Journal of Neurosurgery - 109(1):6

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July 2008 Volume 109, Number = 1

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Outcomes following endoscopic, = expanded=20 endonasal resection of suprasellar craniopharyngiomas: = a case=20 series

Paul A.=20 Gardner, M.D.¹, Amin=20 B. Kassam,=20 = M.D.^1,^2,^3,⁴,=20 Carl H. Snyderman,=20 M.D.^1,³, Ricardo L. Carrau,=20 M.D.^1,⁴, Arlan H. Mintz, = M.D.¹,=20 Steven Grahovac,=20 M.D.^5,⁶, and Susan Stefko, = M.D.⁷

¹Departments of = Neurological=20 Surgery,=20 ⁴Otolaryngology,=20 ⁵Radiology (Division of Neuroradiology),=20 and=20 ⁷Ophthalmology;=20 ²Minimally Invasive endoNeurosurgery = Center;=20 and ³Center = for Cranial=20 Base Surgery, University of Pittsburgh Medical Center, = Pittsburgh, Pennsylvania; and=20 ⁶Department of Radiology, Christiana = Hospital,=20 Newark, Delaware

Abbreviations used in this = paper:=20 CSF =3D cerebrospinal fluid; DI =3D diabetes = insipidus; EEA =3D=20 expanded endonasal approach; GH =3D growth hormone; = GKS =3D Gamma=20 Knife surgery; ICP =3D intracranial pressure; PCA =3D = posterior=20 cerebral artery; TSH =3D thyroid-stimulating hormone; = VP =3D=20 ventriculoperitoneal.

Address correspondence = to: Amin=20 Kassam, M.D., Department of Neurological Surgery, = Suite B-400,=20 Presbyterian University Hospital, 200 Lothrop Street,=20 Pittsburgh, Pennsylvania 15213. email: kassamab@upmc.edu.

DOI: 10.3171/JNS/2008/109/7/0006

Figures = and Tables=20

Abstract	IntroductionMethodsResultsDiscussionConclusionsReferences

Object=20

Craniopharyngiomas are challenging = tumors that=20 most frequently occur in the sellar or suprasellar = regions.=20 Microscopic transsphenoidal resections with various = extensions=20 and variations have been performed with good results. = The=20 addition of the endoscope as well as the further = expansion of=20 the standard and extended transsphenoidal approaches = has not=20 been well evaluated for the treatment of this = pathological=20 entity.

Methods=20

The authors performed a retrospective = review of=20 all patients who underwent a purely endoscopic, = expanded=20 endonasal approach (EEA) for the resection of=20 craniopharyngiomas at their institution between June = 1999 and=20 February 2006. Endocrine and ophthalmological = outcomes, extent=20 of resection, and complications were = evaluated.

Results=20

Sixteen patients underwent endoscopic = EEA for=20 the resection of craniopharyngiomas. Five patients = (31%)=20 presented with recurrent disease. Complete resection = was=20 planned in 11 of the 16 patients. Three elderly = patients with=20 vision loss underwent planned debulking, 1 patient = with vision=20 loss and a moderate-sized tumor had express wishes for = debulking, and 1 patient had a separate, third = ventricular=20 nodule that was not resected. Of those in whom = complete=20 resection was planned, 91% underwent near-total (2/11) = or=20 gross-total (8/11) resection. No patient who underwent = gross-total resection suffered a recurrence. The mean=20 follow-up period was 34 months. Of the 14 patients who = presented with vision loss, 93% had improvement or = complete=20 recovery and 1 patient's condition remained stable. No = patient=20 experienced visual worsening. Eighteen percent of = patients=20 (without preexisting hypopituitarism) developed=20 panhypopituitarism and 8% developed permanent diabetes = insipidus. There were no cases of new obesity. The=20 postoperative cere-brospinal fluid leak rate was 58%. = All=20 leaks were resolved, and there were no cases of = bacterial=20 meningitis. There was 1 vascular injury (posterior = cerebral=20 artery perforator branch) resulting in the only new=20 neurological deficit. No patient died.

Conclusions=20

Endoscopic EEA for the resection of=20 craniopharyngiomas provides acceptable results and = holds the=20 potential to improve outcomes.

Keywords:=20 craniopharyngioma; endonasal resection; endoscopic = resection;=20 outcome.

Introduction	AbstractIntroduction = <<MethodsResultsDiscussionConclusionsReferences		=

The microscopic,=20 transsphenoidal approach for the resection of certain=20 craniopharyngiomas is well established and generally=20 accepted,^{6,1315,17,2024,29,30} and=20 there are several studies comparing this approach with = a=20 transcranial approach.^21,24,30 Although=20 the transsphenoidal approach is traditionally limited = to=20 predominantly sellar lesions with secondary = suprasellar=20 extension,²³ the=20 development and application of the =93extended = approach=94 have=20 provided greater access to suprasellar lesions.^17,20,25 Despite=20 this modification, outcomes from the transsphenoidal = approach=20 for the resection of suprasellar tumors with adherence = to=20 critical surrounding structures have led to more = frequent=20 recurrences and poorer overall outcomes compared with = purely=20 sellar tumors.¹⁷ Some of=20 the limitations of this approach, as previously = described, may=20 be secondary to the use of the microscope,² = distance=20 from the surgical target, the small portal of entry to = the=20 surgical field (that is, the nostril), and the need = for a=20 speculum. Attempting to remedy these issues, in 1979 = Halves=20 and Bushe¹⁰=20 recognized the facilitatory role of the endoscope when = accessing supra-sellar lesions. To date, however, the=20 endoscope has played a limited role in most studies of = craniopharyngioma, and there are few studies⁷ = in which=20 the outcomes following endoscopic, endonasal = craniopharyngioma=20 resection have been evaluated.

