phenylephrine-hydrochloride and Craniopharyngioma

Craniopharyngiomas are locally aggressive neuroepithelial tumors infiltrating nearby critical neurovascular structures. The majority of published surgical series deal with childhood-onset craniopharyngiomas, while the optimal surgical management for adult-onset tumors remains unclear. The aim of this paper is to summarize the main principles defining the surgical strategy for the management of craniopharyngiomas in adult patients through an extensive systematic literature review in order to formulate a series of recommendations.. The MEDLINE database was systematically reviewed (January 1970-February 2019) to identify pertinent articles dealing with the surgical management of adult-onset craniopharyngiomas. A summary of literature evidence was proposed after discussion within the EANS skull base section.. The EANS task force formulated 13 recommendations and 4 suggestions. Treatment of these patients should be performed in tertiary referral centers. The endonasal approach is presently recommended for midline craniopharyngiomas because of the improved GTR and superior endocrinological and visual outcomes. The rate of CSF leak has strongly diminished with the use of the multilayer reconstruction technique. Transcranial approaches are recommended for tumors presenting lateral extensions or purely intraventricular. Independent of the technique, a maximal but hypothalamic-sparing resection should be performed to limit the occurrence of postoperative hypothalamic syndromes and metabolic complications. Similar principles should also be applied for tumor recurrences. Radiotherapy or intracystic agents are alternative treatments when no further surgery is possible. A multidisciplinary long-term follow-up is necessary.

Topics: Adult; Consensus; Craniopharyngioma; Humans; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Practice Guidelines as Topic; Societies, Medical

The advent of endonasal endoscopic skull base surgery (ESBS) has redefined the management of pediatric sellar and suprasellar lesions. To date, the outcomes of these procedures have not been systematically reviewed. This study performed a systematic review with meta-analysis of surgical outcomes for pediatric patients undergoing ESBS for sellar and suprasellar lesions.. PubMed (National Library of Medicine, National Institutes of Health), Scopus (Elsevier), and Cochrane Library (Wiley).. Articles reporting on pediatric patients undergoing ESBS for craniopharyngiomas, pituitary adenomas, and Rathke's cleft cysts were reviewed. The primary outcome was postoperative cerebrospinal fluid (CSF) leak. Secondary outcomes included endocrine, visual, and other complications.. Twenty-five articles reporting on 554 patients were included. Overall postoperative CSF leak rate was 8.6%, with tumor-specific rates of 10.6% in craniopharyngiomas, 6.5% in pituitary adenomas, and 7.2% in Rathke's cleft cysts (. ESBS for pediatric sellar and suprasellar lesions is overall an effective management approach with an increasingly favorable risk-benefit profile. Younger children may be more susceptible to postoperative CSF leak as compared with older pediatric patients. Tumor type does not appear to be an independent risk factor for postoperative CSF leak in this population.

Topics: Adenoma; Central Nervous System Cysts; Child; Craniopharyngioma; Humans; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms; Sella Turcica

The endoscopic endonasal approach for craniopharyngiomas is increasingly used as an alternative to microsurgical transsphenoidal or transcranial approaches. It is a step forward in treatment, providing improved resection rates and better visual outcome. Especially in retrochiasmatic tumors, this approach provides better lesion access and reduces the degree of manipulations of the optic apparatus. The panoramic view offered by endoscopy and the use of angulated optics allows the removal of lesions extending far into the third ventricle avoiding microsurgical brain splitting. Intensive training is required to perform this surgery. This article summarizes the surgical technique, outcome, and complications.

Topics: Craniopharyngioma; Humans; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Pituitary Neoplasms

The endoscope has been used in paranasal sinus surgery for many years. More recently, cooperation between neurosurgeons and ear, nose, and throat (ENT) surgeons has resulted in an extension of use of the endoscope to resection of lesions in the sella turcica region. The procedure described herein involves insertion of the endoscope and surgical instruments through one nostril to provide improved visualization of the pituitary gland and an economy of perioperative trauma. As compared with the traditional sublabial, transseptal approach, endonasal pituitary tumor resection is more direct, less traumatic, and allows excellent exposure of the tumor. These improvements result in reduced morbidity, shorter length of stay, and greater patient satisfaction.

Topics: Craniopharyngioma; Endoscopy; Humans; Neurosurgical Procedures; Nose; Perioperative Nursing; Pituitary Neoplasms; Prolactinoma

Infradiaphragmatic craniopharyngiomas (ICs) represent a distinct subtype, harboring a sellar-suprasellar origin and generally growing in the extra-arachnoidal space contained by the diaphragma sellae. They have been considered ideal for surgical removal through the transsphenoidal approach since the 1960s. The authors present a multicentric national study, intending to selectively analyze IC behavior and the impact of the transsphenoidal endoscopic endonasal approach (EEA) on surgical outcomes.. Craniopharyngiomas that were intraoperatively recognized as infradiaphragmatic and removed with standard EEA between 2000 and 2021 at 6 Italian neurosurgical departments were included in the study. Clinical, radiological, and surgical findings and outcomes were evaluated and reviewed.. In total, 84 patients were included, with 45.23% identified as pediatric cases and 39.28% as having recurrent tumors. The most common presenting symptoms were endocrine (75%), visual (59.52%), and hypothalamic (26.19%) disorders. ICs were classified as extending below (6 intrasellar and 41 occupying the suprasellar cistern) or above (26 obliterating the anterior recesses of the third ventricle and 11 extending up to the foramina of Monro) the chiasmatic cistern. Gross-total resection (GTR) was achieved in 54 cases (64.28%). Tumor extension above the chiasmatic cistern and calcifications were associated with lower likelihood of GTR. The cumulative rate of postoperative complications was 34.53%, with CSF leak being the most common (14.28%). Endocrine, visual, and hypothalamic functions deteriorated postoperatively in 41/78 patients (52.56%), 5/84 (5.95%), and 14/84 (16.67%), respectively. Twenty-eight patients (33.33%) had recurrence during follow-up (mean 63.51 months), with a mean 5-year progression-free survival (PFS) rate of 58%. PFS was greater in patients who achieved GTR than patients with other extent of resection.. This is the largest series in the literature to describe ICs removed with standard EEA, without the need for additional bone and dural opening over the planum sphenoidale. EEA provides a direct route to ICs, the opportunity to manage lesions extending up to the third ventricle without breaching the diaphragma, and high rates of GTR and satisfactory clinical outcomes. Increased surgical complexity and morbidity should be expected in patients with extensive suprasellar extension and involvement of the surrounding vital neurovascular structures.

Topics: Child; Craniopharyngioma; Humans; Neoplasm Recurrence, Local; Neuroendoscopy; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Treatment Outcome

To determine the in-hospital cost implications of an expanded endoscopic endonasal approach (EEEA) for craniopharyngioma resection relative to the traditional open transcranial approach.. All craniopharyngioma surgeries performed at a single institution over a period from January 1st 2001 to October 31th 2017 were evaluated. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables associated with each hospital stay and univariate regression analysis was performed using R software.. Thirty-six patients met study criteria, including 22 undergoing an open approach and 14 undergoing an EEEA. There was a significantly longer average length of stay among patients undergoing open resection (21.5 vs. 10.6 days, p = 0.024). The average total in-hospital cost of a patient undergoing an EEEA was $58979.3 compared to $89142.3 for an open approach (p = 0.127). On univariate regression analysis, the total in-hospital cost for a patient undergoing an open approach relative to an EEEA was $30163.0 (p = 0.127). The open approach was exclusively performed from study onset until April 2010 (16 patients). From April 2010 to August 2013, 6 open approaches and 5 EEEA were performed. The EEEA has been exclusively performed from August 2013 until the conclusion of our study period (9 patients).. There has been a shift toward surgical resection of craniopharyngioma via an EEEA approach for amenable tumors. Our study demonstrates that the EEEA has become the preferred surgical approach at our institution, and shows that the EEEA is associated with shorter postoperative length of stay and lower total in-hospital cost. Laryngoscope, 133:83-87, 2023.

Topics: Craniopharyngioma; Hospital Costs; Humans; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Retrospective Studies

Craniopharyngiomas are benign sellar lesions. Surgical excision of craniopharyngiomas is difficult because of the surrounding important neurovascular structures. The choice of surgery depends on the histological type, location, hormonal status, and size of the craniopharyngioma, surrounding neurovascular structures, and invasion of the brain parenchyma.. We describe the resection of an adamantinomatous craniopharyngioma using an extended endoscopic endonasal approach and discuss the relevant surgical anatomy, indications, limitations, and possible complications.. The extended endoscopic endonasal approach allows successful removal of the craniopharyngioma and poses little risk to surrounding neurovascular structures.

