Transciliary supraorbital approach (eyebrow approach) for resection of retrochiasmatic craniopharyngiomas: an alternative approach, case series, and literature review.

Original Article

Transciliary Supraorbital Approach (Eyebrow Approach) for Resection of Retrochiasmatic Craniopharyngiomas: An Alternative Approach, Case Series, and Literature Review Rabih G. Tawk1,3

Mandy J. Binning1,3

Justin M. Thomas1,3

1 Department of Neurosurgery, School of Medicine and Biomedical

Sciences, University at Buffalo, State University of New York, New York, United States 2 Department of Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, New York, United States 3 Department of Neurosurgery, Kaleida Health, Buffalo, New York, United States

Adnan H. Siddiqui1,2,3

Walter Grand1,3

Address for correspondence Walter Grand, MD, University at Buffalo Neurosurgery, 100 High Street, Suite B4, Buffalo NY 14203, United States (e-mail: [email protected]).

J Neurol Surg A 2014;75:354–364.

Abstract

Keywords

► ► ► ► ► ►

craniopharyngioma supraorbital approach eyebrow transciliary endoscopic retrochiasmatic

received September 14, 2012 accepted after revision June 28, 2013 published online June 4, 2014

Introduction Craniopharyngiomas are known for an irregular growth pattern and extension into the retrochiasmatic space with adherence to adjacent structures. We describe the use of the transciliary supraorbital approach (eyebrow approach) for resection of craniopharyngiomas with retrochiasmatic extension. Methods Our clinical database was reviewed to identify operative cases of craniopharyngiomas between July 1998 and January 2011. Only patients who had retrochiasmatic extension and underwent an eyebrow approach were included in this analysis. Endoscopy was used to aid surgical resection at the discretion of the surgeon. Six patients were identified (three from a retrospective review and three during the course of prospective follow-up evaluation). Results The group included three men and three women (mean age: 41.2 years; range: 28–57 years). All patients had visual and hormonal deficits at presentation. Complete resection was achieved in four patients. Endoscopic assistance was used in three patients. Opening of the frontal sinus occurred in two cases during surgery; an additional surgical procedure was required for repair of a cerebrospinal fluid leak in one of these cases. The duration of clinical follow-up ranged from 18 to 97 months. All patients had excellent cosmetic results, visual improvement to a serviceable level, and a Karnofsky performance scale score 80. Conclusions The eyebrow approach is safe for resection of craniopharyngiomas with retrochiasmatic extension. This approach offers a reasonable surgical corridor for resection of the retrochiasmatic tumor component and can be enhanced using endoscopic assistance.

© 2014 Georg Thieme Verlag KG Stuttgart · New York

DOI http://dx.doi.org/ 10.1055/s-0033-1358609. ISSN 2193-6315.

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

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Eyebrow Approach for Retrochiasmatic Craniopharyngioma Resection

Historically, aggressive resection of craniopharyngiomas has been associated with high morbidity and mortality due to the adherence of these tumors to critical surrounding structures, such as the hypothalamus, pituitary gland, and optic apparatus. In the early 1960s, aggressive resection was called into question as a result of mortality rates that were reportedly as high as 40%, coupled with a relatively low gross total resection rate. In the mid-1970s, with improvement of microsurgical techniques and equipment, there was renewed enthusiasm for total resection. In 1990, Yaşargil and colleagues 1 published the long-term results of total removal in a series of 144 patients and suggested that primary total resection (via a transsphenoidal, pterional, transcortical, interhemispheric-anterior transcallosal-transforaminal, or a combined pterional-transcallosal approach) yielded the best long-term outcomes. With advances in microsurgical techniques, a variety of surgical approaches have been described to access the suprasellarparasellar area, with the pterional approach used most commonly. 2–4 Reported approaches for craniopharyngioma resection have been described with a variable degree of success.1–24 The supraorbital approach was first described as a modification of the subfrontal approach for resection of lesions in the anterior cranial fossa, the middle cranial fossa, or the sellar region, including craniopharyngiomas.25–29 Exposure and resection of craniopharyngiomas with retrochiasmatic extension remains difficult owing to the hidden position of these lesions behind the optic chiasm, their upward extension into the third ventricle, and their downward extension in front of the brainstem. This article reviews the results of consecutive cases of retrochiasmatic craniopharyngioma in which resection was performed via the supraorbital approach.