We present a series of 16 cases in which we = undertook a=20 purely endoscopic EEA for the resection of = craniopharyngiomas.=20 Short-term ophthalmological and endocrine outcomes = along with=20 extent of resection were examined. This report is = meant to be=20 an early evaluation of the technique's value in the = management=20 of these formidable lesions. By comparing these = results with=20 those previously published for other approaches, we = hope to=20 better judge both approaches in terms of their = respective=20 advantages and disadvantages.

Although authors of many past studies = have=20 assessed craniopharyngioma resection via a = transsphenoidal=20 route,^{2,17,23,24,29}=20 few⁷ = have used=20 a purely endoscopic technique and most are biased = toward the=20 resection of tumors with minimal supra- or parasellar=20 extension. Our series consists of tumors located above = and/or=20 with extension superior and lateral to the sella, = superior and=20 posterior to the chiasm, and even extending into the = third=20 ventricle.

Methods	AbstractIntroductionMethods <<ResultsDiscussionConclusionsReferences

After obtaining institutional review board = approval, we=20 reviewed the medical records and imaging studies of = all=20 patients with the histopathological diagnosis of=20 craniopharyngioma treated via an EEA between June 1999 = and=20 February 2006. No patient was excluded or lost to = follow-up,=20 resulting in a series of 16 patients (Table 1). = Patients'=20 ages ranged from 36 to 80 years (mean age 55 years). = There was=20 a male/ female ratio of 5:3. Five patients (31%) = presented to=20 us with recurrent disease. One patient had undergone = prior=20 transsphenoidal resection, 4 had prior craniotomies (1 = of whom=20 also underwent prior stereotactic cyst drainage with=20 intracystic brachytherapy), and 1 had undergone = radiosurgery.=20 In addition, 1 patient underwent a previous = transsphenoidal=20 procedure for a pituitary adenoma (histopathology = verified).=20 Other complicating conditions included obesity, = chronic=20 obstructive pulmonary disease, and pregnancy. Most = patients=20 (14 [87.5%] of 16) presented with progressive visual = deficit=20 as the primary indication for surgery (Table 2). = We report=20 ophthalmological and endocrine outcomes, as well as = extent of=20 resection and complications. The follow-up period for = this=20 study ranged from 2 to 82 months (mean follow-up 34=20 months).

TABLE 1=20 Characteristics in patients who = underwent an=20 endoscopic EEA for=20 = craniopharyngioma

TABLE 2=20 Ophthalmological results*

Operative Technique=20

We detail the operative technique elsewhere.¹⁹ As such,=20 only a brief overview will be provided here. The = operations=20 were all performed by 2 surgeons (A.B.K. or P.A.G. and = C.H.S.=20 or R.L.C.), a neurosurgeon, and an otolaryngologist. A = binarial, purely endoscopic, image-guided approach was = used.=20 The patient was placed supine, the head fixed in pins, = the=20 neck in a neutral or slightly extended position = (10=9615=B0,=20 depending on the anterior/superior extent of the = tumor), and=20 the head turned 5=9610=B0 toward the surgeon to allow = comfortable=20 hand position and improve access. First, = oxymetazoline-soaked=20 pledgets were placed into the nares for several = minutes, prior=20 to preparation. Then, the image-guided system was = calibrated=20 with the patient. We preferred to use MR imaging, but = we used=20 CT angiography in cases in which the patient was = unable to=20 undergo MR imaging or the bone anatomy or involved = vasculature=20 was critical for resection. Next, the abdomen (for fat = graft=20 harvest) and midface were prepared with = Betadine-soaked=20 sponges. The patient was then draped, leaving only the = nose=20 and prepared abdomen exposed. Imaging guidance was = once more=20 confirmed, using external landmarks.

Entering the right nostril, the middle turbinate = was either=20 lateralized or removed under endoscopic guidance and = the=20 anterior wall of the sphenoid was entered. The = contralateral=20 nostril was then entered and the sphenoid similarly=20 approached, with lateralization of the middle = turbinate. Next,=20 the critical step of partial removal of the posterior=20 internasal septum (~ 1 cm) was performed. This = permitted=20 introduction of instrumentation from the contralateral = naris=20 without obscuring the endoscopic view. After the = posterior=20 wall of the sphenoid sinus was exposed, the image = guidance was=20 once more introduced to confirm bone landmarks as well = as=20 tumor location. This step is important, as the normal = sellar=20 anatomy is often greatly distorted by tumor. The bone = over the=20 tumor's dural covering was next drilled and completely = removed=20 using angled rongeurs. Through this process, the = surrounding=20 anatomy was defined, with special attention given to = the=20 location of the cavernous sinuses, carotid arteries, = and optic=20 nerves. The bone over the superior inter-cavernous = sinus was=20 removed next (if necessary) using a combination of = drill and=20 rongeur. At this point, the critical portion of the = sellar=20 bone removal, over the medial opticocarotid recess, = was=20 carried out as described elsewhere.¹⁹ This=20 variable indentation on the sphenoid sinus side of the = lateral=20 tuberculum represents the medial confluence of the = optic=20 nerve, carotid artery, and anterior skull base, = providing a=20 =93keyhole=94 of sorts for this access. When = necessary, the=20 superior intercavernous sinus was carefully and = completely=20 coagulated using bipolar cautery, prior to its = division. This=20 additional rostral exposure often provided the = starting point=20 for tumor surgery and/or dural entry, especially when=20 approaching a supra- or retrochiasmatic lesion. In = suprasellar=20 lesions, the dura was opened in a cruciate manner, and = the=20 tumor was located if not immediately apparent. An=20 extracapsular dissection allowed the surgeon to define = tumor=20 as well as key surrounding structures (for example, = the optic=20 chiasm and perforating vessels, pituitary gland and = stalk, and=20 major arteries). The tumor capsule was then entered, = and=20 debulking was performed. Finally, the extracapsular = dissection=20 was completed, and the tumor was removed from any = adherent=20 normal structures by using sharp dissection. After a = final=20 inspection, the dural closure was begun. This = reconstruction=20 step has undergone considerable evolution during our=20 experience and continues to be evaluated for = improvement. By=20 the end of the series, a lumbar drain was used only in = cases=20 in which the third ventricle was entered or in = communication=20 as a result of the resection.