Topics: Craniopharyngioma; Endoscopy; Humans; Neuroendoscopy; Neurosurgical Procedures; Nose; Pituitary Neoplasms

Craniopharyngiomas remain surgically challenging because of the strong adhesion to vital neurovascular structures. We propose a system for the selection of surgical approaches based on the optic recess (OR) displacement pattern to facilitate surgical planning and obtain optimum visual and endocrinologic outcomes.. Craniopharyngiomas were divided into 3 types based on the OR displacement pattern: superior, anterior, and involvement types. Selected surgical approaches and patient outcome were retrospectively reviewed according to these classifications. Visual and endocrinologic outcomes were compared among the groups.. This study included 26 patients with primary craniopharyngiomas who underwent surgery at our institution, classified into 11 anterior, 11 superior, and 4 involvement types. The extended endoscopic endonasal approach provided excellent exposure inferodorsal aspect of the chiasm for manipulation of the dissection plane in the anterior and superior types with midline location. A unilateral subfrontal approach was required for tumor of the superior type with lateral extension. An interhemispheric translamina terminalis approach could provide safe dissection under direct vision of strong adhesion at the superior aspect of the chiasm in the involvement type. Visual and endocrinologic outcomes were better in the involvement type compared with the superior and anterior types. Visual outcome was significantly correlated with preoperative visual function.. Craniopharyngiomas with the involvement type are indicated for the translamina terminalis approach to achieve the best visual and endocrinologic outcome. Our classification of the OR displacement pattern is useful to select the optimal surgical approach for craniopharyngiomas more accurately and concisely, especially in cases with third ventricular extension.

Topics: Craniopharyngioma; Humans; Nose; Pituitary Neoplasms; Retrospective Studies; Third Ventricle

Craniopharyngioma is a benign but surgically challenging brain tumor. Controversies exist regarding its ideal treatment strategy, goals of surgery, efficacy of radiation, and the long-term outcomes of these decisions. The authors of this study performed a detailed analysis of factors predictive of the extent of resection and recurrence in large series of craniopharyngiomas removed via an endoscopic endonasal approach (EEA) with long-term follow-up.. From a prospective database of all EEAs done at Weill Cornell Medical College by the senior author from 2004 to 2022, a consecutive series of histologically proven craniopharyngiomas were identified. Gross-total resection (GTR) was generally the goal of surgery. Radiation was often given if GTR had not been achieved. The stalk was preserved if not infiltrated with tumor but was sacrificed to achieve GTR. Intentional subtotal resection (STR) was performed in select cases to avoid hypothalamic injury.. Among the 111 identified cases were 88 adults and 23 children. Newly diagnosed cases comprised 58.6% of the series. GTR was attempted in 77.5% of the patients and among those cases was achieved in 89.5% of treatment-naive tumors and 72.4% of recurrent tumors. An inability to achieve GTR was predicted by prior surgical treatment (OR 0.13, 95% CI 0.03-0.6, p = 0.009), tumor diameter ≥ 3.5 cm (OR 0.11, 95% CI 0.02-0.53, p = 0.006), and encasement of the optic nerve or a major artery (OR 0.11, 95% CI 0.01-0.8, p = 0.03). GTR with stalk preservation maintained some anterior pituitary function in 64.5% of cases and prevented diabetes insipidus in 25.8%. After a median follow-up of 51 months (IQR 17-80 months), the recurrence rate after GTR was 12.5% compared with 38.5% after non-GTR. The median recurrence-free survival was 5.5 years after STR, 8.3 years after near-total resection (≥ 98%), and not reached after GTR (p = 0.004, log-rank test). GTR was the strongest predictor of recurrence-free survival (OR 0.09, 95% CI 0.02-0.42, p = 0.002), whereas radiation did not show a statistically significant impact (OR 1.17, 95% CI 0.45-3.08). In GTR cases, the recurrence rate was higher if the stalk had been preserved (22.6%) as opposed to a sacrificed stalk (4.9%; OR 5.69, 95% CI 1.09-29.67).. The study data show that GTR should be the goal of surgery in craniopharyngiomas if it can be achieved safely. Although stalk preservation can maintain some endocrine function, the risk of recurrence is higher in such cases. Radiation may not be as effective as previously reported.

Topics: Adult; Child; Craniopharyngioma; Endoscopy; Humans; Neoplasm Recurrence, Local; Neuroendoscopy; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome

The endoscopic endonasal transtuberculum approach grants access to suprasellar and retrochiasmatic lesions with hypothalamic involvement. Here, we present a case of a 13-year-old boy with a history of stunted growth, decreased vision, headaches, and low energy with a tuberoinfundibular craniopharyngioma. The patient consented to the procedure.. Evaluation of the sphenoid sinus pneumatization, internal carotid artery disposition, presence of clinoidal rings, variations of the infrachiasmatic corridor (optic chiasm location, height of dorsum sella), and location of the pituitary stalk are crucial for surgical strategy.. Harvesting of nasoseptal flap and access to the sphenoid sinus; drilling the sella, tuberculum, and chiasmatic sulcus up to the limbus sphenoidalis and laterally exposing the clinoidal carotid artery segment; wide dural opening to the level of distal rings inferolaterally and falciform ligaments superolaterally; identification and coagulation of superior hypophyseal branches providing tumor supply; intracapsular dissection and debulking and subpial sharp dissection at the hypothalamic tumor interface to achieve complete removal; and reconstruction with inlay collagen, fascia lata, and nasoseptal flap.. Preservation of the superior hypophyseal arteries and stalk is essential for preventing pituitary dysfunction. Preoperative reckoning of hypothalamic invasion and identification of adequate interface aids in avoiding complications. To reduce CSF leak risk, multilayer reconstruction was performed and lumbar drain placed postoperatively.. For retroclival extension, intradural pituitary transposition should be considered to expand the corridor; in patients with preoperative hypopituitarism, pituitary sacrifice is most effective to increase retroclival access.

Topics: Adolescent; Craniopharyngioma; Humans; Male; Nose; Optic Chiasm; Pituitary Gland; Pituitary Neoplasms

The aim of this study was to report the authors' experience developing a Lean Six Sigma clinical care pathway (CCP) for endoscopic endonasal transsphenoidal operations.. Using Lean Six Sigma quality improvement principles-including the define, measure, analyze, improve, and control framework-the authors developed a CCP for endoscopic endonasal transsphenoidal operations, incorporating preoperative, intraoperative, and inpatient and outpatient postoperative phases of care. Efficacy and quality metrics were defined as postoperative length of stay (LOS), presentation to the emergency department (ED) or readmission within 30 days of discharge, and hospital charges. The study included all adult patients who underwent elective endoscopic endonasal resection for pituitary adenoma, Rathke's cleft cyst, craniopharyngioma, pituicytoma, or arachnoid cyst during the sampling period (April 1, 2018, to December 31, 2022).. Two hundred twenty-eight patients met criteria and were included; 94 were treated before and 134 were treated after implementation of the CCP. Differences between groups in age, gender, race, BMI, American Society of Anesthesiologists classification, geographic distribution, preoperative serum sodium, tumor size, adenoma functional status, and prior surgery were not significant. The mean postoperative LOS significantly decreased from 4.5 to 1.7 days following CCP implementation (p < 0.0001); LOS variability also decreased, with the standard deviation declining from 3.1 to 1.5 days. The proportion of patients discharged on postoperative day (POD) 1 significantly increased from 0% to 61.9% (p < 0.0001). Fewer than one-quarter of the patients (23.4%) were discharged by POD 2 prior to the CCP, while 88.8% of were discharged by POD 2 after CCP implementation (p < 0.0001). Rates of 30-day ED presentations or readmissions were not significantly different (2.1% vs 6.0%, p = 0.20, and 7.5% vs 6.7%, p > 0.99, respectively). Mean per-patient hospital costs declined from $38,326 to $26,289 (p < 0.0001), with an associated change in cost variability from a standard deviation of $16,716 to $12,498.. CCP implementation significantly improved LOS and costs of endoscopic endonasal resection, without adversely impacting postoperative ED presentations or readmissions.

Topics: Adenoma; Adult; Craniopharyngioma; Endoscopy; Humans; Nose; Pituitary Gland; Pituitary Neoplasms; Postoperative Complications; Quality Improvement; Retrospective Studies; Treatment Outcome

Third ventricle craniopharyngioma (TVC) refers to the tumor originating from the tuberoinfundibular, and completely located in the third ventricle; unlike most TVCs, the retrochiasmatic-infundibulum corridor is too narrow to expose the tumor with anterior extension via an endoscopic endonasal approach.. Retrospective analysis of two TVCs via an endoscopic endonasal combined pre-retrochiasmatic approach.. The tumor inside the third ventricle can be satisfactorily exposed through a combined pre-retrochiasmatic approach and be completely removed with the lowest injury of the hypothalamus and optic nerve.

Topics: Craniopharyngioma; Humans; Nose; Pituitary Neoplasms; Retrospective Studies; Third Ventricle

With relevant surrounding neurological structures and potential involvement of the hypothalamus, the surgical management of craniopharyngiomas is complex. Compared to the transcranial approach, the expanded endoscopic endonasal approach provides direct access to the supradiaphragmatic and retrochiasmatic areas without crossing nerves and arteries.. Based on our substantial experience of 68 patients operated on between 2008 and 2022 by endoscopic surgery, our strategy has evolved such that all of our midline infundibular craniopharyngiomas with hypothalamic involvement are currently treated with an expanded endonasal route, except for tumours isolated to the third ventricle. Vascularized mucosal nasoseptal flaps are required for closure. Fine details of the related anatomy and surgical technique are described.. Expanded endoscopic endonasal approach is a safe and effective route for resection of midline suprasellar craniopharyngiomas with hypothalamic involvement in centres of expertise.