Methods and Materials Patients with craniopharyngiomas who had surgery between July 1998 and January 2011 were identified from a review of our clinical database. Only patients with retrochiasmatic extension of the tumor who underwent a transciliary supraorbital (eyebrow) approach were included in the present analysis. Six patients were identified and evaluated (three from a retrospective review; three during the course of prospective follow-up evaluation). An endoscope was used to assist surgical resection at the discretion of the operating surgeon (when visualization of the operative field outside the line of sight was needed). Treatment results were obtained from a review of patient charts, clinic notes, operative reports, and imaging studies. Follow-up involved computed tomographic (CT) and magnetic resonance (MR) imaging and serial evaluations with neurologic examinations, including visual testing and testing to determine the need for hormone supplementation. The Karnofsky performance scale (KPS) was used to evaluate functional outcome and as a measurement of quality of life. This study was

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approved by the institutional review board at the University of Buffalo.

Surgical Approach Patients were placed in a supine position with the head slightly extended 10 to 15 degrees and turned 30 degrees to the contralateral side. Because we encountered a cerebrospinal fluid (CSF) leak that required surgical repair early in our experience, all patients had the abdomen prepared for the removal of fat in case of inadvertent penetration into the frontal sinus. An incision was made at the superior edge of the eyebrow from the midpupillary line extending to just behind the frontal process of the zygomatic bone. Dissection was performed to expose the pericranium over the frontal bone and the temporalis fascia to the edge of the supraorbital foramen to preserve the supraorbital nerve and its branches. The corrugator supercilii muscle was gently pushed downward during the dissection. The temporalis fascia was incised a few millimeters before its insertion at the anterior temporal line, leaving a small fascial cuff for re-attachment during closure. The keyhole was exposed by subperiosteal dissection of the temporalis muscle while avoiding aggressive dissection to prevent injury to the frontalis nerve branch and subsequent postoperative muscle atrophy. The skin flap was retracted using silk sutures. The pericranial flap, with its base at the orbital rim, was gently stripped from the roof of the orbit while maintaining its continuity with the periorbita. In all cases, a burr hole was drilled a few millimeters above the frontosphenoid suture. The bone flap was turned from the burr hole, ending just lateral to the supraorbital foramen. The goal was always to create a 3-cm wide and 2-cm tall bone flap. After removal of the bone flap, we carefully inspected for violation of the frontal sinus. Then, using a small burr, we extradurally flattened out the orbital bony ridges. This flattened the trajectory to the parasellar and suprasellar region, and eliminated bony obstruction of this view. Subsequently, the dura was retracted and was kept moist throughout the procedure. In cases of frontal sinus violation, the mucosa was removed and the sinus was exenterated; fat was collected from the abdominal wall and used to pack the sinus; then a pericranial flap was sutured down over the exenterated sinus. Surgical resection was performed using the operative microscope and microsurgical tools. Endoscopic assistance was used in cases where adhesions could not be observed and resected safely under the microscope and to enhance visualization of the intraventricular tumor component. The surgical site was closed in the usual fashion to include a watertight dural closure and appropriate fixation of the bone flap. The skin was closed meticulously to ensure an optimal cosmetic result.

Results The study group included three men and three women (mean age: 41.2 years; range: 28–57 years) (►Table 1). All patients had visual and hormonal deficits at presentation prior to surgery. Using the supraorbital eyebrow approach, complete resection was achieved in four patients. A 30-degree endoscope was used to assist surgical resection in three of these Journal of Neurological Surgery—Part A

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Introduction

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46, M

27, F

57, M

34, M

3

4

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5

6

Limited due to severe adhesions from previous surgeries. Optic apparatus adequately decompressed. Pterional approach performed 2 mo later. Total resection was impossible; only fenestration of the recurrent cyst was accomplished

Complete resection. Patient underwent previous transsphenoidal resection

Complete resection with use of endoscopic assistance. Sinus breach repaired initially with muscle

Complete resection with use of endoscopic assistance. Sinus breach repaired successfully with muscle and fibrin glue

Complete resection with use of endoscopic assistance

Opening of the lamina terminalis for resection of the intraventricular component. Incomplete due to inability to resect calcifications of the third ventricle walls