Throughout this series, some type of = onlay=20 graft, followed by fat graft has been used. At the end = of the=20 series, this has progressed to an inlay of DuraGen = (Integra=20 Lifesciences Corp.), followed by an acellular dermal = onlay=20 graft. The sphenoid sinus was ultimately packed with = fat,=20 which was covered with Surgicel (Ethicon) and followed = by=20 nasal stents and either pledgets or a Foley catheter = balloon=20 as a buttress. Since then, we have begun using a = vascularized=20 nasal septal mucosal flap as a final layer over the = onlay=20 graft with promising results.⁹

Results	AbstractIntroductionMethodsDiscussionConclusionsReferences

Ophthalmological Results=20

All 16 patients underwent a detailed = neuroophthalmological=20 examination before and after surgery (Table 2). = The=20 conditions of 2 patients without preoperative visual = deficits=20 were unchanged postoperatively. The remaining 14 = patients had=20 progressive visual deficits preoperatively. Six (43%) = of these=20 patients had complete resolution of their visual = defect (Fig. 1),=20 and 7 (50%) had improvement but not complete = resolution (Fig. 2).=20 One patient's deficit remained stable. It was = difficult to=20 determine changes in this patient's vision related to = the=20 endoscopic procedure because her vision was extremely = poor=20 preoperatively, due in part to unrelated retinal = disease. No=20 patient had worsening of vision from optic apparatus = damage=20 following surgery. One patient had visual worsening 4 = days=20 after surgery secondary to hydrocephalus. His vision = improved=20 following the placement of a VP shunt.

View=20 larger version = (192K)

Fig. 1. = Humphrey=20 visual field tests. A: Preoperative study=20 demonstrating a dense temporal defect. B:=20 Postoperative visual field testing showing = resolution of visual deficit.

View=20 larger version = (218K)

Fig. 2. = Humphrey=20 visual field tests. A: Preoperative study = showing=20 dense bilateral defects, greatest = bitemporally. B:=20 Postoperative study performed in the same = patient=20 demonstrating significant improvement = compared=20 with preoperative testing.

Endocrine Results=20

All 16 patients underwent endocrine evaluation both = pre-and=20 postoperatively with complete serum pituitary hormone = panels=20 interpreted by an endocrinologist. Five patients = suffered from=20 panhypopituitarism (anterior gland) preoperatively (1 = had DI),=20 1 had DI with other deficits, and 1 had isolated DI = (Table 3).=20 Only 1 (8%) of 12 patients who underwent long-term = follow-up=20 suffered permanent DI. Four others developed temporary = DI in=20 the postoperative period that resolved at last = follow-up=20 without further treatment. Of the 11 patients without=20 preoperative panhypopituitarism, 2 developed new-onset = panhypopituitarism following surgery (18%). One = patient had a=20 new, single axis deficit that required TSH = replacement. One=20 patient's hormone dysfunction (GH and TSH) resolved = following=20 tumor resection. The 7 remaining patients had no = change in the=20 anterior gland.

TABLE 3 = Endocrine=20 results*

When evaluated by tumor = classification,=20 preoperative anterior gland panhypopituitarism or = significant=20 dysfunction (Case 12) seemed to be more common in = primary=20 (nonrecurrent) Type II tumors (2 of 3, compared with 0 = of 2=20 Type I and 2 of 6 Type III). All patients with Type I = tumors=20 suffered from panhypopituitarism postoperatively (1 of = these=20 patients had already been suffering from = panhypopituitarism).=20 Not surprisingly, the only patient with preoperative = DI had a=20 Type II tumor. In addition, permanent DI was more = common,=20 although not universal, in postoperative (whether = treated with=20 EEA or prior surgery) Type II tumors (3 of 5 [1 new = after EEA]=20 vs 1 of 3 [new] Type I and 0 of 8 Type III).

Extent of Resection and = Recurrence=20

Extent of resection was determined using pre- and=20 postoperative volumetric analysis of MR images (Table 4). = Fat=20 saturation was used during postoperative = contrast-enhanced=20 imaging to remove any confusion between enhancing = tumor and=20 fat graft. The comparison was performed by an = independent=20 neuroradiologist (S.G.).

