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The endoscopic endonasal approach for the management of craniopharyngiomas involving the third ventricle

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Abstract

The third ventricle has historically represented one of the most challenging areas to access surgically, so that lesions directly harboring into the ventricular chamber or secondarily extending into it from adjacent areas have been approached by means of different transcranial routes. The aim of this work is to report our experience with the endoscopic endonasal approach in the management of a series of patients affected by craniopharyngiomas, extending into or arising from the third ventricle, evaluating pros and cons of this technique, also in regards of the anatomy and the pathology dealt with. During the period between January 2001 and February 2011, 12 patients, 9 male and 3 female (mean age 50.4 years; range 12-68) underwent an endoscopic endonasal approach for the treatment of a craniopharyngioma involving or arising from the third ventricle. According to the grade of involvement of the third ventricle, we identified three main ventricular growth patterns: (1) stalk–infundibulum; (2) infundibulum–ventricular chamber; (3) stalk–infundibulum–ventricular chamber. Though gross total removal was achieved in eight patients (66.7 %), in three patients (25 %) was possible a near total removal (>95 %) and only in one case (8.3 %) tumor removal has been partial (<50 %). The overall analysis revealed a rate of 77.8 % improvement of post-operative visual defects. Concerning the complications, we reported an overall CSF rate of 16.7 %; two patients developed a subdural hematoma that has been treated with a surgical drainage. One patient died after the occurrence of a brainstem hemorrhage. The endoscopic endonasal route provides a good exposure, especially of the sub- and retro-chiasmatic areas, as well as of the stalk–infundibulum axis, which represents, when directly involved by a lesion, a gate to access the third ventricle chamber. Despite this study reporting only a preliminary experience, it seems that in properly selected cases—namely tumors growing mostly along the pituitary stem–infundibulum–third ventricle axis—this approach could be advocated as a valid route among the wide kaleidoscope of surgical approaches to the third ventricle.

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  1. Department of Neurological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Via Pansini 5, 80131, Naples, Italy

    Luigi Maria Cavallo, Domenico Solari, Felice Esposito & Paolo Cappabianca

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  1. Luigi Maria Cavallo
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Alvaro Campero and Abraham Agustín Campero, Tucumán, Argentina

The paper “The endoscopic endonasal approach for the management of craniopharyngiomas involving the third ventricle” is indeed well related to present day treatment of a very difficult surgical pathology: craniopharyngiomas affecting the third ventricle. Abstract is well summarized. Introduction guides us to a brief, as should be, historical background, pointing out differences between craniotomy, endonasal microscopic and endonasal endoscopic approaches; all of them are, of course, microsurgical in nature. Review of surgical operations carried out in a span of 10 years, with a total of 12 patients with craniopharyngiomas involved at different degrees the third ventricle, operated is large enough and really very comprehensive for what authors call a preliminary experience; besides, the technique applied was basically the same in every patient and lesions had different types of extensions in those areas. We find relevant to this kind of surgery the mention by the authors of Kassam very useful classification based upon the presence of craniopharyngiomas somewhere within the infundibulum, rather behind this most important structure either with rostral or caudal expansions, or even inside the third ventricle including its optic recess. Anatomy of the operating zone with emphasis on optic chiasm, pituitary stalk and mammillary bodies is well synthesized. Explanations regarding surgical anatomy, as observed after changes provoked by the expanding process, are also properly explained. Surgical technique has been expressed quite well including modern ways of avoiding CSF fistula among other complications. Conclusions are short, with each paragraph being self-explanatory and pointing out the anatomical limits as seen in the various pre-operative images for the strategy of this treatment. We consider this paper well written, easy to read, with every necessary detail properly explained which no doubt will be useful for both neurosurgeons and trainees; it is therefore an article worth publishing.

Giannantonio Spena and Marco Maria Fontanella, Brescia, Italy

In this paper, Cavallo et al. describe their experience with the endoscopic transsphenoidal resection of craniopharyngiomas (CPs). In these 12 patients, the authors achieved very good results in terms of extent of resection with a very large percentage of near total or gross total resection. Clinically, more than two thirds of the subjects improved their visual acuity. Although small, this series gives us the opportunity to make some surgical and technical consideration. First, the extensive experience of the authors in the field of transsphenoidal surgery made it possible to face such a complex and somewhat rare pathology. In fact, the “conditio sine qua non” to extirpate these CPs is that they must be located predominantly on the midline. In 2008, Kassam proposed a classification of these tumors (used in the current paper too) based on the relationship of the craniopharyngiomas with the infundibulum and indicating the transsphenoidal approach for the purely midline suprasellar craniopharyngiomas. Actually, the presence of a parasellar extension would make unsafe a single endonasal endoscopic approach, which rather would be better employed as the perfection of a transcranial route. Moreover, a favorable anatomy (a tumor that pushes the third ventricle toward the sella, a pre-fixed or anteriorly displaced chiasm, a very good pneumatization of the sphenoidal sinus in children) is mandatory for the safety and efficacy of such an approach. Taken together, all these conditions are rarely found and hence transsphenoidal route cannot be proposed routinely for CPs and selected Centers have to be detected in order to collect an increasing number of cases.

Concerning the complication rate, CSF fistulas are reported in 16.7 % of patients that globally seems not negligible. In that sense, the authors describe a technique of closure by using fibrin glue and other synthetic materials.

Cerebrospinal fluid leakage is an important problem in extended endoscopic approaches. In our opinion, most important points in closing the defect are using autogenic material such as fascia lata and mucosal flaps.

Deanna Sasaki-Adams, University of North Carolina in Chapel Hill, NC

Drs. Cavallo, Cappabianca, et al. have outlined their experience with the expanded endoscopic endonasal transphenoidal surgery for resection of craniopharyngiomas extending into the third ventricle over the past 10 years. Craniopharyngiomas are notoriously difficult tumors to treat with respect to embryology and intimate association with the pituitary neurohypophysis. Lesions residing within the third ventricle also pose a significant surgical challenge due to the close association with essential neurovascular structures and fiber tracts. In their series, gross total resection was achieved in two thirds of patients and near total resection in a quarter of patients. A near 80 % improvement was seen in visual defects and a CSF leak was identified in 16.7 % of patients. The sample size is small and so firm conclusions cannot be cemented. However, these tumors are challenging entities and the presented manuscript provides a welcome addition to the literature outlining the potential pitfalls as well as the benefits offered by this surgical route. As the endoscope becomes more firmly established in the neurosurgeon's armamentarium, reflecting on surgical outcomes and technique as the above paper describes will allow further advancement of this cadre of neurosurgery.

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Cavallo, L.M., Solari, D., Esposito, F. et al. The endoscopic endonasal approach for the management of craniopharyngiomas involving the third ventricle. Neurosurg Rev 36, 27–38 (2013). https://doi.org/10.1007/s10143-012-0403-4

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