Resection/Comments

Yes

No

No

No

No

Yes

Adhesions precluding safe resection, yes/no

Predominantly solid

Mixed

Mixed, predominantly cystic

Predominantly cystic

Mixed

Mixed, predominantly solid

Solid vs cystic component

Structure

Yes

Yes

Yes

Yes

Yes

Yes

Into third ventricle

None

None

CSF leak requiring additional surgery

None

None

None

Complications

20/50 (right); 20/70 (left)

20/20 (bilaterally)

20/20 (bilaterally)

20/20 (bilaterally)

20/20 (bilaterally)

20/20 (left), 20/30 (right)

Visual outcome


Yes

Yes

Yes

Yes

Yes

Yes

Retrochiasmatic

Extension

90 (HRT)

90 (HRT)

80 (HRT, polyphagia, weight gain)

90 (HRT)

90 (HRT)

90 (HRT)

Karnofsky performance scalea


Abbreviations: CSF, cerebrospinal fluid; HRT, hormone replacement therapy. a All patients had persistence of preexisting hormonal deficit requiring continuation of HRT after surgery.

37, M

45, F

1

2

Age, y, sex

Patient no.

Table 1 Clinical characteristics

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patients (patients 2, 3, and 4). Patient 5 had undergone a transsphenoidal approach with resection of the intrasellar tumor extension prior to the eyebrow approach for excision of the suprasellar component. We were able to achieve complete resection of the residual tumor in the suprasellar compartment, and no significant adhesions were encountered. Two patients had incomplete resection (patients 1 and 6). Patient 1 had residual calcified adhesions on the walls of the third ventricle. Resection of the calcifications was thought to pose a high risk of damaging the walls of the third ventricle and hypothalamus. This patient had regrowth of a cystic mass at the time of the 1-year follow-up evaluation and required drainage, which was accomplished through the placement of an Ommaya reservoir. Patient 6 had undergone several previous surgeries for resection of a craniopharyngioma with a cystic component. This patient presented with worsening vision and underwent the eyebrow approach for tumor resection. We were able to decompress the chiasm adequately with improvement of vision. However, the presence of severe adhesions precluded complete resection. He underwent a pterional craniotomy 2 months later for residual tumor, again without complete resection because of the adhesions. Opening of the frontal sinus occurred in two cases during surgery (patients 3 and 4). One of these patients (patient 4) required an additional operation for repair of a CSF leak. The duration of clinical follow-up for the 6 patients ranged from 18 to 97 months. All patients had improvement of visual acuity to a functional status or to baseline level. All patients had persistence of a preoperative hormonal deficit requiring continuation of hormone replacement therapy (HRT) postoperatively. Only one patient had difficulties with weight control (patient 4). There were no infections, and all patients had excellent cosmetic results. No significant impairment in quality of life could be demonstrated postoperatively; all patients had a KPS score of 80.

Illustrative Cases Case 1 (►Fig. 1; patient 1 in ►Table 1): This 45-year-old woman presented with progressive confusion, blurry vision, and vomiting. A noncontrast cranial CT scan revealed a 3.7 cm 2.2 cm cystic suprasellar retrochiasmatic mass with calcified margins, consistent with a craniopharyngioma. Preoperatively, visual acuity was 20/200 in both eyes. The patient underwent a right supraorbital eyebrow craniotomy for tumor resection. The exposure was adequate to visualize the right optic nerve, chiasm, and tumor within the right carotid-optic triangle. Tumor resection was performed through this window, with decompression of the optic apparatus and pituitary stalk, which was preserved. The lamina terminalis was opened, and tumor was removed from the third ventricle. The margins of the tumor were calcified and adherent to the walls of the third ventricle; a decision was made to leave these calcified adhesions to prevent damage to the walls of the third ventricle and the hypothalamus. The patient had a period of agitation and somnolence during the immediate postoperative period. Her