Evaluation of the series without consideration of = goal of=20 surgery has shown that 12 (75%) of the 16 patients = underwent=20 at least near-total resection. Two of these had a = small amount=20 of residual enhancement within the stalk (Fig. 3) = and 2 had=20 < 5% residual tumor, for a gross-total resection = rate of=20 50%. However, complete resection was planned for only = 11 of=20 the 16 patients. Of these 11 patients, 8 (73%) = underwent=20 gross-total resection (Fig. 4) = and 2 other=20 patients (Cases 9 and 12) had only residual = enhancement within=20 the stalk (Fig. 3), = resulting=20 in 91% (10/11) with gross-total or near-complete (> = 95%)=20 resection. The 2 patients with residual stalk = enhancement=20 underwent intentional =93stalk-sparing=94 surgery = during which=20 tumor was dissected from the stalk, but the stalk was = not=20 sacrificed, thus preserving pituitary function. One of = these=20 patients suffered regrowth, and the other's condition = has=20 remained stable (treated with radiosurgery = postoperatively).=20 One patient underwent an unintentional, subtotal (70%) = resection. This case was aborted due to arterial (PCA = branch)=20 injury. All patients with primary (nonrecurrent) = tumors=20 underwent gross- or near-total resection. Six (75%) of = 8=20 patients with primary tumors underwent gross-total = resection.=20 The other 2 patients with primary tumors underwent=20 =93stalk-sparing=94 surgery.

TABLE 4 = Extent of=20 = resection

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Fig. 3. = Preoperative=20 (left) and postoperative = (right)=20 coronal MR images showing suprasellar, = Type II=20 (infundibular) craniopharyngioma treated = using a=20 stalk-sparing resection. The enhancement = seen=20 under the chiasm has not progressed during = follow-up (see text on = recurrence).

View=20 larger version = (190K)

Fig. 4.=20 Contrast-enhanced T1-weighted MR images.=20 Preoperative sagittal (A) and coronal (B) = images=20 showing a complex craniopharyngioma with=20 suprasellar extension. Postoperative = sagittal (C)=20 and coronal (D) images showing gross-total = resection.

Five patients underwent intentional, incomplete=20 resections/debulking. Three of these patients were = > 65=20 years old with large tumors causing visual compromise = (Fig. 5).=20 Two were recurrent tumors. One patient had a large,=20 supra-sellar solid portion as well as a large cyst = that=20 extended well into the third ventricle (similar to a = Type IV,=20 purely intra-ventricular lesion). He was a highly = educated=20 patient and expressed distinct wishes for a subtotal = resection=20 with preservation of pituitary function. The cyst was = treated=20 separately via stereotactic ³²P injection. = All=20 patients had relief of compressive symptoms, and = residual=20 solid tumor was treated with radiosurgery. One patient = underwent complete resection of a suprasellar=20 craniopharyngioma with the exception of a small, = separate,=20 enhancing nodule in the lateral wall of the third = ventricle=20 (Fig.=20 6). This area was treated using radiosurgery, but = the=20 nodule recurred considerably and was treated using = repeated=20 EEA. The decision to merely debulk these tumors rather = than=20 attempt complete resection was complex and depended on = patient=20 age and overall condition, patient wishes, potential = impact of=20 aggressive resection given tumor location (for = example,=20 hypothalamic or vascular involvement), and presenting = symptoms=20 among other factors.

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Fig. 5.=20 Contrast-enhanced T1-weighted MR images.=20 Preoperative sagittal (A) and coronal (B) = images=20 showing a giant, complex = craniopharyngioma, with=20 extension into the third and lateral = ventricles in=20 an elderly man with vision loss. = Postoperative=20 sagittal (C) and coronal (D) images = showing=20 debulking of this giant tumor. Debulking = was=20 chosen due to the patient's advanced age = and=20 concern over potential hypothalamic and = thalamic=20 injury with aggressive = resection.

View=20 larger version = (91K)

Fig. 6. = Coronal=20 contrast-enhanced T1-weighted MR images.=20 Left: Preoperative image showing a=20 suprasellar craniopharyngioma with a = separate=20 nodule (arrow) in the lateral wall = of the=20 third ventricle. Resection of the nodule = was not=20 planned as the floor of the third = ventricle=20 appeared intact on preoperative imaging. = In=20 retrospect and with further experience, = perhaps=20 this nodule would have been accessible.=20 Right: Postoperative image obtained = in the=20 same patient showing resection of the = suprasellar=20 tumor, with the third ventricular nodular = residual=20 lesion (arrow).

In this series we treated tumor = remnants,=20 whether left intentionally or not, using radiosurgery. = No=20 patient suffered recurrence in the setting of = gross-total=20 resection. Four patients with known residual tumor = experienced=20 regrowth. One of these patients, mentioned earlier, = with only=20 residual rim enhancement within the stalk, experienced = regrowth of the remnant. This patient (Case 12) had a=20 particularly aggressive tumor and underwent repeated=20 endoscopic EEA twice, successfully treating visual = symptoms,=20 followed by stereotactic radiosurgery. The patient's = tumor has=20 responded to radiosurgery and was noted to be = decreasing at=20 last follow-up. Three other patients had regrowth of a = known=20 remnant. All 3 were recurrent prior to EEA. The = patients in=20 Cases 5 and 11 experienced regrowth and were treated=20 endonasally, and the patient in Case 7 underwent a = second=20 resection via a craniotomy due to growth lateral to = the middle=20 cerebral artery. The advantage to the endonasal = approach lies=20 in treating tumors that are medial to neurovascular=20 structures, thus allowing resection without traversing = these=20 structures. This advantage was negated in this = situation,=20 making an endonasal approach impractical. This patient = eventually died (3 years after EEA) secondary to = complications=20 associated with stereotactic cyst treatment.