Topics: Craniopharyngioma; Humans; Hypothalamus; Neuroendoscopy; Nose; Pituitary Neoplasms

In the clinical practice of neurosurgery, the endoscopic endonasal approach (EEA) has been the mainstream approach in the management of sellar region diseases. However, clinicians have come to realize that EEA procedure is associated with intraoperative hemorrhage. Due to the limited surgical field and poor proximal control under endoscope, massive hemorrhage always leads to severe complication or even perioperative death. Previously, intraoperative hemorrhage used to be attributed to endoscopic intervention of cavernous sinus or internal carotid artery, but our recent understanding of EEA indicated that preoperatively complicated intracranial aneurysms (IAs) may play a role. In this article, we retrospectively reviewed the baseline characteristics, treatment strategy, pathology, intraoperative findings, as well as radiological profiles of sellar region lesions complicated with IAs. With the focus put on the high comorbidity rate of sellar region lesions and IAs, we did further statistical analysis to sketch the outline of this coexisting circumstance and to emphasize the importance of computed tomography angiography (CTA) as routine EEA preoperative examination. Thorough patient-surgeon communication should be proceeded before the formulation of an individualized treatment strategy.

Topics: Chordoma; Computed Tomography Angiography; Craniopharyngioma; Female; Humans; Intracranial Aneurysm; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Retrospective Studies

The infrachiasmatic corridor is the most important surgical access route for craniopharyngiomas and was identified and used in clinical series. The aims of this study were to describe the characteristics that assist dissection and resection rates in endoscopic surgery of solid, cystic, and recurrent cases and their importance in the infrachiasmatic corridor in endoscopic surgery.. One hundred operations on 84 patients with pathologically identified craniopharyngioma were included in the study. The MRI findings were evaluated, and the location of the lesions was classified as (1) infrasellar; (2) sellar; or (3) suprasellar. In the sagittal plane, we measured the longest diameter of cystic and solid components and the height of chiasm-sella. Images were assessed for the extent of resection and were classified as gross total resection. This was deemed as the absence of residual tumor and subtotal resection, which had residual tumor.. The infrasellar location was reported in 7/84 (8.3%) patients, the sellar location in 8/84 (9.5%), and the suprasellar location in 69/84 (82.1%) patients. The narrow and high chiasm-sella were observed in 28/69 (40.5%) and 41/69 patients (59.4%), respectively. The mean distance of the chiasm-sella was 9.46± 3.76. Gross total tumor resection was achieved in 60/84 (71.4%) and subtotal tumor resection was performed in 24/84 (28.6%) patients. The results revealed that suprasellar location (OR: 0.068; p = 0.017) and recurrent cases (OR: 0.011; p<0.001) were negative predictive factors on GTR. Increasing the experience (OR: 42,504; p = 0.001) was a positive predictor factor for GTR.. An EETS approach that uses the infrachiasmatic corridor is required for skull base lesions extending into the suprasellar area. The infrachiasmatic corridor can determine the limitations of endoscopic craniopharyngioma surgery. This corridor is a surgical safety zone for inferior approaches.

Topics: Craniopharyngioma; Endoscopy; Humans; Neuroendoscopy; Nose; Pituitary Neoplasms; Retrospective Studies; Skull Base; Treatment Outcome

Adult craniopharyngiomas are low-grade tumors of the pituitary infundibulum that can be locally aggressive and frequently present with profound visual deficits and endocrinopathies. Surgical resection remains the preferred initial treatment for these lesions, and recently endoscopic endonasal approaches (EEAs) have become increasingly used. However, minimal data exist comparing these techniques with traditional transcranial (TC) methods. The purpose of this study was to evaluate perioperative differences in EEA and TC approaches for adult craniopharyngiomas over the past several decades.. Craniopharyngioma surgeries in the Nationwide Inpatient Sample from 1998 to 2014 were identified. Complication rates, mortality rates, and annual treatment trends were stratified by procedure. Annual caseload was assessed with linear regression, and multivariate logistic regression models were created to determine predictors of inpatient mortality and perioperative complications.. From 1998-2014, a significant increase in EEAs for craniopharyngiomas (+4.36/year, r. Over the past several decades, utilization of EEAs to resect adult craniopharyngiomas has increased. EEAs appear to be associated with lower rates of perioperative mortality and complications. However, long-term, prospective studies controlling for tumor size, location, and preoperative symptomatology are needed to determine when one approach should be used preferentially over the other.

Topics: Adult; Craniopharyngioma; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Pituitary Neoplasms; Postoperative Complications

Topics: Craniopharyngioma; Endoscopy; Humans; Nose; Pituitary Neoplasms

The efficacy of the endoscopic transcortical transventricular approach (ETTA) for craniopharyngioma in the third ventricle with hydrocephalus has been reported focusing on its reduced invasiveness. On the other hand, suprasellar craniopharyngioma without ventriculomegaly is generally surgically managed by craniotomy or the endoscopic endonasal approach (EEA). Here, we report an elderly patient who received cyst fenestration and Ommaya reservoir placement in ETTA for recurrent suprasellar cystic craniopharyngioma without ventriculomegaly. The ETTA as a less invasive procedure is feasible in patients not only with intraventricular craniopharyngioma but also with suprasellar craniopharyngioma without hydrocephalus provided a navigational system is applied and the surgeon has ample experience with transcranial endoscopic procedures.

Topics: Aged; Brain Neoplasms; Central Nervous System Cysts; Craniopharyngioma; Craniotomy; Cysts; Drug Delivery Systems; Female; Humans; Hydrocephalus; Male; Neuroendoscopy; Nose; Otologic Surgical Procedures; Pituitary Neoplasms; Prostheses and Implants; Third Ventricle

Skull base reconstruction after extended endoscopic endonasal approaches (EEAs) can be challenging. In addition to the nasoseptal flap, which has been adopted by most centers, autologous fascia lata is also often utilized. Harvesting of fascia lata requires a separate thigh incision, may prolong recovery, and results in a visible scar. In principal, the use of non-autologous materials would be preferable to avoid a second incision and maintain the minimally invasive nature of the approach, assuming the CSF leak rate is not compromised.. To assess the efficacy of acellular dermal matrix (ADM) as a non-autologous alternative to autologous fascia lata graft for watertight closure of the cranial base following EEAs.. A retrospective chart review of extended EEAs performed before and after the transition from fascia lata to ADM was performed. Cases were frequency matched for approach, pathology, BMI, use of lumbar drainage, and tumor volume. Power analysis was performed to estimate the sample size needed to demonstrate non-inferiority.. ADM was used for watertight closure of the cranial base in 19 consecutive extended endoscopic endonasal approaches (16 gasket-seals and 3 buttons) with 1 postoperative CSF leak at the last follow-up (median 5.3, range 1.0-12.6 months). All patients had high-flow intraoperative leaks. The cohort included 8 meningiomas, 8 craniopharyngiomas, 2 chordomas, and 1 pituicytoma ranging in size from 0.2 to 37.2cm. Preliminary results suggest that ADM provides a non-inferior non-autologous alternative to fascia lata for watertight gasket-seal and button closures following extended EEAs, potentially reducing or eliminating the need to harvest autologous tissue.

Topics: Acellular Dermis; Adult; Aged; Craniopharyngioma; Drainage; Fascia Lata; Female; Humans; Male; Meningeal Neoplasms; Meningioma; Middle Aged; Nose; Pituitary Neoplasms; Plastic Surgery Procedures; Retrospective Studies; Skull Base; Surgical Flaps; Treatment Outcome

Post-operative CSF leak is the major source of morbidity following endoscopic transsphenoidal surgery. The purpose of this study was to identify factors associated with post-operative CSF leak in patients undergoing this surgery and facilitate the prospective identification of patients at higher risk of this complication.. A review of a prospectively maintained database containing details of 270 endoscopic transsphenoidal operations performed by the senior author over a 9-year period was performed. Univariate analysis was performed using the Chi-squared and Fisher's exact tests, as appropriate. A logistic regression model was constructed for multivariate analysis.. The rate of post-operative CSF leak in this series was 9%. On univariate analysis, previous surgery, resection of craniopharyngiomas, adenomas causing Cushing's disease and intra-operative CSF leaks were associated with an increased risk of post-operative CSF leak. The use of a vascularised nasoseptal flap and increasing surgical experience were associated with a decreased rate of CSF leak. On multivariate analysis, a resection of tumour for Cushing's disease (OR 5.79, 95% CI 1.53-21.95, p = 0.01) and an intra-operative CSF leak (OR 4.56, 95% CI 1.56-13.32, p = 0.006) were associated with an increased risk of post-operative CSF leak. Increasing surgical experience (OR 0.14, 95% CI 0.04-0.46, p = 0.001) was strongly associated with a decreased risk of post-operative CSF leak.. Increasing surgical experience is a strong predictor of a decreased risk of developing post-operative CSF leak following endoscopic transsphenoidal surgery. Patients with Cushing's disease and those who develop an intra-operative CSF leak should be managed with meticulous skull base repair and close observation for signs of CSF leak post-operatively.