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imaging revealed persistent calcifications within the third ventricle. She was discharged home on HRT, and her visual acuity improved to 20/20 on the left and 20/30 on the right. The neurologic examination was otherwise normal. At 1-year follow up, she was found to have a cystic lesion with progressive enlargement. Visual acuity remained stable. She had placement of an Ommaya reservoir for drainage of the cyst and has been stable with no regrowth at the 3-year follow-up evaluation. Case 2 (►Fig. 2; patient 4 in ►Table 1): This 27-year-old woman presented with acute worsening of headaches and visual impairment. Her past medical history was remarkable for amenorrhea for 9 months; laboratory investigation showed hormonal insufficiency. Imaging studies demonstrated a suprasellar cystic mass consistent with craniopharyngioma. The patient underwent surgical resection using the supraorbital eyebrow approach. The cystic portion of the lesion contained amber fluid, and it collapsed after drainage. The capsular portion was stripped away from the underside of the optic chiasm and right optic nerve, extending to the midline and in front of the optic chiasm. Endoscopic assistance was used to inspect the operative field, and gross total resection was achieved. A small breach of the frontal sinus occurred during craniotomy. This defect was packed with periosteum after exenteration of the sinus. Postoperatively, the patient had improvement of vision and persistence of diabetes insipidus. In addition, she was noted to have CSF rhinorrhea a few days after surgery. A lumbar drain was inserted, but the rhinorrhea persisted. She was taken again to surgery for exploration and sealing of the CSF leak. A small piece of periosteum was used to seal two spots of dural dehiscence. Fibrin glue and fat were used to fill the frontal sinus. The patient did well and was discharged home a few days later. At the 5-year follow up, she is still on HRT, with no evidence of tumor recurrence. Case 3 (►Fig. 3; patient 3 in ►Table 1): This 46-year-old man presented with headaches and decreased visual acuity. MR imaging revealed a sellar-suprasellar mass with retrochiasmatic extension (►Fig. 3A). The lesion was partially cystic and calcified with extension into the third ventricle, causing obstructive hydrocephalus. The patient was taken to the operating room for placement of a ventriculostomy drain followed by a right supraorbital craniotomy for tumor resection. The operative microscope was used, and after exposure of the carotid-optic triangle, the tumor was identified between the right optic nerve and the internal carotid artery. The tumor and arachnoid adhesions were released. After resection of the exposed tumor, the extension behind the chiasm into the lamina terminalis was rendered accessible. The tumor was resected with endoscopic assistance, and radical resection was achieved. Postoperative imaging revealed no residual tumor (►Fig. 3B). At the 1-month follow-up visit, the patient was on complete HRT and regained 20/20 visual acuity in both eyes. At the time of the 11-year follow-up visit, he was on HRT and remained neurologically intact; MR imaging revealed no evidence of residual or recurrent tumor (►Fig. 3C). Journal of Neurological Surgery—Part A

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Discussion Craniopharyngioma is a slow-growing tumor with an irregular growth pattern and a propensity for adherence to adjacent vital structures, such as the optic chiasm, hypothalamus, and carotid arteries, which leads to a significant increase in operative morbidity and mortality. Since the introduction of the operative microscope and subsequent development of complex cranial approaches, resection has improved and recommendations for complete resection have changed significantly over time. Concurrently, alternative methods of treatment have advanced, especially with improvement of image-guided radiosurgery. However, radiation carries risks, including dysfunction of the hypothalamic-pituitary-axis, degeneration of the optic nerves, and the development of neuropsychological deficits, delayed vascular disease (such as

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moyamoya disease), and secondary tumors.30,31 Therefore, the argument persists regarding the optimal treatment consisting of radical resection versus safe and subtotal resection because radical resection offers long-term progression-free survival but carries a significant risk of complications.32–34 According to two relatively large series, complete resection was reported in 45 to 70% of patients.10,35 Using a wide variety of microsurgical approaches, Yaşargil and colleagues1 reported a 90% complete resection rate and a 7% recurrence rate. Despite the controversy surrounding different surgical approaches, the universal challenge is largely attributed to tumor adherence to surrounding structures and the inability to perform a complete initial resection, which may lead to recurrence associated with an increased rate of complications.10,22 In particular, retrochiasmatic expansion has been

Fig. 1 (A) Noncontrast cranial computed tomography (CT) scan reveals a cystic suprasellar mass with calcification at the margins. The mass extends into the third ventricle. (B) Sagittal and (C) coronal magnetic resonance (MR) T1-weighted gadolinium-enhanced images showing a cystic, slightly rim-enhancing suprasellar retrochiasmatic mass extending into the third ventricle. The imaging does not reveal significant hydrocephalus. Intraoperative microscopic images of the exposure: (D) Basilar artery complex with the origin of both superior cerebellar and posterior cerebral arteries. (E) Carotid-optic window after resection. (F) Opening of the lamina terminalis. (G) Calcifications adherent to the walls of the third ventricle. Postoperative images: (H) Sagittal MR T1-weighted gadolinium-enhanced image confirms a near-complete resection of the tumor. (I) Noncontrast cranial CT scans pre- (right) and postresection (left). (J) Lateral skull X-ray showing the craniotomy site and size. (K) Surgical scar at the superior aspect of the eyebrow at 1-year follow-up. (L) Sagittal MR T2-weighted image showing tip of the catheter that is connected to the Ommaya reservoir within the cystic lesion at 3-year follow-up.


