Elsevier

World Neurosurgery

Volume 109, January 2018, Pages e265-e273
World Neurosurgery

Original Article
Subtemporal Approach for Gross Total Resection of Retrochiasmatic Craniopharyngiomas: Our Experience on 30 Cases

https://doi.org/10.1016/j.wneu.2017.09.159Get rights and content

Background

Surgical treatment of retrochiasmatic craniopharyngiomas is associated with higher rates of complications, mortality, failure of complete removal, and recurrence compared with craniopharyngiomas located elsewhere. These tumors lie behind the optic chiasm and when large can extend upward into the third ventricle and downward along the brain stem, making their adequate exposure challenging. Most of the proposed techniques either use a translamina terminalis route or require wide bony exposures. In this study, we assessed the feasibility of a subtemporal approach for achieving gross total resection of retrochiasmatic craniopharyngiomas.

Methods

Thirty patients with retrochiasmatic craniopharyngioma underwent surgery via a subtemporal approach. The technique and surgical and preoperative and postoperative endocrinologic outcomes are described in detail.

Results

Gross total resection was achieved in all cases. The average tumor volume was 7.59 mL. The average postsurgical observation time was 73.8 months. During this time, 3 recurrences were observed (10.7%). The perioperative mortality was 6.6%. The pituitary stalk was preserved in 13 cases. Partial preservation of the pituitary stalk did not offer any advantage in terms of pituitary function. No postoperative vision worsening or new fixed neurologic deficits were observed. Among the 22 patients with preoperative vision impairment, 18 reported a significant improvement. The most common abnormalities within the temporal lobe on the side of the exposure seen on control magnetic resonance imaging were mild temporal horn enlargement (13 cases) and T2 hyperintensity (7 cases).

Conclusions

A subtemporal approach can be an attractive alternative approach to accessing retrochiasmatic craniopharyngiomas. Outcomes are comparable to those associated with other widely used and time-consuming exposures.

Introduction

Craniopharyngiomas are embryonic epithelial tumors that, despite benign histology, pose a significant treatment challenge owing to their location and proximity to vital structures, mainly the visual pathways, pituitary gland, and diencephalic structures.1 These tumors can arise anywhere along the craniopharyngeal duct, but most often occur in the sellar/parasellar region.2 The annual incidence is 0.5–2 cases per million, and 30%–50% of all cases present during childhood and adolescence.3, 4 A bimodal age distribution is observed, with the first peak in children aged 0–19 years and a second peak in adults aged 40–79.5 Although these lesions present challenges in terms of their location and the difficulty of radical resection, complete removal offers the best curative chance, whereas subtotal removal is reportedly associated with higher recurrence rates.6

The choice of surgical approach for craniopharyngiomas is dictated mainly by the location of the tumor in relation to the sella turcica and optic chiasm. If the predominant portion of the tumor is sellar, then a transsphenoidal approach is advocated.1 Even some suprasellar portions of the tumor can be manipulated into the sella and resected.7 However, for mainly suprasellar craniopharyngiomas, pterional craniotomy remains the most frequently used approach.8, 9, 10, 11, 12

In relation to the optic chiasm, suprasellar tumors can be prechiasmatic, infrachiasmatic, retrochiasmatic, or a combination of these.13 Retrochiasmatic lesions lie behind the optic chiasm and when large can extend into the third ventricle and along the brain stem.14 Thus, they are the most challenging to treat and are associated with higher surgical mortality, failure of complete removal, increased complications, and higher recurrence rate.6, 7, 8, 13, 15, 16 Several techniques have been proposed for achieving adequate exposure of retrochiasmatic craniopharyngiomas. Most of these techniques either use a translamina terminalis route or require wide bone exposures otherwise used for accessing lesions located in the interpeduncular fossa. The first group includes subfrontal, combined subfrontal and transsphenoidal, pterional (with its modifications), and bifrontal interhemispheric approaches.7, 10, 12, 13, 15, 17, 18, 19 The latter group includes zygomatic, basal interhemispheric, suprachiasmal or infrachiasmal, and petrosal approaches.14, 20, 21

In this study, we present our experience with the use of a subtemporal approach for the complete resection of retrochiasmatic craniopharyngiomas. Technical details and our experience with 30 cases are described.

Section snippets

Patients

Thirty patients with a diagnosed retrochiasmatic craniopharyngioma were operated on by the senior author (G.Z.) between 2003 and 2015 at our department using the subtemporal approach. A retrospective analysis of their medical records was performed. The mean patient age at the time of surgery was 40.5 years (range, 17–68 years). There were 19 females and 11 males. The average observation time was 73.8 months. Institutional Review Board/Ethics Committee approval was not required for this study,

Resection Outcomes

GTR was achieved in all patients. The pituitary stalk was preserved in 13 patients and resected with the tumor in 9 patients. In the remaining 8 patients, only a shred of the stalk was left. There were 2 perioperative deaths. One patient (case 1) became comatose immediately after awaking from anesthesia and developed left-sided hemiparesis. An emergency head computed tomography scan revealed a massive right-sided epidural hematoma posterior to the site of her subtemporal craniotomy. The patient

Discussion

Conventional anterolateral approaches to retrochiasmatic craniopharyngiomas carry a risk of injuring the perforators of the optic chiasm and hypothalamus, because the tumor is hidden behind the optic chiasm and, if large enough, invaginates the floor of the third ventricle.14, 23, 24 Compared with prechiasmatic craniopharyngiomas, visualization of the tumor is unsatisfactory, and the working distance is large in these approaches.14, 24 Craniopharyngiomas invading mainly the third ventricle are

Conclusions

The subtemporal approach is a convenient route for GTR of retrochiasmatic craniopharyngiomas, offering an excellent caudal-to-cranial angle of attack without the need for extensive bone removal. GTR with excellent recurrence-free survival is achievable even with large lesions penetrating into the third ventricle and compressing the brain stem. Perioperative mortality, recurrence rate, and the incidence of new endocrinologic disturbances are comparable to those reported in other series of

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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