Postoperative Complications=20

The most common complication in this series was=20 postoperative CSF leak. There were 11 CSF leaks (58%) = during=20 19 total operations (including 3 reoperations for=20 recurrence/regrowth; 69% not including reoperations) = (Table 5).=20 Lumbar drain diversion in the immediate postoperative = period=20 is used in all cases requiring extensive arachnoid = dissection=20 or ventricular transgression. One leak resolved with = lumbar=20 drainage alone, and 10 leaks were managed with = reexploration=20 and repair. Long-term CSF diversion was required in 6 = (40%) of=20 15 patients who had lumbar puncture=96proven chronic = elevation=20 in ICP. Another patient developed delayed visual = decline=20 postoperatively because of documented hydrocephalus. = This=20 condition resolved to the immediate postoperative, = improved=20 state after shunt treatment.

TABLE 5 = Surgical=20 complications*

The overall shunt placement rate was 7 (44%) of 16, = and=20 despite CSF leaks there were no cases of bacterial = meningitis.=20 Shunt treatment was not used as a primary modality for = CSF=20 leak repair. Rather, it was used as an adjuvant in = those=20 patients with recurrent leakage and documented (lumbar = puncture) increase in ICP.

Several tumors were closely associated with or = attached to=20 posterior and anterior circulation arteries. During = one such=20 case, a PCA (P₁) perforating vessel was = injured.=20 Copious irrigation with the aid of a ventriculostomy = catheter=20 inserted into the naris revealed the site of arterial=20 avulsion, and a successful repair/closure was achieved = using=20 hemostatic agent (Syvek marine polymer [off-label = use]) with=20 gentle compression. The patient did suffer a small = thalamic=20 infarction from this arterial injury with resultant = aphasia,=20 but fortunately has recovered well with minimal = residual=20 aphasia. The overall vascular injury rate for all=20 surgeries⁸ = was 5% (1=20 of 19). The rate of permanent neurological deficit is = the same=20 (same patient).

No patient died during or as a result = of surgery=20 or during the 30-day postoperative period. As = mentioned=20 earlier, 1 patient died following a stereotactic cyst=20 treatment 3 years after EEA. One patient died of = complications=20 of anticoagulation therapy (acute subdural hematoma, = distant=20 from the site of surgery) 2 months following surgery. = Another=20 patient died of an unrelated medical condition ~ 2 = years after=20 surgery.

Discussion	AbstractIntroductionMethodsResultsConclusionsReferences

Although small, this series demonstrates the = potential of=20 the purely endoscopic EEA as another aid in the = treatment of=20 suprasellar craniopharyngiomas. The addition and sole = use of=20 the endoscope in the expanded, microscopic approaches=20 described by others^17,20,25 allows=20 improved visualization, which, in turn, allows the = further=20 expansion of the previously described approaches.

Craniopharyngiomas are notoriously difficult to = cure, but=20 complete resection has been shown to provide a = survival=20 benefit.^{1,35,8,16,27,33,34} Complete=20 resection rates reported in the literature range from = 6 to=20 0%,^{3,5,6,12,13,24,26,27,31,32,3436} with the exception of = the study by=20 Yaşargil et al.,³⁶ in which=20 the authors reported a 90% gross-total resection rate = (at the=20 cost of a 16.7% mortality rate). Our small series of=20 suprasellar tumors has a 73% gross-total resection = rate for=20 tumors intended for complete resection (50% for the = overall=20 series). The series' size limits direct comparisons; = however,=20 thus far, the rates of resection compared with = historical case=20 series do seem to be equivalent or better. Even more = difficult=20 to quantify is the patient's quality of life following = tumor=20 resection. Although the aim in most cases is complete=20 resection and cure, there is a greater potential for = some=20 decrement in the patient's function, whether = neurological,=20 ophthalmological, or endocrinological, following = radical=20 surgery. In our study, all patients were functional=20 postoperatively. Indeed, only 1 patient suffered a = decrement=20 in function (the patient with a PCA branch infarct). = This=20 resulted in a significant aphasia that recovered over = the=20 course of a year. This patient is living independently = at=20 home. In this series, the extent of resection was = evaluated=20 using an emphasis on an intent-to-treat analysis; only = those=20 tumors in which complete resection was the goal based = on=20 clinical factors were used in the analysis. Han et = al.¹¹ have=20 previously reported on surgical cohorts using this = type of=20 intention-to-treat analysis.

No patient who underwent a gross-total resection=20 experienced recurrence. The regrowth rate for the = series is=20 25% (9% for those intended for complete resection). It = is=20 worth noting that all patients in our series who = suffered=20 recurrence or regrowth were patients with Type II=20 (transinfundibular) tumors (Table 4), = which=20 grow and presumably originate from within the = infundibulum.=20 These tumors are perhaps the most difficult to cure = surgically=20 (3 of the 4 in this study had been previously = resected). In=20 all of these cases, an attempt was made to preserve = the stalk,=20 with resultant preservation of existing endocrine=20 function.¹³ Although=20 this was successful, in the future, it may be wiser to = merely=20 sacrifice the stalk in those cases in which there is = no other=20 remnant. Although certain to provide worse endocrine = outcomes,=20 in the long term, this practice may benefit the = patient by=20 reducing recurrence rates.²⁸

As an initial evaluation of the endoscopic EEA = technique,=20 this series shows it to be effective in chiasmal=20 decompression. Although published studies have = reported rates=20 of postoperative visual decline ranging from 2 to = 15%,^{5,6,26,32,34,35} there=20 were no such occurrences in this series. Furthermore, = the=20 likelihood of improvement in or complete recovery of = vision=20 was 92%.