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Fig. 1 (Continued)

associated with a high rate of mortality, incomplete tumor removal, tumor recurrence, and increased surgical complications, specifically hypothalamic dysfunction.10,18,22,36,37 Total removal of retrochiasmatic craniopharyngiomas has been reported in 31 to 100% of cases.6,7,10,18,22 The lesion size influences the rate of total removal, and the risk of permanent damage to hypothalamic and pituitary functioning is high in patients with large lesions (4 cm).10,13,15,20,23 The commonly used pterional surgical approach has the benefit of being extremely familiar to neurosurgeons and can be combined with an anterior clinoidectomy to improve the extent of resection.38 Fahlbusch and associates10 used the pterional approach in almost 40% of cases, and they and others have pointed out some of its deficiencies. Among these is that the narrow lateral operative window afforded by the pterional approach may be obstructed by perforating vessels and preclude the accomplishment of gross total resection, especially for retrochiasmatic lesions.7,10,13,18,39 Because many surgeons continued to advocate total resection during the initial operation, the basal bifrontal interhemispheric approach was then adopted for these select tumors.9,21,24 This approach allows wide visualization and avoids potential

blind spots encountered with unilateral approaches.40 It also provides excellent exposure of the high suprasellar and intraventricular region but entails a significant amount of frontal lobe retraction and provides limited exposure to tumors in the parasellar and infratentorial areas. By comparison, the supraorbital approach reported here avoids division of bilateral anterior bridging veins and the risk of bilateral frontal lobe injury from retraction. The supraorbital approach can be extended laterally and, as is the case with anterior approaches, requires dissection through the carotid-optic window. Al-Mefty and colleagues5 approached giant retrochiasmatic craniopharyngiomas posteriorly and used the petrosal approach to avoid supply from the anterior perforators to the hypothalamus and chiasm. Similarly, the subtemporal approach has been described for unilateral retrochiasmatic tumors for avoiding damage to the optic apparatus from subfrontal approaches.41 Compared with these approaches, the supraorbital approach is minimally invasive and offers a viable and safe operative corridor for resection of the retrochiasmatic component of the tumor. From an anatomical standpoint, it is adequate because retrochiasmatic tumors have no arterial Journal of Neurological Surgery—Part A

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Fig. 2 Cranial magnetic resonance (MR) images. (A) Sagittal T2-weighted image, (B) axial T2-weighted image, and (C) coronal T1-weighted image with gadolinium reveal a large cystic suprasellar mass with rim of enhancement extending posteriorly behind the chiasm and superiorly beyond the third ventricle. Postoperative images: (D) Axial T2-weighted image and (E) sagittal T2-weighted image show evidence of complete resection.

supply from the posterior circulation. The tumor expands the carotid-optic space, which facilitates the resection. Endoscopic assistance can be useful in certain cases to visualize structures that are beyond the direct line of sight with the operating microscope, especially the retrochiasmatic area. However, this approach is not recommended for routine use or as a stand-alone approach for regular use in lesions with retrochiasmatic extension. Encasement and adherence of neurovascular structures, one or both internal carotid arteries, and/or the anterior communicating artery complex, and/or the optic apparatus, and/or hypothalamus generate a situation that limits the effectiveness of surgery independently of the approach. It is also important to note that tumor size, characteristics, and the surgeon’s expertise are also common limiting factors for achieving complete resection.10,42 Indeed, the craniopharyngioma population comprises a heterogeneous mix of patients with unique characteristics, and many algorithms for the management of these lesions have been developed and refined by neurosurgeons whose philosophies may even have changed during the course of their careers. In recent years, we have witnessed a change in our approaches and now favor an endoscopic transnasal approach for similar lesions. In our series, complete resection was achieved in four patients with no significant impairment in neuropsychological performance or quality of life in any of the six patients. Only one patient had evidence of polyphagia and excessive weight gain caused by hypothalamic dysfunction. No patient had alterations in mental state or sleep-waking cycle, temperature regulatory problems, electrolyte abnormalities (other than persistence of diabetes insipidus in all patients), or any other evidence of hypothalamic dysfunction. On the basis of these results, the supraorbital approach compares favorably with classic skull base approaches. The Journal of Neurological Surgery—Part A