Topics: Adenoma; Adult; Cerebrospinal Fluid Leak; Craniopharyngioma; Female; Humans; Male; Middle Aged; Multivariate Analysis; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Skull Base; Skull Base Neoplasms

Surgical resection of skull base tumors in children is increasingly accomplished through an expanded endonasal approach (EEA). We aim to evaluate the potential effect of the EEA on midfacial growth as a result of iatrogenic damage to nasal growth zones.. We performed a retrospective review of children undergoing craniopharyngioma resection via an open transcranial or EEA. Pre- and postoperative magnetic resonance imaging was evaluated for growth in four midfacial measurements based on established cephalometric landmarks: anterior midface height, posterior midface height, palatal length, and sella-nasion distance. Statistical analysis was conducted using a mixed-effects linear regression model.. Twenty-two patients underwent an EEA (n = 12) or open transcranial approach (n = 10) for tumor resection with 3 years of imaging follow-up. There was no difference in midfacial growth between groups for each measurement. Compared to the open group, patients undergoing EEA demonstrated relative anterior midface height growth of -0.42 mm (P = 0.880), posterior midface height growth of -0.44 mm (P = 0.839), palatal length growth of 0.35 mm (P = 0.894), and sella-nasion distance growth of -2.16 (P = 0.365).. We found no difference in midfacial growth measurements between patients undergoing craniopharyngioma resection via an EEA and the open transcranial route after 3 years of imaging follow-up. Preliminary results on midfacial growth demonstrate that the EEA is a safe alternative to traditional transcranial approaches for the pediatric population. Further investigation with larger sample size and longer duration of follow-up is warranted to more thoroughly investigate the long-term implications of the EEA to the skull base.. 3 Laryngoscope, 130:338-342, 2020.

Topics: Adolescent; Child; Child, Preschool; Craniopharyngioma; Female; Humans; Male; Maxillofacial Development; Nose; Orthopedic Procedures; Pituitary Neoplasms; Retrospective Studies; Skull Base

To avoid deterioration of visual function, extended endoscopic endonasal transsphenoidal surgery (TSS) for craniopharyngioma was performed with visual evoked potential (VEP) monitoring using light-emitting diodes (LEDs).. The position of the optic chiasm was carefully evaluated on the preoperative midsagittal magnetic resonance (MR) images. Intraoperatively, direct and sharp dissection of the tumor from the optic chiasm was performed under VEP monitoring with LEDs through extended endoscopic endonasal TSS. If the VEP finding changed and became unstable, the operator were informed and stopped the surgical manipulation for the optic chiasm to recover. After 5-10 min, recovery of VEP findings was checked and the procedure resumed.. Extended endoscopic endonasal TSS with VEP monitoring was performed in consecutive 7 adult patients with newly diagnosed suprasellar craniopharyngiomas with maximum diameters of 25-41 mm (mean 33.7 mm). VEPs were stable throughout the surgery in 5 cases, but showed temporary instability and amplitude decrease in 2 cases, although the VEPs had recovered at the end of the surgery. Visual function, evaluated using visual impairment score, was improved after surgery in all patients. Gross total removal was achieved in 5 cases, and subtotal removal (90%) in 2 cases.. Intraoperative VEP monitoring is the only way to test visual function during surgery, and may be important and helpful in extended endoscopic endonasal TSS, which requires direct dissection between the optic nerve and craniopharyngioma under the endoscope.

Topics: Adult; Aged; Craniopharyngioma; Evoked Potentials, Visual; Female; Humans; Intraoperative Neurophysiological Monitoring; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms

Currently, due to the rarity of pathology, there are limited data surrounding outcomes of pediatric skull base surgery. Traditionally, surgeons have proceeded with caution when electing endonasal endoscopic transsellar/transplanum approaches to the skull base in pediatric patients due to poor sphenoid pneumatization. In this study, we review outcomes of endoscopic pediatric skull base surgery based on sphenoid pneumatization patterns.. Retrospective chart review.. A review of all cases of pediatric (age < 18 years) craniopharyngioma managed via an endoscopic endonasal approach at a tertiary academic medical center.. A total of 27 patients were included in the analysis. The median age was 8 years. Nineteen (70%) patients were male. Presellar, sellar/postsellar, and conchal sphenoid pneumatizations were found in 6, 11, and 10 patients, respectively. There was no significant association between sphenoid pneumatization pattern and extent of resection (gross vs. subtotal, P = .414), postoperative cerebrospinal fluid (CSF) leak (P = .450), intraoperative estimated blood loss (P = .098), total operative time (P = .540), and length of stay (P = .336). On multivariate analysis, after accounting for age, sex, preoperative cranial nerve involvement, and cavernous sinus invasion, there remained no significant association between sphenoid pneumatization pattern and extent of resection (P = .999) and postoperative CSF leak (P = .959).. Sphenoid pneumatization pattern does not appear to affect outcomes in endoscopic skull base surgery in the pediatric population. Importantly, lack of sphenoid pneumatization does not impede gross total resection or increase complications. Thorough knowledge of the anatomy during the endoscopic approach is critical to optimize outcomes.. 4 Laryngoscope, 129:832-836, 2019.

Topics: Air; Child; Craniopharyngioma; Endoscopy; Female; Humans; Male; Nose; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Skull Base; Sphenoid Bone; Treatment Outcome

Craniopharyngiomas are dysontogenic tumors with benign histology but aggressive behavior. The surgical challenges posed by the tumor are well recognized. Neuroendoscopy has recently contributed to its surgical management. This study focuses on our experience in managing craniopharyngiomas in recent years, highlighting the role of combined endoscopic trans-ventricular and endonasal approach.. Ninety-two patients have been treated for craniopharyngioma from 2000 to 2016 by the senior author. A total of 125 procedures, microsurgical (58) and endoscopic (67), were undertaken. Combined endoscopic approach was carried out in 18 of these patients, 16 children and 2 young adults. All of these patients presented with a large cystic suprasellar mass associated with hydrocephalus. In the first instance, they were treated with a transventricular endoscopic procedure to decompress the cystic component. This was followed by an endonasal transsphenoidal procedure for excision within the next 2 to 6 days. All these patients improved after the initial cyst decompression with relief of hydrocephalus while awaiting remaining tumor removal in a more elective setting. Gross total resection could be done in 84% of these patients. Diabetes insipidus was the most common postsurgical complication seen in 61% patients in the immediate period but was persistent in only two patients at 1-year follow-up. None of the children in this group developed morbid obesity. There was one case of CSF leak requiring repair after initial surgery. Peri-operative mortality was seen in one patient secondary to ventriculitis.. The patients who benefit most from the combined approach are those who present with raised intracranial pressure secondary to a large tumor with cyst causing hydrocephalus. Intraventricular endoscopic cyst drainage allows resolution of hydrocephalus with restoration of normal intracranial pressure, gives time for proper preoperative work up, and has reduced incidence of CSF leak after transnasal surgery.. Combined endoscopic approach thus gives a unique opportunity to remove these lesions more radically with less morbidity.

Topics: Adolescent; Adult; Child; Craniopharyngioma; Disease Management; Female; Humans; Magnetic Resonance Imaging; Male; Microsurgery; Neuroendoscopy; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome

Despite advances in endoscopic techniques, retrochiasmatic craniopharyngiomas (CPs) are difficult to remove completely, because the low-lying optic chiasm often provides an obstacle to an endoscopic endonasal approach. This study aimed to identify the endoscopic surgical outcomes of the retrochiasmatic CP and resolve the issues related to low-lying optic chiasm.. We reviewed 154 consecutive patients with CP who underwent endonasal endoscopic resection from February 2009 to April 2017 at 2 independent institutions. The topographic relationship of the tumor with the third ventricle, stalk, and optic chiasm and clinical outcomes were investigated.. Retrochiasmatic CPs were found in 142 of 154 patients (92.2%). The median follow-up time was 25 months. Gross total resection and near-total resection were achieved in 113 patients (79.6%) and 21 patients (13.8%), respectively. Postoperative cerebrospinal fluid leaks were found in 16 patients (11.3%). Low-lying and high-lying chiasms were found in 44 patients (31.0%) and 98 patients (69.0%), respectively. Low-lying chiasm did not affect clinical outcomes including the extent of resection. Patients with low-lying chiasm showed a marginal trend for postoperative visual deterioration. The ventricular growth pattern representing the origin of the tumor and previous surgery were significantly associated with the position of the optic chiasm (P = 0.007 and 0.001, respectively).. An endoscopic endonasal approach is an effective surgical approach for retrochiasmatic CP, even in tumors with low-lying chiasm. However, a thorough and careful dissection is necessary to prevent visual deterioration.

Topics: Adolescent; Adult; Aged; Cerebrospinal Fluid Rhinorrhea; Craniopharyngioma; Female; Humans; Imaging, Three-Dimensional; Male; Middle Aged; Neuroendoscopy; Nose; Ophthalmology; Optic Chiasm; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Statistics, Nonparametric; Tomography Scanners, X-Ray Computed; Young Adult

Topics: Craniopharyngioma; Endoscopy; Humans; Nose; Pituitary Neoplasms

OBJECTIVE The aim of this study was to analyze the outcomes of transsphenoidal surgery (TSS) in a single-center clinical series of pediatric craniopharyngioma patients treated with gross-total resection (GTR). METHODS The authors retrospectively reviewed the surgical outcomes for 65 consecutive patients with childhood craniopharyngiomas (28 girls and 37 boys, mean age 9.6 years) treated with TSS (45 primary and 20 repeat surgeries) between 1990 and 2015. Tumors were classified as subdiaphragmatic or supradiaphragmatic. Demographic and clinical characteristics, including extent of resection, complications, incidence of recurrence, pre- and postoperative visual disturbance, pituitary function, and incidence of diabetes insipidus (DI), as well as new-onset obesity, were analyzed and compared between the primary surgery and repeat surgery groups. RESULTS Of the 45 patients in the primary surgery group, 26 (58%) had subdiaphragmatic tumors and 19 had supradiaphragmatic tumors. Of the 20 patients in the repeat surgery group, 9 (45%) had subdiaphragmatic tumors and 11 had supradiaphragmatic tumors. The only statistically significant difference between the 2 surgical groups was in tumor size; tumors were larger (mean maximum diameter 30 mm) in the primary surgery group than in the repeat surgery group (25 mm) (p = 0.008). GTR was accomplished in 59 (91%) of the 65 cases; the GTR rate was higher in the primary surgery group than in the repeat surgery group (98% vs 75%, p = 0.009). Among the patients who underwent GTR, 12% experienced tumor recurrence, with a median follow-up of 7.8 years, and recurrence tended to occur less frequently in primary than in repeat surgery patients (7% vs 27%, p = 0.06). Of the 45 primary surgery patients, 80% had deteriorated pituitary function and 83% developed DI, whereas 100% of the repeat surgery patients developed these conditions. Among patients with preoperative visual disturbance, vision improved in 62% but worsened in 11%. Visual improvement was more frequent in primary than in repeat surgery patients (71% vs 47%, p < 0.001), whereas visual deterioration was less frequent following primary surgery than repeat surgery (4% vs 24%, p = 0.04). Among the 57 patients without preoperative obesity, new-onset postoperative obesity was found in 9% of primary surgery patients and 21% of repeat surgery patients (p = 0.34) despite aggressive resection, suggesting that hypothalamic dysfunction was rarely associated with GTR by TSS in this