In terms of endocrinopathy, panhypopituitarism and = DI are=20 particularly common following the resection of=20 craniopharyngiomas; rates in the literature have = ranged from=20 24 to 66% and 43 to 79%,^6,31,3436 respectively. In our = series, 18%=20 of patients developed panhypopituitarism and 8% = developed=20 permanent DI.

Perhaps most surprising is the high rate of=20 panhypopituitarism following resection of Type I = tumors. This=20 may be due to the fact that both Type I tumors without = preoperative dysfunction were resected early (first) = in the=20 series. Therefore, it is difficult to know if this = finding is=20 a result of tumor location or a reflection of our = learning=20 curve. In contrast, Type III tumors had a very low = rate of=20 dysfunction (1 [20%] of 5).

The aggressiveness of resection obviously has a = significant=20 effect on the aforementioned rates. This small series, = however, appears to support the use of purely = endoscopic=20 techniques to provide a high rate of endocrine = function=20 preservation, while concurrently achieving respectable = resections. This is especially true for Types I=20 (preinfundibu-lar) and III (retroinfundibular) tumors, = where=20 the stalk can be separated and potentially preserved. = In this=20 series, this is illustrated by Type III tumors, where = there=20 was a very low rate of postoperative pituitary = dysfunction.=20 Although there are only a few patients in whom = complete=20 resection with preservation of current hormonal status = can be=20 achieved (2 in this series, both with Type III = tumors), we=20 believe that an attempt at preservation of pituitary = gland and=20 stalk is reasonable and at times successful. Given the = tumor=20 type and locations, some degree of postoperative = pituitary=20 dysfunction is expected and preservation of function = must be=20 weighed against the recurrence risk. Once again, this = is=20 emphasized by Type II tumors, in which the tumor has = often=20 invaded the pituitary stalk. This problem illustrates = the=20 difficulty in dealing with such a pathological = entity.

Our experience with EEA resection of = craniopharyngiomas has=20 demonstrated the need for new techniques that prevent=20 postoperative CSF leaks. Leakage rates were higher in = this=20 series than in our experience with other sellar and=20 suprasellar lesions, and there are several reasons for = this.=20 One is the extensive, intentional violation of the = anterior=20 skull base dura that is necessary for lesion access. = This=20 larger opening is more difficult to effectively seal, = and its=20 proximity to critical neurovascular structures = (carotid=20 arteries, optic nerves, and so on) increases the = challenge of=20 obtaining a watertight repair.

Of particular interest has been our realization = that=20 despite similar size exposures for other anterior = skull base=20 and parasellar pathological entities such as pituitary = adenomas and meningiomas, craniopharyngiomas have a=20 disproportionately higher incidence of CSF leakage = following=20 surgery.^7,18 This=20 increased rate may be related to a higher incidence of = either=20 transient or permanent hydrocephalus associated with=20 craniopharyngiomas.^5,12,36 This is=20 also reflected in the high rate of permanent CSF = diversion=20 demonstrated in this series. Given the early and often = ineffective reconstruction techniques used in this = series, any=20 increased ICP, whether transient or permanent, was=20 detrimental. However, the most important = differentiating=20 factor for increased CSF leakage is likely that = resection of=20 craniopharyngiomas, more than other parasellar = lesions,=20 involves the violation of arachnoid cisterns and = offers entry=20 into the third ventricle. This violation inevitably = creates a=20 greater obstacle to defect closure. Further = modification of=20 closure techniques will hopefully provide reduction in = the CSF=20 leakage rate, as has been the case after changes = instituted=20 later in this series. Through constant modification, = the CSF=20 leakage rates decreased considerably over the course = of this=20 study (Fig. 7). = From 1998=20 to 2004, the leakage rate was 69%. The following year = it was=20 reduced to 20% (including the reoperations for tumor = regrowth=20 in this group, not listed in Table 5), = once=20 suturing and balloon buttresses were used. The recent = addition=20 of a vascularized, nasal septal flap⁹ = to our=20 reconstructions appears to hold tremendous = promise.

View=20 larger version = (30K)

Fig. 7. Bar = graph=20 illustrating CSF leakage rates early in = the series=20 compared with the last year of the series. = The=20 time periods are misleading, as only 1 = case of CSF=20 leakage occurred prior to 2003, making = this=20 comparison largely one of 2003=962004 and=20 2005.

It is important to note that all CSF fistulas were=20 eventually sealed without associated morbidity. This = result=20 was associated with a high permanent CSF diversion = rate in=20 this series. There were no cases of bacterial = meningitis and=20 no complications associated with reoperation or shunt=20 placement, although the potential for serious = complication=20 clearly exists. With careful management and awareness = of this=20 issue, CSF leakage is not believed to be an = insurmountable=20 problem and does not negate the efficacy of this = approach for=20 craniopharyngioma.

As for vascular injury, perhaps the = most feared=20 complication of endoscopic manipulation of = neurovascular=20 structures, our rate of injury was low (5%). Just as = important=20 was the ability to successfully manage an arterial = injury=20 during a purely endoscopic endonasal = approach.

