ipsilateral hypothalamus
Increased access to the posterior clinoid, Same as pterional basilar apex and suprasellar region;
improved manoeuvrability of surgical instruments to these regions
Transpetrosal
Allows for visualisation and wide exposure of retrochiasmatic tumours
Intraventricular Transcallosal and transventricular Transcortical and transventricular
Translamina terminalis
Combined Approaches Subtemporal and transpetrosal
Pterional and
transcallosal Subfrontal and pterional
CSF = cerebrospinal fluid.
subdiaphragmatic) tumours because it allows access to the sellar and suprasellar regions with a decreased risk of visual injury. Disadvantages include that it may be difficult in young children with a non-pneumatised sphenoid sinus and the approach carries a higher risk of CSF leak. The subfrontal approach is most appropriate for grade III and IV suprasellar tumours. This approach allows for a straight frontal trajectory with direct access to the anterior third ventricle through the lamina terminalis7 pre-chiasmatic dissection of the tumour.
and enables
Case series examining this approach have demonstrated that, regardless of size, at least 90% of all craniopharyngiomas can be removed using the subfrontal and pterional approaches.1,6,10,13 Potential complications of the subfrontal approach include the risk of potential violation of the frontal sinus as well as damage to the olfactory tract. In addition, this approach may be technically more complicated in the presence of a pre-fixed chiasm, although this is not an absolute contraindication to the use of the subfrontal approach.
Anterolateral Approach
The pterional approach is often used in craniopharyngioma resection due to its advantages in accessing the suprasellar cistern,
EUROPEAN NEUROLOGICAL REVIEW
facilitating the resection of intrasellar, suprasellar, pre-chiasmatic and retrochiasmatic tumours.7,13
and the ipsilateral
hypothalamic wall makes visualisation of the posterior third ventricle across the lamina terminalis especially difficult.4
The orbitozygomatic approach expands on the pterional approach with the addition of removal of the supraorbital rim, zygomatic arch or both, thus increasing access to the posterior clinoid, basilar apex and suprasellar region and improved manoeuvrability of surgical instruments to these regions.7,22–24
This approach is useful for lesions
with significant suprasellar extension. Transpetrosal Approach
The resection of large retrochiasmatic craniopharyngiomas is facilitated by the anteriorly and superiorly oriented surgical corridor made possible by this approach. Conventional anterior approaches carry a risk of injury to the anterior perforators that supply the hypothalamus and chiasm. Injury to the hypothalamus and optic pathways can be minimised by mobilisation of the sigmoid sinus medially, allowing for dissection of a retrochiasmatic tumour under direct visualisation.25,26
109
Increased visualisation of lateral tumour, particularly within Sylvian fissure
Retrochiasmatic, unilateral
tumours extending to posterior fossa along clivus
Large craniopharyngioma Tumours with greater lateral extent
Dependent on dilated foramen of Monroe
Lower risk of retraction injury than transcallosal approach
Lower risk to anterior perforators than subfrontal approach
Retraction injury
Violation of cortex and increased risk of post-operative seizures
Large retrochiasmatic tumours
Same as pterional; especially useful for tumours with significant suprasellar extension
pre-chiasmatic and retrochiasmatic tumours
Intraventricular tumours
Cases with large ventricles with tumour extending to dorsal surface of brain
This approach has significant
disadvantages; a restricted view of the contralateral opticocarotid triangle, the contralateral retrocarotid space11
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