Topics: Adolescent; Body Mass Index; Child; Child, Preschool; Craniopharyngioma; Diagnostic Techniques, Ophthalmological; Endoscopes; Female; Hormones; Humans; Infant; Magnetic Resonance Imaging; Male; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Retrospective Studies; Sphenoid Bone; Tomography Scanners, X-Ray Computed; Treatment Outcome

Radiation therapy is often advocated for residual or recurrent craniopharyngioma following surgical resection to prevent local recurrence. However, radiation therapy is not always effective and may render tumors more difficult to remove. If this is the case, patients may benefit more from reoperation if gross total resection can be achieved. Nevertheless, there is little data on the impact of radiation on reoperations for craniopharyngioma. In this study, we sought to analyze whether a history of previous radiation therapy (RT) affected extent of resection in patients with recurrent craniopharyngiomas subsequently treated with reoperation via endoscopic endonasal approach (EEA).. The authors reviewed a prospectively acquired database of EEA reoperations of craniopharyngiomas over 13 years at Weill Cornell, NewYork-Presbyterian Hospital. All procedures were performed by the senior author. The operations were separated into two groups based on whether the patient had surgery alone (group A) or surgery and RT (group B) prior to recurrence.. A total of 24 patients (16 male, 8 female) who underwent surgery for recurrent craniopharyngioma were identified. The average time to recurrence was 7.64 ± 4.34 months (range 3-16 months) for group A and 16.62 ± 12.1 months (range 6-45 months) for group B (p < 0.05). The average tumor size at recurrence was smaller in group A (1.85 ± 0.72 cm; range 0.5-3.2) than group B (2.59 ± 0.91 cm; range 1.5-4.6; p = 0.00017). Gross total resection (GTR) was achieved in 91% (10/11) of patients in group A and 54% (7/13) of patients in group B (p = 0.047). There was a near significant trend for higher average Karnofsky performance status (KPS) score at last follow-up for group A (83 ± 10.6) compared with group B (70 ± 16.3, p = 0.056).. While RT for residual or recurrent craniopharyngioma may delay time to recurrence, ability to achieve GTR with additional surgery is reduced. In the case of recurrent craniopharyngioma, if GTR can be achieved, consideration should be given to endonasal reoperation prior to the decision to irradiate residual or recurrent tumor.

Topics: Adult; Aged; Craniopharyngioma; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neoplasm Recurrence, Local; Neuroendoscopy; Nose; Pituitary Neoplasms; Postoperative Complications

This study aimed to report the authors' single-center clinical experience about craniopharyngiomas and discuss surgical outcomes of these patients according to the type of surgical approach (endoscopic endonasal or open microscopic transcranial approach).Twenty-four patients diagnosed with craniopharyngiomas between May 2013 and April 2017 were considered for inclusion. The patients were divided into 2 groups according to the surgical approach (open transcranial microscopic approach [group A] and endoscopic endonasal approach [group B]). These groups were compared in terms of postoperative surgical outcome scores (extent of tumor removal, visual deficit, hydrocephalus, metabolic disorders, and Glasgow coma scale) and hospitalization interval.There was no patient of mortality in both groups. In this study, 4 of the 13 patients in group A and 9 of the 11 patients in group B underwent gross total resection. However, 1 patient in group B underwent repair because of cerebrospinal fluid leakage postoperatively. In addition, 1 patient in group A had a wound healing problem postoperatively. The postoperative outcome scores were 9.5 in group A and 11.5 in group B. The hospitalization interval in group A (range, 7-9 days) was longer than that in group B (range, 5-7 days).The endoscopic endonasal approach should be considered the first-line surgical treatment modality in patients with a preliminary diagnosis of craniopharyngioma in terms of low complication risk, minimal invasiveness, and better outcome scores. Open microscopic transcranial procedures may be combined with this approach in a single session for challenging cases.

Topics: Adolescent; Adult; Aged; Child; Craniopharyngioma; Craniotomy; Female; Humans; Male; Microsurgery; Middle Aged; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Period; Tomography, X-Ray Computed; Treatment Outcome; Young Adult

The endoscopic endonasal approach is considered an alternative minimally invasive approach for suprasellar craniopharyngiomas. However, the complicated surgical manipulations required by this approach have limited its application. We evaluate whether the approach features a learning curve. Thirty-three patients were retrospectively reviewed and grouped as early (17 patients) and late (16 patient) groups. The operation time, extent of removal, ophthalmology, endocrinology, reconstruction and modifications of standard technique were evaluated. Between the two groups, the operation time decreased from 201.1±105.3min in the early group to 107.6±90.0min in the late group (p<0.05). Regarding clinical outcomes, non-significantly increasing trends toward the rate of gross total resection, visual improvement and (from 76.5% to 87.5%, 73.3% to 93.3%), significantly decreasing trends toward the rate of tumor recurrence (from 23.5% to 0% p<0.05) and non-significantly decreasing trends toward the rate of hypopituitarism recovery (26.7% to 0%) were observed between the two groups. With respect to complications, non-statistically significant decreasing trends toward transient cranial nerve paralysis (from 5.9% to 0%) and non-statistically significant increasing trends toward rate of CSF leakage, meningitis and new hypothyroidism (from 11.8% to 25%, 11.8% to 31.3%, 0 to 3%) were observed. We identified a learning curve for the endoscopic endonasal approach for suprasellar craniopharyngiomas. The exact number of patients necessary to establish a significant improvement in the clinical outcomes and decrease in the complications warrants further investigation. The outcomes of tumor recurrence may be associated with duration of follow-up. The CSF leakage represented the most common complication.

Topics: Adult; Aged; Cerebrospinal Fluid Rhinorrhea; Craniopharyngioma; Female; Humans; Learning Curve; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Nose; Pituitary Neoplasms; Postoperative Complications

Endoscopic endonasal approaches (EEAs) constitute a reasonable option for the treatment of lesions that involve the sellar and clival regions.. We describe, step by step, the full EEA expanded to the middle and lower clivus for the treatment of perisellar lesions. Delimiting different modules around the sellar region is useful in establishing the best endoscopic approach for each tumor. A craniopharyngioma (CP) with clival extension will be used as an illustrative example of the modularity concept of these approaches.. Transsellar-transclival EEA allows complete resection of lesions located in the sellar and infrasellar region with a low rate of complications.

Topics: Cranial Fossa, Posterior; Craniopharyngioma; Endoscopy; Humans; Neurosurgical Procedures; Nose; Skull Base Neoplasms; Surgery, Computer-Assisted

The evolution of skull base surgery over the past decade has been influenced by advancement in visualization technology. Recently, as a result of such improvements, three-dimensional (3-D) scopes have been widely used during endoscopic endonasal approaches. In the present study, we describe the use of 3-D stereoscopic endoscope for the treatment of a variety of skull base lesions.. From January 2010 to June 2015, a 3-D endoscopic endonasal approach (4 and 4.9 mm, 0°, and 30° rigid endoscopes) was performed in 70 patients with the following lesions: 42 large extrasellar pituitary macroadenomas, seven tuberculum sellae meningiomas, seven clivus chordomas, five craniopharyngiomas, three fibrous dysplasia of the clivus, three sinonasal malignancies, one orbital lymphangioma, one trigeminal neurinoma, one primary suprasellar lymphoma.. Total tumor removal was obtained in 50 patients (71.4 %) while in 14 (20 %), subtotal removal was possible in six (8.6 %) only partial removal was achieved. Overall complications included diabetes insipidus in eight patients (11.4 %), hypopituitarism in seven patients (10 %), CSF leak in five patients (7.1 %), cranial nerve injury in two patients (2.8 %), panhypopituitarism in two patients (2.8 %), meningitis in one (1.4 %) and one postoperative central retinal artery occlusion (1.4 %). There was no mortality in the series. The mean follow-up time was 39 months (range, 6-72 months).. In our experience, the 3-D endoscope represents a critical development in visualization, thus enabling improved hand-eye coordination and depth perception, which are mandatory for the management of complex intradural neurovascular structures during tumor removal surgery.