Conclusions	AbstractIntroductionMethodsResultsDiscussionConclusions = <<References

The incorporation of the transplanum modification = into=20 traditional transsphenoidal approaches, facilitated by = the use=20 of the endoscope, has provided access to many tumors = with=20 suprasellar or even retrochiasmatic extension, = previously=20 thought to be unresectable via a transsphenoidal = route.=20 Craniopharyngioma is one such tumor. In our opinion, = the use=20 of the endoscope as the sole means of visualization in = the EEA=20 provides surgeons improved visualization of a region=20 inherently fraught with potential disaster and helps = to expand=20 the indications for transsphenoidal resection of = sellar region=20 tumors in general and craniopha-ryngiomas in = particular.

Comparison of our results with those = previously=20 described is best left to others. Hopefully, however, = these=20 data will help guide the future development of = endoscopic=20 techniques. This series illustrates the ability to = access=20 complex suprasellar, parasellar, and retrosellar=20 craniopharyngiomas via an EEA, regardless of the = degree of=20 sellar expansion. Difficulties with preventing = postoperative=20 CSF leakage are highlighted by this series. Together = with=20 standard approaches and other technological advances = such as=20 ste-reotactic cyst therapies and radiosurgery, the = endoscopic=20 EEA may prove a valuable weapon in the armamentarium = against=20 this truly challenging tumor. Expansion of the series, = both in=20 terms of number of patients and period of follow-up is = critical for complete and accurate evaluation of the = approach=20 and technique.

References	AbstractIntroductionMethodsResultsDiscussionConclusionsReferences = <<