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surgeon can readily access the retrochiasmatic area through the carotid-optic window and then reach the prepontine area and visualize the retrochiasmatic and interpeduncular cistern and upper basilar trunk (Illustrative Case 1). In large craniopharyngiomas and in cases with recurrent and residual lesions, total resection is not always possible with only “one approach.” For example, Cavallo et al8 could not access the most inferior and posterior portions of these tumors via the pterional route and thus could not achieve total resection. Therefore, surgical versatility is very important for such a capricious disease with broad variability in tumor consistency, extension, and potential for recurrence. Appreciation of the adherence to the stalk, optic apparatus, and other critical structures is a must, especially in patients with normal pituitary and visual function. Accordingly, we encourage a low threshold to contemplate the use of variations to this approach, such as adding an orbitotomy or lateral extension of the craniotomy when the risks posed to vital structures are excessively high. Removal of the orbital roof facilitates access to high lesions and offers similar advantages to the orbitozygomatic approach.27 Further, we support the use of an endoscope to assist in visualization and resection. Endoscopes with different angles allow exposure of the operative field and the blind tumor spots and adhesions behind the optic chiasm and pituitary stalk. The tumor’s upward extension into the third ventricle is readily accessible via the lamina terminalis, and the endoscope can help inspection of the third ventricle through this pathway. With extreme upward extension, the endoscope can be inserted through the frontal cortex and navigated into the lateral ventricle, the foramen of Monro, and the third ventricle to better visualize the intraventricular tumor component. A large cystic tumor component can be pulled from below,


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Fig. 3 Cranial magnetic resonance (MR) T1-weighted images with contrast: (A) sagittal, (B) coronal, and (C) axial reveal a large cystic mass with rim of enhancement with significant mass effect on adjacent structures. Preoperative images are shown on the left and postoperative images are on the right, showing evidence of complete resection.

which was achieved easily during patient 3’s operation (Illustrative Case 3). If this cannot be achieved safely or the tumor extension is inaccessible through the supraorbital approach, a maximum safe resection with debulking can be accomplished to decompress the chiasm, and the surgeon can use adjunctive approaches. Indeed, despite surgical preser-

vation of the pituitary stalk and regardless of the surgical approach, diabetes insipidus (either temporary or permanent) can develop; this condition is potentially treatable, whereas other complications, such as decreased visual acuity or blindness, third cranial nerve injury, and stroke, are much less manageable.7,22,23,37,42–46 Journal of Neurological Surgery—Part A

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Eyebrow Approach for Retrochiasmatic Craniopharyngioma Resection In our series, endoscopic assistance was very helpful in completion of tumor removal, especially with the retrochiasmatic extensions under the third ventricle and into the interpeduncular area. Indeed, we believe that the endoscope helped visualization and probably rendered this approach more efficient compared with surgery without an endoscope. In other words, the endoscope helped by overcoming the limitations of direct or “inline” visualization that would have been encountered otherwise with only microscopic resection. The use of supplementary methods, such as opening the lamina terminalis and endoscopic assistance through the third ventricle, may help visualization of superior extension and may avoid the need for a superior approach, such as the transcallosal approach. Although outside the scope of this article, the advent of new scopes with improvements in working channels have allowed us to use endoscopic resection lately, and we have been combining endoscopic transventricular resection to other transcranial approaches with encouraging results. For small lesions and cysts confined to the third ventricle, resection can be performed purely by endoscopic transventricular technique. As with other approaches, the major limitations of the transciliary supraorbital approach lie in overcoming its learning curve. Compared with a subfrontal approach, the supraorbital approach minimizes the surgical corridor and does not increase the surgical view. The microscopic view is probably more limited with this approach than with the pterional approach given the small bone opening and limitation of maneuverability. By using the endoscope with variable angles, the capability of visualizing the pituitary stalk improves significantly, which is extremely important for such a protean disease. The endoscopic area of observation may be wider, but the working angle is not necessarily improved. Although the endoscope provides a wider view of the operative field, true three-dimensional views are not obtainable and the operative corridor is more cramped, thus limiting instrument access to what is visualized by the angled scope. Another limitation of the supraorbital approach might manifest in patients with thin eyebrows, where a surgical scar can become evident on the forehead. In cases with tumor recurrence, the supraorbital approach also has limitations, and the surgical approach should be selected carefully. As with every approach, an eccentric extension of the tumor out of the safe range for surgical instruments is a real limitation. We therefore ask readers to interpret our results carefully because we are describing only the safety and feasibility of this approach for lesions with retrochiasmatic extension; we do not recommend this approach for routine practice and suggest careful selection of cases. Despite our familiarity with the supraorbital approach, we use the transsphenoidal approach for craniopharyngiomas extending primarily into the sphenoid sinus, the pterional approach for cases involving tumor recurrence, and the petrosal approach for cases in which the lesion extends significantly below the posterior clinoidal processes. As with the transsphenoidal approach,16–18 the extenJournal of Neurological Surgery—Part A