Topics: Adolescent; Adult; Aged; Craniopharyngioma; Female; Humans; Male; Meningeal Neoplasms; Meningioma; Middle Aged; Natural Orifice Endoscopic Surgery; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Skull Base Neoplasms

The collection of the greatest possible amount of pathologic tissue is of paramount importance in neurosurgery to achieve the most accurate histopathologic diagnosis, to perform all of the necessary biomolecular tests on the pathologic specimen, and to collect biological material for basic or translational science studies. This problem is particularly relevant in pituitary surgery because of the possible small size and soft consistency of tumors, which make them suitable for removal through suction, reducing the amount of available pathologic tissue. To solve this issue, we adopted a filter connected to the suction tube, which allows the surgeon to collect all of the tissue aspirated during surgery.. Our experience of 1734 endoscopic endonasal procedures, performed adopting this device since 1998 to December 2015, has been revised to assess its advantages and limitations.. This system is easy-to-use, does not impair the surgical maneuvers, and does not add any relevant cost to the surgery. The tissue collected through the filter proved useful for diagnostic histologic and biomolecular analyses and for research purposes, without any relevant artifacts as a result of this method of collection.. The use of a filter has allowed us to obtain the greatest amount possible of pathologic tissue at each surgery. This surgical material has revealed to be helpful both for diagnostic and basic science purposes. The use of the filter has proven to be of particular importance for microadenomas, soft tumors, and supradiaphragmatic or skull base lesions with heterogeneous features, improving the accuracy of histopathologic diagnosis.

Topics: Adenoma; Central Nervous System Cysts; Central Nervous System Neoplasms; Chondrosarcoma; Chordoma; Cranial Fossa, Posterior; Craniopharyngioma; Glioma; Humans; Hypothalamic Neoplasms; Meningeal Neoplasms; Meningioma; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Nose; Pituitary Neoplasms; Plasmacytoma; Retrospective Studies; Skull Base Neoplasms; Suction

To assess the efficacy of the combined use of a gasket seal closure and a vascularized pedicle nasoseptal flap (VP-NSF) multilayered reconstruction technique for high-flow cerebrospinal fluid (CSF) leaks resulting from endonasal endoscopic skull base surgery.. From October 2009-June 2011, a VP-NSF multilayered reconstruction technique was used (single technique group) for patients with intraoperative high-flow CSF leaks; from July 2011-February 2013, a combination of a gasket seal closure and a VP-NSF multilayered reconstruction technique was used (combined technique group). A lumbar drain was placed after the operation. The rates of postoperative CSF leaks and repair-related complications in the 2 groups were analyzed.. The single technique group comprised 18 patients with a mean follow-up of 31.7 months; there were 5 postoperative CSF leaks (27.7%). The combined technique group comprised 15 patients with a mean follow-up of 13.6 months; no CSF leaks occurred (P < 0.05). The rate of intracranial infection in the single technique group was significantly higher than in the combined technique group.. The combined use of a gasket seal closure and a VP-NSF multilayered reconstruction technique for high-flow CSF leaks after endonasal endoscopic skull base surgery may significantly reduce the rates of postoperative CSF leaks and intracranial infections. Lumbar drainage after the operation is a necessary auxiliary method.

Topics: Adult; Aged; Cerebrospinal Fluid Leak; Craniopharyngioma; Drainage; Female; Follow-Up Studies; Humans; Lumbosacral Region; Magnetic Resonance Imaging; Male; Middle Aged; Nasal Septum; Neuroendoscopy; Nose; Pituitary Neoplasms; Plastic Surgery Procedures; Retrospective Studies; Skull Base; Surgical Flaps; Treatment Outcome; Wound Closure Techniques

The translamina terminalis corridor was used in the transcranial anterior route to treat third ventricular craniopharyngioma (TVC), which presents a challenge to neurosurgeons. The endoscopic endonasal approach (EEA) has recently been used to treat craniopharyngiomas. However, there are few reports of the EEA being used to treat TVC. The authors' novel surgical approach of treating selected TVC by the endoscopic endonasal route via the suprachiasmatic translamina terminalis (STLT) corridor is described.. In this single-center study, the EEA via the STLT corridor was used to resect TVC with great upper and anterior extension causing bulged lamina terminalis, and TVC with a residual upper compartment, after routine infrachiasmatic transmetastalk corridor resection.. The STLT corridor was used in 3 patients. Gross-total resection was achieved in all cases. One patient achieved visual improvement, and the other 2 patients showed partial visual improvement. Leakage of CSF occurred in 1 patient. Postoperative hormone replacement therapy was required in all patients.. The STLT corridor is a complementary minimally invasive corridor used in the EEA for treating selected TVC. The STLT alone or combined with infrachiasmatic transmetastalk corridors should be selected depending on the size of suprachiasmatic and infrachiasmatic space.

Topics: Adult; Brain Neoplasms; Craniopharyngioma; Female; Humans; Male; Neuroendoscopy; Nose; Third Ventricle

To determine the pediatric age groups viable for nasoseptal flap (NSF) reconstruction of endoscopic endonasal approaches (EEA) to intracranial pathology of suprasella neoplasms.. Retrospective cohort study.. Retrospective review of 16 pediatric patients who underwent EEA with NSF reconstruction for a suprasellar defect from 2012 to 2014. Radioanatomic analysis was utilized to assess feasibility of NSF reconstruction of suprasellar neoplasms approached via EEA. Computed tomography (CT) measurements for defect size and potential flap coverage were measured by preoperative maxillofacial CT. Radiographic measurements and surgical outcomes were compared to determine if flap size would be sufficient to cover said defects in two pediatric age groups: those>10 years of age (mean age 14 years) and those<10 years (mean age 6 years).. Of all patients encountered in this cohort, one postoperative cerebrospinal fluid leak was identified in the >10 years of age population, and this was not due to insufficient flap coverage. Average potential flap length and width are sufficient to cover average suprasellar defect length and width in both age groups (P<.05 in all age groups).. Patient selection is critical for successful pediatric EEA. Preoperative radiographic assessment of NSF feasibility is a critical to ensure adequate flap coverage for suprasellar defects. NSF appears to provide a sufficient and reliable coverage option in reconstruction of suprasellar defects in pediatric patients.. 4.

Topics: Adolescent; Cerebrospinal Fluid Leak; Child; Cohort Studies; Craniopharyngioma; Endoscopy; Humans; Nasal Septum; Nose; Pituitary Neoplasms; Plastic Surgery Procedures; Postoperative Complications; Retrospective Studies; Skull Base Neoplasms; Surgical Flaps; Tomography, X-Ray Computed

To analyze the clinical and imaging characteristics of patients with cystic lesions in sella region and to describe the experience of endoscopic transsphenoidal surgery.. Fourty-six cases of cystic lesions in sella region confirmed by surgery and pathology between June 2003 and September 2013 were retrospectively analysed. The clinical features, imaging, surgical technique and postoperative recurrence in 46 cases were presented.. All lesions were resected through transsphenoidal endoscopic endonasal approach. Followed up lasted from 6 months to 6 years. Postoperatively, headache was recovered in 26 cases and wasn't recovered in 8 cases, visual was improved in 12 cases and wasn't improved in 2 cases, hypopituitarism was relieved in 18 cases and wasn't relieved in 15 cases, polyuria was disappeared in 8 cases and wasn't disappeared in 4 cases. Seven cases recurred, including 4 cases of craniopharyngioma, 2 cases of pituitary abscess, 1 case of cystic adenoma. There were no death and serious complication. The small age of onset, visual acuity and visual field symptoms, tumor in suprasellar, third ventricle compression was easy to occur in craniopharyngioma; cystic tumor, cavernous sinus invasion, the solid part homogeneous enhancement could be seen in cystic adenoma; Rathke cyst showed simple cystic, lighter clinical symptoms and a short course. Prone to diabetes insipidus, low multiple hormone level and the lesions of annular enhancement was more common in pituitary abscess.. The clinical features and imaging of cystic lesions in sella region feature overlap each other, but there are certain specificity. Transsphenoidal endoscopic endonasal approach for the surgery of cystic lesions in sella is effective and safe.

Topics: Abscess; Adenoma; Craniopharyngioma; Cysts; Endoscopy; Headache; Humans; Hypopituitarism; Neoplasm Recurrence, Local; Nose; Pituitary Diseases; Pituitary Neoplasms; Retrospective Studies; Sella Turcica

Despite their benign histological appearance, craniopharyngiomas can be considered a challenge for the neurosurgeon and a possible source of poor prognosis for the patient. With the widespread use of the endoscope in endonasal surgery, this route has been proposed over the past decade as an alternative technique for the removal of craniopharyngiomas.. The authors retrospectively analyzed data from a series of 103 patients who underwent the endoscopic endonasal approach at two institutions (Division of Neurosurgery of the Università degli Studi di Napoli Federico II, Naples, Italy, and Division of Neurosurgery of the Bellaria Hospital, Bologna, Italy), between January 1997 and December 2012, for the removal of infra- and/or supradiaphragmatic craniopharyngiomas. Twenty-nine patients (28.2%) had previously been surgically treated.. The authors achieved overall gross-total removal in 68.9% of the cases: 78.9% in purely infradiaphragmatic lesions and 66.3% in lesions involving the supradiaphragmatic space. Among lesions previously treated surgically, the gross-total removal rate was 62.1%. The overall improvement rate in visual disturbances was 74.7%, whereas worsening occurred in 2.5%. No new postoperative defect was noted. Worsening of the anterior pituitary function was reported in 46.2% of patients overall, and there were 38 new cases (48.1% of 79) of postoperative diabetes insipidus. The most common complication was postoperative CSF leakage; the overall rate was 14.6%, and it diminished to 4% in the last 25 procedures, thanks to improvement in reconstruction techniques. The mortality rate was 1.9%, with a mean follow-up duration of 48 months (range 3-246 months).. The endoscopic endonasal approach has become a valid surgical technique for the management of craniopharyngiomas. It provides an excellent corridor to infra- and supradiaphragmatic midline craniopharyngiomas, including the management of lesions extending into the third ventricle chamber. Even though indications for this approach are rigorously lesion based, the data in this study confirm its effectiveness in a large patient series.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cerebrospinal Fluid Rhinorrhea; Child; Child, Preschool; Craniopharyngioma; Female; Humans; Male; Middle Aged; Natural Orifice Endoscopic Surgery; Neuroendoscopy; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Retrospective Studies; Treatment Outcome; Young Adult