1.	Chakrabarti I, Amar AP, = Couldwell W, = = Weiss MH:=20 = Long-term=20 neurological, visual, and endocrine outcomes = following=20 transnasal resection of craniopharyngioma. J = Neurosurg=20 102:650=96657, 2005
2.	Couldwell WT, Weiss MH, = Rabb C, = Liu JK, = Apfelbaum = RI,=20 = Fukushima=20 T: = Variations=20 on the standard transsphenoidal approach to the = sellar=20 region, with emphasis on the extended approaches = and=20 parasellar approaches: surgical experience in = 105 cases.=20 Neurosurgery=20 55:539=96547, 2004
3.	De Vile CJ, Grant DB, = Kendall BE,=20 = Neville=20 BG, =20 Stanhope R, Watkins KE,=20 et = al.:=20 Management of childhood craniopharyngioma: can = the=20 morbidity of radical surgery be predicted?. = J = Neurosurg=20 85:73=9681, 1996
4.	Dhellemmes P, Vinchon M:=20 = Radical=20 resection for craniopharyngiomas in children: = surgical=20 technique and clinical results. J Pediatr = Endocrinol=20 Metab 19:1 Suppl329=96335, 2006
5.	Duff JM, Meyer FB, = Ilstrup DM,=20 = Laws ER,=20 = Schleck=20 CD, =20 Scheithauer BW: =20 Long-term outcomes for surgically resected=20 craniopharyngiomas. Neurosurgery=20 46:291=96302, 2000
6.	Fahlbusch R, Honegger J,=20 = Paulus W,=20 = Huk W,=20 = Buchfelder M: =20 Surgical treatment of craniopharyngiomas: = experience=20 with 168 patients. J=20 Neurosurg 90:237=96250, 1999
7.	Frank G, Pasquini E,=20 = Doglietto=20 F, =20 Mazzatenta D, Sciarretta = V,=20 = Farneti=20 G, et = al.: The=20 endoscopic extended transsphenoidal approach for = craniopharyngiomas. Neurosurgery 59:1=20 SupplONS75=96ONS83, 2006
8.	Gupta DK, Ojha BK, = Sarkar C, = Mahapatra = AK,=20 = Sharma=20 BS, Mehta=20 VS: = Recurrence=20 in pediatric craniopharyngiomas: analysis of = clinical=20 and histological features. Childs Nerv = Syst=20 22:50=9655, 2006
9.	Hadad G, = Bassagasteguy L,=20 = Carrau=20 RL, =20 Mataza JC, Kassam A, = Snyderman = CH,=20 et = al.: A novel=20 reconstructive technique following endoscopic = expanded=20 endonasal approaches: vascular pedicle = nasoseptal flap.=20 Laryngoscope=20 116:1881=961885, 2006
10.	Halves E, Bushe KA: = Transsphenoidal = operation on=20 craniopharyngiomas with extrasellar extensions. = The=20 advantage of the operating endoscope. Acta Neurochir = Suppl=20 (Wien) 28:362, 1979
11.	Han PP, Ponce FA, = Spetzler RF: = =20 Intention-to-treat analysis of Spetzler-Martin = grades IV=20 and V arteriovenous malformations: natural = history and=20 treatment paradigm. J = Neurosurg 98:3=967,=20 2003
12.	Hoffman HJ, DeSilva M,=20 = Humphreys=20 RP, Drake=20 JM, Smith=20 ML, =20 Blaser SI: =20 Aggressive management of craniopharyngiomas in = children.=20 J = Neurosurg=20 76:47=9652, 1992
13.	Honegger J, Buchfelder = M,=20 = Fahlbusch=20 R: = Surgical=20 treatment of craniopharyngiomas: = endocrinological=20 results. J = Neurosurg 90:251=96257, 1999
14.	Honegger J, Buchfelder = M,=20 = Fahlbusch=20 R, =20 Daubler B, Dorr HG: = Transsphenoidal = microsurgery=20 for craniopharyngioma. Surg = Neurol=20 37:189=96196, 1992
15.	Im SH, Wang KC, = Kim SK, = Chung YN, = Kim HS, = Lee CH, = et al.: = Transsphenoidal=20 microsurgery for pediatric craniopharyngioma: = special=20 considerations regarding indications and method. = Pediatr = Neurosurg=20 39:97=96103, 2003
16.	Isaac MA, Hahn SS, = Kim JA, = Bogart JA,=20 = Chung CT:=20 = Management of=20 craniopharyngioma. Cancer J = 7:516=96520,=20 2001
17.	Kaptain GJ, Vincent DA,=20 = Sheehan=20 JP, Laws=20 ER Jr: =20 Transsphenoidal approaches for the extracapsular = resection of midline suprasellar and anterior = cranial=20 base lesions. Neurosurgery=20 49:94=96100, 2001
18.	Kassam AB, Carrau RL,=20 = Snyderman=20 CH, =20 Gardner P, Mintz A: = Evolution of = reconstructive=20 techniques following endoscopic expanded = endonasal=20 approaches. Neurosurg = Focus=20 19:1E8, 2005
19.	Kassam AB, Gardner PA,=20 = Snyderman=20 CH, =20 Carrau RL, Mintz AH, = Prevedello = DM:=20 = Expanded=20 endonasal approach, a fully endoscopic = transnasal=20 approach for the resection of midline = suprasellar=20 craniopharyngiomas: a new classification based = on the=20 infundibulum. J=20 Neurosurg 108:715=96728, 2008 [Abstract]
20.	Kouri JG, Chen MY, = Watson JC,=20 = Oldfield=20 EH: = Resection=20 of suprasellar tumors by using a modified=20 transsphenoidal approach. Report of four cases. = J = Neurosurg=20 92:1028=961035, 2000
21.	Laws ER Jr: Comment on: = Surgical=20 treatment of craniopharyngiomas: an evaluation = of the=20 transsphenoidal and pterional approaches. Neurosurgery=20 36:724, 1995
22.	Laws ER Jr: Transsphenoidal = microsurgery=20 in the management of craniopharyngioma. J = Neurosurg=20 52:661=96666, 1980
23.	Laws ER Jr: Transsphenoidal = removal of=20 craniopharyngioma. Pediatr = Neurosurg=20 21:57=9663, 1994
24.	Maira G, Anile C, = Rossi GF, = Colosimo C:=20 = Surgical=20 treatment of craniopharyngiomas: an evaluation = of the=20 transsphenoidal and pterional approaches. Neurosurgery=20 36:715=96724, 1995
25.	Mason RB, Nieman LK,=20 = Doppman=20 JL, =20 Oldfield EH: =20 Selective excision of adenomas originating in or = extending into the pituitary stalk with = preservation of=20 function. J=20 Neurosurg 87:343=96351, 1997
26.	Matson DD, Crigler JF = Jr:=20 = Radical=20 treatment of craniopharyngioma. Ann Surg=20 152:699=96704, 1960
27.	McMurry FG, Hardy RW, = Dohn DF, = Sadar E, = Gardner J:=20 Long = term=20 results in the management of craniopharyngiomas. = Neurosurgery=20 1:238=96241, 1977
28.	Minamida Y, Mikami T, = Hashi K, = Houkin K: = Surgical = management of the=20 recurrence and regrowth of craniopharyngiomas. = J = Neurosurg=20 103:224=96232, 2005
29.	Norris JS, Pavaresh M,=20 = Afshar F:=20 = Primary=20 transsphenoidal micro-surgery in the treatment = of=20 craniopharyngiomas. Br J = Neurosurg=20 12:305=96312, 1998
30.	Patterson RH: Comment on: = Surgical=20 treatment of craniopharyngiomas: an evaluation = of the=20 transsphenoidal and pterional approaches. Neurosurgery=20 36:724, 1995
31.	Shirane R, Su C, = Kusaka Y, = Jokura H, = Yoshimoto T: = = Surgical=20 outcomes in 31 patients with craniopharyngiomas=20 extending outside the suprasellar cistern: an = evaluation=20 of the frontobasal approach. J = Neurosurg=20 96:704=96712, 2002
32.	Symon L: An approach to = radical=20 excision of craniopharyngioma by the temporal = route.=20 Pediatr=20 Neurosurg 21:1 Suppl64=9668, 1994
33.	Tena-Suck ML, Salinas-Lara = C,=20 = Arce-Arellano RI, = Rembao-Bo-j=F3rquez D,=20 = Morales-Espinosa D, Sotelo J, = et al.: = Clinico-pathological=20 and immunohistochemical characteristics = associated to=20 recurrence/regrowth of craniopharyngiomas. Clin Neurol=20 Neurosurg 108:661=96669, 2006
34.	Van Effenterre R, = Boch AL: = Craniopharyngioma = in adults=20 and children: a study of 122 surgical cases. = J = Neurosurg=20 97:3=9611, 2002
35.	Weiner HL, Wisoff JH,=20 = Rosenberg=20 ME, =20 Kupersmith MJ, Cohen H, = Zagzag D, = et al.: = Craniopharyngiomas: a=20 clinicopathological analysis of factors = predictive of=20 recurrence and functional outcome. Neurosurgery=20 35:1001=961011, 1994
36.	Yaşargil MG, = Circic M, = Kis M, = Siegenthaler = G,=20 = Teddy PJ,=20 = Roth P:=20 Total = removal=20 of craniopharyngiomas: approaches and long-term = results=20 in 144 patients. J=20 Neurosurg 73:3=9611, 1990