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sive transnasal endoscopic approach will likely play a key role in primary resection of lesions with retrochiasmatic extension. Surgical results with expanded endoscopic endonasal resection of suprasellar craniopharyngiomas have been encouraging because this approach allows a direct midline surgical trajectory and avoids the need for brain retraction.8,11,12,14 However, the wide adoption of this approach depends on overcoming the pitfalls of CSF leaks and becoming proficient in reaching the interpeduncular cisterns and the basilar artery. We recently adopted this approach and have noted a significant advantage during tumor dissection, especially during removal from the inferior aspect of the chiasm, infundibulum, third ventricle, and retro- and parasellar areas. This is because when these areas are approached from below, they are first dealt with along the same surgical trajectory, and no supplemental neurovascular dissection is required.

Conclusion Realization of the wide variation of surgical opinions in craniopharyngioma surgery provided the impetus for the present analysis of the supraorbital approach for resection of craniopharyngiomas with retrochiasmatic extension. The approach is safe, practical, and compares favorably with other established approaches for craniopharyngiomas. It seems to offer a viable surgical corridor for adequate exposure and resection of the retrochiasmatic tumor component but does not compensate for adhesions to major structures that preclude safe resection. The use of the endoscope can optimize visualization and help with resection. Nevertheless, not all craniopharyngiomas are amenable to this operative approach, and such a protean tumor requires diverse treatment methods for its proper management. Therefore, we do not recommend its use in routine practice and, as is the case with every approach, considering the potential morbidity associated with resection of retrochiasmatic craniopharyngiomas, residual tumor is usually left behind when the risk of further cytoreduction is too high. Acknowledgments We thank Paul H. Dressel, BFA, for preparation of the illustrations and Debra J. Zimmer for editorial assistance. Previous Presentation Portions of this work were presented in poster form at the Annual Meeting of the American Association of Neurological Surgeons, Philadelphia, Pennsylvania, USA, May 1–5, 2010.

Note The study reported here was conducted in Buffalo, New York, United States, where all authors were working at the time. Dr. Binning is presently affiliated to Department of Neurosciences, Stroke and Cerebrovascular Center of New Jersey, Capital Health, Trenton, New Jersey, United States. Dr. Tawk is presently affiliated to Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, United States.


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11 Frank G, Pasquini E, Doglietto F, et al. The endoscopic extended

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Financial Relationships/Potential Conflicts of Interest Walter Grand has received honoraria for participating in a lecture series and practical courses sponsored by Aesculap. Adnan H. Siddiqui has received research grants from the National Institutes of Health (co-investigator: NINDS 1R01NS064592–01A1, Hemodynamic induction of pathologic remodeling leading to intracranial aneurysms) and the University at Buffalo (Research Development Award) (neither related to the present article); holds financial interests in Hotspur, Intratech Medical, StimSox, Valor Medical and Blockade Medical; serves as a consultant to Codman & Shurtleff, Inc., Concentric Medical, Covidien Vascular Therapies, GuidePoint Global Consulting, Penumbra, Inc., Stryker Neurovascular and Pulsar Vascular; belongs to the speakers’ bureaus of Codman & Shurtleff, Inc. and Genentech; serves on National Steering Committees for Penumbra, Inc. 3D Separator Trial and Covidien SWIFT PRIME Trial; serves on an advisory board for Codman & Shurtleff and Covidien Vascular Therapies; and has received honoraria from American Association of Neurological Surgeons’ courses, Annual Peripheral Angioplasty and All That Jazz Course, Penumbra, Inc., and from Abbott Vascular and Codman & Shurtleff, Inc. for training other neurointerventionists in carotid stenting and for training physicians in endovascular stenting for aneurysms. Dr. Siddiqui receives no consulting salary arrangements. All consulting is per project and/or per hour. The remaining authors having nothing to disclose.