The aim of this study was to evaluate the effectiveness of the extended endoscopic endonasal transsphenoidal approach (TSA) for recurrent or residual craniopharyngiomas, focusing on the extent of tumor resection and complications resulting from surgery at a single institution.. Twelve adult patients (six men and six women) underwent extended endoscopic endonasal TSA for a recurrent or residual craniopharyngioma after a previous surgical intervention at a single institution by a single surgeon. The mean number of surgeries patients had undergone before TSA was 1.3 (range, 1-3). The mean period between patients' most recent surgery and extended TSA was 55.9 months (range, 1-184). The mean preoperative (that is, pre-extended TSA) tumor volume was 2.87 cm³. The mean follow-up period was 15.8 months (range, 4-32). We reviewed clinical and radiological features in each case, focusing on the degree of tumor resection as well as endocrinological and ophthalmological outcomes.. Gross total resection was achieved in ten patients (83.3 %), and the mean resection rate was 87 % in the other two cases. There were no significant differences between pre- and postoperative endocrine function, except in one patient who suffered postoperative panhypopituitarism resulting in pituitary stalk resection, which was necessary because of obvious tumor involvement. Three patients suffered transient diabetic insipidus (DI). With respect to ophthalmological outcomes, three patients showed improvement, two others showed decline, and the remainder showed no significant changes.. The extended endoscopic endonasal transsphenoidal approach is an effective and safe surgical approach for treating recurrent or residual craniopharyngioma.

Topics: Adult; Craniopharyngioma; Female; Humans; Hypopituitarism; Male; Middle Aged; Neuroendoscopy; Neurosurgical Procedures; Nose; Pituitary Gland; Pituitary Neoplasms; Postoperative Period; Recurrence; Treatment Outcome; Tumor Burden

The interpeduncular cistern, including the retrochiasmatic area, is one of the most challenging regions to approach surgically. Various conventional approaches to this region have been described; however, only the endoscopic endonasal approach via the dorsum sellae and the transpetrosal approach provide ideal exposure with a caudal-cranial view. The authors compared these 2 approaches to clarify their limitations and intrinsic advantages for access to the interpeduncular cistern.. Four fresh cadaver heads were studied. An endoscopic endonasal approach via the dorsum sellae with pituitary transposition was performed to expose the interpeduncular cistern. A transpetrosal approach was performed bilaterally, combining a retrolabyrinthine presigmoid and a subtemporal transtentorium approach. Water balloons were used to simulate space-occupying lesions. "Water balloon tumors" (WBTs), inflated to 2 different volumes (0.5 and 1.0 ml), were placed in the interpeduncular cistern to compare visualization using the 2 approaches. The distances between cranial nerve (CN) III and the posterior communicating artery (PCoA) and between CN III and the edge of the tentorium were measured through a transpetrosal approach to determine the width of surgical corridors using 0- to 6-ml WBTs in the interpeduncular cistern (n = 8).. Both approaches provided adequate exposure of the interpeduncular cistern. The endoscopic endonasal approach yielded a good visualization of both CN III and the PCoA when a WBT was in the interpeduncular cistern. Visualization of the contralateral anatomical structures was impaired in the transpetrosal approach. The surgical corridor to the interpeduncular cistern via the transpetrosal approach was narrow when the WBT volume was small, but its width increased as the WBT volume increased. There was a statistically significant increase in the maximum distance between CN III and the PCoA (p = 0.047) and between CN III and the tentorium (p = 0.029) when the WBT volume was 6 ml.. Both approaches are valid surgical options for retrochiasmatic lesions such as craniopharyngiomas. The endoscopic endonasal approach via the dorsum sellae provides a direct and wide exposure of the interpeduncular cistern with negligible neurovascular manipulation. The transpetrosal approach also allows direct access to the interpeduncular cistern without pituitary manipulation; however, the surgical corridor is narrow due to the surrounding neurovascular structures and affords poor contralateral visibility. Conversely, in the presence of large or giant tumors in the interpeduncular cistern, which widen the spaces between neurovascular structures, the transpetrosal approach becomes a superior route, whereas the endoscopic endonasal approach may provide limited freedom of movement in the lateral extension.

Topics: Craniopharyngioma; Humans; Interpeduncular Nucleus; Nose; Pituitary Neoplasms; Sella Turcica

The proximity of craniopharyngiomas to vital neurovascular structures and their high recurrence rates make them one of the most challenging and controversial management dilemmas in neurosurgery. Endoscopic endonasal surgery (EES) has recently been introduced as a treatment option for both pediatric and adult craniopharyngiomas. The object of the present study was to present the results of EES and analyze outcome in both the pediatric and the adult age groups.. The authors retrospectively reviewed the records of patients with craniopharyngioma who had undergone EES in the period from June 1999 to April 2011.. Sixty-four patients, 47 adults and 17 children, were eligible for this study. Forty-seven patients had presented with primary craniopharyngiomas and 17 with recurrent tumors. The mean age in the adult group was 51 years (range 28-82 years); in the pediatric group, 9 years (range 4-18 years). Overall, the gross-total resection rate was 37.5% (24 patients); near-total resection (> 95% of tumor removed) was 34.4% (22 patients); subtotal resection (≥ 80% of tumor removed) 21.9% (14 patients); and partial resection (< 80% of tumor removed) 6.2% (4 patients). In 9 patients, EES had been combined with radiation therapy (with radiosurgery in 6 cases) as the initial treatment. Among the 40 patients (62.5%) who had presented with pituitary insufficiency, pituitary function remained unchanged in 19 (47.5%), improved or normalized in 8 (20%), and worsened in 13 (32.5%). In the 24 patients who had presented with normal pituitary function, new pituitary deficit occurred in 14 (58.3%). Nineteen patients (29.7%) suffered from diabetes insipidus at presentation, and the condition developed in 21 patients (46.7%) after treatment. Forty-four patients (68.8%) had presented with impaired vision. In 38 (86.4%) of them, vision improved or even normalized after surgery; in 5, it remained unchanged; and in 1, it temporarily worsened. One patient without preoperative visual problems showed temporary visual deterioration after treatment. Permanent visual deterioration occurred in no one after surgery. The mean follow-up was 38 months (range 1-135 months). Tumor recurrence after EES was discovered in 22 patients (34.4%) and was treated with repeat surgery (6 patients), radiosurgery (1 patient), combined repeat surgery and radiation therapy (8 patients), interferon (1 patient), or observation (6 patients). Surgical complications included 15 cases (23.4%) with CSF leakage that was treated with surgical reexploration (13 patients) and/or lumbar drain placement (9 patients). This leak rate was decreased to 10.6% in recent years after the introduction of the vascularized nasoseptal flap. Five cases (7.8%) of meningitis were found and treated with antibiotics without further complications. Postoperative hydrocephalus occurred in 7 patients (12.7%) and was treated with ventriculoperitoneal shunt placement. Five patients experienced transient cranial nerve palsies. There was no operative mortality.. With the goal of gross-total or maximum possible safe resection, EES can be used for the treatment of every craniopharyngioma, regardless of its location, size, and extension (excluding purely intraventricular tumors), and can provide acceptable results comparable to those for traditional craniotomies. Endoscopic endonasal surgery is not limited to adults and actually shows higher resection rates in the pediatric population.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Child, Preschool; Combined Modality Therapy; Craniopharyngioma; Endoscopy; Female; Follow-Up Studies; Humans; Male; Middle Aged; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Postoperative Complications; Radiosurgery; Retrospective Studies; Treatment Outcome

Topics: Cranial Fossa, Anterior; Craniopharyngioma; History, 20th Century; History, 21st Century; Humans; Meningioma; Neuroendoscopy; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Skull Base; Skull Base Neoplasms; Sphenoid Bone

Retrochiasmatic craniopharyngiomas are formidable cranial base tumors to resect because of their intimate relationship with neighboring critical neurovascular structures, particularly the undersurface of the optic chiasm and hypothalamus. Radical resection offers the best chance of minimizing tumor recurrence, although this may be associated with significant surgical morbidity. Although various transcranial approaches have been utilized (transbasal subfrontal, frontobasal interhemispheric, pterional, orbitozygomatic, and petrosal) for resection of retrochiasmatic craniopharyngiomas, each is associated with some degree of brain retraction, and direct visualization of the retrochiasmatic region is often incomplete, therefore resulting in blind dissection. The endoscopic endonasal transplanum transtuberculum approach provides the most direct route to the retrochiasmatic region while affording unmatched visualization of the undersurface of the optic chiasm, third ventricle, and hypothalamus. This advantage allows for direct bimanual tumor dissection off of these critical structures by using microsurgical principles. The endonasal route also has the advantage of avoiding brain retraction and risk of cerebral edema that can be associated with transcranial approaches. In this operative video atlas report, the authors demonstrate their step-by-step techniques for resection of a suprasellar retrochiasmatic craniopharyngioma using a purely endoscopic endonasal transplanum transtuberculum approach. They describe and illustrate the operative nuances and surgical pearls to safely and efficiently perform the approach, tumor resection, and multilayered reconstruction of the cranial base defect. The video can be found here: http://youtu.be/ZIbJvAyRxYU.

