Extended endoscopic transsphenoidal approach for extrasellar craniopharyngiomas

OBJECTIVE: Suprasellar craniopharyngiomas have been classically removed using a variety of transcranial approaches. Historically, the transsphenoidal route was reserved for intrasellar-infradiaphragmatic, and preferably cystic, lesions. With the advent of the endoscope in transsphenoidal surgery, its obvious advantages combined with neurosurgeons' increasing interest in extended transsphenoidal approaches made suprasellar and even intraventricular craniopharyngiomas accessible for removal via such a low route. PATIENTS AND METHODS: Between January of 2004 and April of 2006, six men and four women (mean age, 57.2 yr; range, 26-70 yr) underwent surgery for craniopharyngioma, including two intrasuprasellar, one suprasellar, six suprasellar-intraventricular, and one that was purely intraventricular. Three patients had undergone a previous transcranial surgery via the pterional approach, whereas one patient had undergone a transsphenoidal microsurgical approach. The surgical method consisted of an extended endoscopic transsphenoidal approach with removal of the upper half of the sella, the tuberculum sellae, and the posterior part of the planum sphenoidale, using a "three-four hands" technique. RESULTS: Total craniopharyngioma removal was achieved for seven patients, subtotal removal was possible for two patients, and one patient had a partial removal. Two patients developed a postoperative cerebrospinal fluid leak that required a successful endoscopic revision of the cranial base reconstruction. One patient died 5 weeks later because of hypothalamic dysfunction. All patients with visual field and/or visual acuity defect improved except one patient, in which we observed a slight worsening of visual acuity in one eye. Preoperative pituitary dysfunction did not improve in any patient. In three patients, we observed the new occurrence of permanent diabetes insipidus. One patient developed a sphenoid sinus mycosis, which was treated with antimycotic therapy. We did not observe carotid injury, epistaxis from the sphenopalatine artery, or airway difficulties. CONCLUSION: For selected patients, the extended endoscopic endonasal approach for removal of suprasellar craniopharyngioma seems to provide a valid alternative to transcranial approaches.