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the lamina terminalis to tumors of the anterior part of the third ventricle. Surg Neurol 1984;22(2):157–163 Symon L, Sprich W. Radical excision of craniopharyngioma. Results in 20 patients. J Neurosurg 1985;62(2):174–181 Hakuba A, Nishimura S, Inoue Y. Transpetrosal-transtentorial approach and its application in the therapy of retrochiasmatic craniopharyngiomas. Surg Neurol 1985;24(4):405–415 Al-Mefty O, Hassounah M, Weaver P, Sakati N, Jinkins JR, Fox JL. Microsurgery for giant craniopharyngiomas in children. Neurosurgery 1985;17(4):585–595 Honegger J, Buchfelder M, Fahlbusch R. Surgical treatment of craniopharyngiomas: endocrinological results. J Neurosurg 1999;90(2):251–257 Lehrnbecher T, Müller-Scholden J, Danhauser-Leistner I, Sörensen N, von Stockhausen HB. Perioperative fluid and electrolyte management in children undergoing surgery for craniopharyngioma. A 10-year experience in a single institution. Childs Nerv Syst 1998; 14(6):276–279 Poretti A, Grotzer MA, Ribi K, Schönle E, Boltshauser E. Outcome of craniopharyngioma in children: long-term complications and quality of life. Dev Med Child Neurol 2004;46(4):220–229

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Copyright of Journal of Neurological Surgery. Part A. Central European Neurosurgery is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Endoscopic endonasal transplanum transtuberculum approach for resection of retrochiasmatic craniopharyngioma.

Surgical outcomes of the minimum anterior and posterior combined transpetrosal approach for resection of retrochiasmatic craniopharyngiomas with complicated conditions.

Endoscopic Endonasal Approach for Craniopharyngiomas.

Early outcome in endoscopic extended endonasal approach for removal of supradiaphragmatic craniopharyngiomas: a case series and a comprehensive review.

Endoscopic Endonasal Approach for Resection of Infundibular Granular Cell Tumor: Case Report and Literature Review.

The supraorbital endoscopic approach for aneurysms.

Subciliary Approach for Inferior Orbital Rim Fractures; Case Series and Literature Review.

The supraorbital endoscopic approach for tumors.

Minimizing immunosuppression: an alternative approach for anesthesiologists?

Contrast additivity: an alternative approach.

Limited-Form Wegener Granulomatosis Case: Anaesthetic Approach and Literature Review.

An alternative approach to NHI.

Editorial: The endoscopic keyhole supraorbital approach.

Unilateral Basal interhemispheric approach through the sphenoid sinus to retrochiasmatic and intrasellar craniopharyngiomas: surgical technique and results.

Nephroureterectomy for emphysematous pyelonephritis: An aggressive approach is sometimes necessary. A case report and literature review.

Intracavitary Irradiation as a Safe Alternative for Cystic Craniopharyngiomas: Case Report and Review of the Literature.

Microsurgical resection of extensive craniopharyngiomas using a frontolateral approach: operative technique and outcome.

Bronchoplastic closure as an alternative approach for tracheal reconstruction following resection of a massive tracheal tumour.

Extended endoscopic endonasal approach for recurrent or residual adult craniopharyngiomas.

Screening mammography guidelines: an alternative proactive approach.

Gynecological cancers: an alternative approach to healing.

Hypnotizability is modifiable: an alternative approach.

An alternative approach for removal of placental remnants: hysteroscopic morcellation.

Interfascial Dissection for Protection of the Nerve Branches to the Frontalis Muscles during Supraorbital Trans-Eyebrow Approach: An Anatomical Study and Technical Note.