Topics: Craniopharyngioma; Humans; Microsurgery; Neuroendoscopy; Nose; Skull Base Neoplasms

Accessing intra- and extradural tumors via an endonasal approach requires working safely in a relatively narrow area with unobstructed visibility. The authors describe their experience to highlight the utility of a side-cutting aspiration device for endoscopic endonasal resection of skull base tumors.. The authors used this device in 13 nonconsecutive endoscopic endonasal procedures for different skull base tumors (8 pituitary macroadenomas, 2 craniopharyngiomas, 1 chordoma, 1 recurrent ependymoma, and 1 lymphoma). Illustrative cases and video are presented to demonstrate its use.. The instrument was easy to use and effective in the removal of the lesions presented in this series. In 10 patients (77%), gross-total resection was possible; in the other 3 patients (23%), more than 80% of the tumor was resected. No collateral tissue damage or any other complication resulted from device-related debulking or aspiration.. The side-cutting tissue resector is a safe, easy to use, and effective tool for internal debulking and extracapsular dissection of nonvascularized tumors that are too firm for bimanual suction or blunt ring curette dissection. It is particularly useful when working through a deep and narrow corridor such as is encountered in endoscopic endonasal skull base surgery.

Topics: Adenoma; Aged; Craniopharyngioma; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Neuroendoscopy; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Sphenoid Bone

Retrochiasmatic craniopharyngiomas are challenging tumors to remove given their deep location and proximity to critical neurovascular structures. Complete surgical removal offers the best chance of cure and prevention of recurrence. The endoscopic endonasal extended transsphenoidal approach offers direct midline access to the retrochiasmatic space through a transplanum transtuberculum corridor. Excellent visualization of the undersurface of the optic chiasm and hypothalamus can be obtained to facilitate bimanual extracapsular dissection to permit complete removal of these formidable tumors. In this report the authors review the endoscopic endonasal extended transsphenoidal approach, with specific emphasis on technical operative nuances in removing retrochiasmatic craniopharyngiomas. An illustrative intraoperative video demonstrating the technique is also presented.

Topics: Craniopharyngioma; Endoscopy; Female; Humans; Hypophysectomy; Magnetic Resonance Imaging; Middle Aged; Nose; Optic Chiasm; Pituitary Neoplasms; Sphenoid Sinus

The endoscopic endonasal transsphenoidal approach (EETA) to the pituitary is performed by ear, nose, and throat (ENT) surgeons in collaboration with neurosurgeons but also by neurosurgeons alone even though neurosurgeons have not been trained in rhinological surgery.. To register the frequency of endonasal anatomical variations and to evaluate whether these variations hinder the progress of EETA and require extra rhinological surgical skills.. A prospective cohort study of 185 consecutive patients receiving an EETA through a binostril approach was performed. All anatomical endonasal variations were noted and the relevance for the progress of surgery evaluated.. In 48% of patients, anatomical variations were recognized, the majority of which were spinae septi and septum deviations. In 5% of patients, the planned binostril approach had to be converted into a mononostril approach; whereas in 18% of patients with an anatomical variation, a correction had to be performed. There was no difference between the ENT surgeon and the neurosurgeon performing the approach. Complications related to the endonasal phase of the surgery occurred in 3.8%. Fluoroscopy or electromagnetic navigation has been used during 6.5% of the surgeries.. Although endonasal anatomical variations are frequent, they do not pose a relevant obstacle for EETA.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Central Nervous System Cysts; Child; Cohort Studies; Craniopharyngioma; Endoscopy; Female; Humans; Male; Middle Aged; Nasal Septum; Neuroendoscopes; Neuronavigation; Nose; Pituitary Diseases; Pituitary Neoplasms; Prospective Studies; Sphenoid Sinus; Tomography, X-Ray Computed; Young Adult

To assess the feasibility of passive marker computer-aided surgery in a single institution, we performed 22 procedures in 21 patients with disorders including sinonasal tumors (n = 9), fungal sinusitis (n = 4), recurrent polyps (n = 3), chronic sinusitis (n = 3), and cerebrospinal fluid rhinorrhea (n = 2). Passive marker computer-aided surgery was successful in 19 of the 21 patients. The accuracy was on the order of 1.35 mm. Probe conversion, rotation, and cordlessness were helpful in all 19 cases. The system helped with landmarks (n = 14), margins (n = 7), skull base (n = 6), orbit (n = 5), and approach (n = 4). Computer-aided surgery accurately confirmed the location of an instrument and demonstrated tumor-normal tissue interfaces. It aided the surgeon in procedures on the sinonasal area and cranial base. The potential advantages of a passive marker system as compared with other available technologies center around the ability to convert and/or rotate virtually any instrument to a cordless imaging probe on demand during the operation.

Topics: Angiofibroma; Cerebrospinal Fluid Otorrhea; Cerebrospinal Fluid Rhinorrhea; Craniopharyngioma; Endoscopy; Humans; Magnetic Resonance Imaging; Meningeal Neoplasms; Meningioma; Nasopharyngeal Neoplasms; Nose; Otorhinolaryngologic Surgical Procedures; Paranasal Sinuses; Pituitary Neoplasms; Safety; Sinusitis; Skull Base; Surgery, Computer-Assisted; Tomography, X-Ray Computed

Submucosal dissection of the nasal septum is often performed as part of the transseptal approach to the sella. To evaluate whether this submucosal dissection is a necessary component of this operation, we compared the morbidity of a direct transmucosal endonasal approach to that of the transseptal approach in patients undergoing pituitary surgery.. Forty-one consecutive patients undergoing pituitary surgery from January 1996 to March 1999 were included in this study. The first 21 patients underwent the standard transseptal operation through either a sublabial or columellar incision. The latter 20 patients were operated on through an endoscopically guided, direct endonasal exposure, without any submucosal dissection of the nasal septum. The operative morbidity, the duration of surgery, and the length of hospitalization for each group were compared.. The sphenoid sinus exposure obtained through the endonasal route was comparable with the transseptal approach and was adequate for resection of most pituitary tumors. Although the morbidity of the two approaches was similar, patients undergoing the endonasal operation had less postoperative facial pain. Furthermore, the endonasal approach significantly decreased the length of the operation (116 minutes vs. 161 minutes, p = 0.002) and the duration of hospitalization (3.6 vs. 5.1 days, p = 0.003) as compared with the transseptal route.. Morbidity of the endonasal approach to the sphenoid sinus is comparable to that of a conventional transseptal approach. By eliminating the submucosal dissection, the endonasal approach reduces postoperative facial discomfort and decreases length of surgery and hospitalization.

Topics: Adenoma; Adult; Carcinoma, Renal Cell; Central Nervous System Cysts; Craniopharyngioma; Endoscopy; Female; Fibrosis; Germinoma; Humans; Male; Middle Aged; Neurosurgical Procedures; Nose; Pituitary Neoplasms; Treatment Outcome

The direct transnasal transsphenoidal approach to the pituitary fossa has been used in our unit since 1987. We describe the procedure and report its use in 48 patients with pituitary lesions. Successful access to the pituitary fossa was made in 46 out of 50 operations (92%). In two cases, repeat transnasal exploration was successfully performed for recurrent tumour 3 and 5 years following an initial trans-nasal exploration. This approach is straightforward, quick and does not require dissection of nasal mucosa or removal of septal cartilage. There was a 5.8% rate of major post-operative complications, and this compares favourably with other routes of access to the pituitary fossa. No long-term nasal, septal or dental complications have occurred, such as may happen with the other routes to the sphenoid sinus and pituitary fossa.

Topics: Adenoma; Adolescent; Adult; Aged; Child; Craniopharyngioma; Craniotomy; Female; Follow-Up Studies; Histiocytic Sarcoma; Humans; Male; Middle Aged; Neoplasm Recurrence, Local; Nose; Pituitary Diseases; Pituitary Neoplasms; Postoperative Complications; Retrospective Studies; Sphenoid Sinus

The results of transnasal-transsphenoidal surgery in 31 patients with craniopharyngioma are evaluated. To assess the value of transnasal surgery in cases with visual impairment, the results are compared to cases operated transcranially. There was only one death occurred on the 5th postoperative day. Two patients developed rhinoliquorrhoea, and one a transient oculomotor palsy. Recurrences leading to re-operation occurred frequently after mere cyst aspiration and only once after subtotal tumour removal. Normal glandotrope functions of the hypophysis were preserved in 75%, disturbed functions were normalized in 19% of primary transnasal surgery. Visual disturbances were normalized or improved in 94% cases after transnasal surgery, whereas an improvement was observed in only 65% after transcranial surgery. A deterioration never appeared after transnasal surgery, but in 26% after transcranial operations.

Topics: Adolescent; Adult; Aged; Child; Craniopharyngioma; Cysts; Female; Humans; Male; Middle Aged; Neoplasm Recurrence, Local; Nose; Pituitary Hormones; Pituitary Neoplasms; Postoperative Complications; Quality of Life; Vision Disorders