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Neurosurgical Review

, Volume 36, Issue 1, pp 27–38 | Cite as

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

  • Luigi Maria Cavallo
  • Domenico Solari
  • Felice Esposito
  • Paolo Cappabianca
Original Article

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.

Keywords

Craniopharyngioma Endoscopic endonasal surgery Third ventricle surgery Transsphenoidal surgery Endoscopic anatomy 

Notes

References

  1. 1.
    Amar AP, Ghosh S, Apuzzo MLJ (2004) Ventricular tumors. In: Winn HR (ed) Youmans neurological surgery. WB Saunders, Philadelphia, pp 1237–1263Google Scholar
  2. 2.
    Apuzzo ML (1988) Surgery of masses affecting the third ventricular chamber: techniques and strategies. Clin Neurosurg 34:499–522PubMedGoogle Scholar
  3. 3.
    Apuzzo ML, Chikovani OK, Gott PS, Teng EL, Zee CS, Giannotta SL, Weiss MH (1982) Transcallosal, interfornicial approaches for lesions affecting the third ventricle: surgical considerations and consequences. Neurosurgery 10(5):547–554PubMedCrossRefGoogle Scholar
  4. 4.
    Apuzzo MLJ, Litofsky NS (1993) Surgery in and aound the anterior third ventricle. In: Apuzzo MLJ (ed) Brain surgery. Churchill Livingstone, New York, pp 541–579Google Scholar
  5. 5.
    Cai R, Di X (2010) Combined intra- and extra-endoscopic techniques for aggressive resection of subependymal giant cell astrocytomas. World Neurosurg 73(6):713–718. doi: 10.1016/j.wneu.2010.02.068 PubMedCrossRefGoogle Scholar
  6. 6.
    Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A, de Divitiis E (2008) Extended endoscopic endonasal approach to the midline skull base: the evolving role of transsphenoidal surgery. In: Pickard JD, Akalan N, Di Rocco C et al (eds) Advances and technical standards in neurosurgery. Springer, Wien, pp 152–199Google Scholar
  7. 7.
    Cappabianca P, Cinalli G, Gangemi M, Brunori A, Cavallo LM, de Divitiis E, Decq P, Delitala A, Di Rocco F, Frazee J, Godano U, Grotenhuis A, Longatti P, Mascari C, Nishihara T, Oi S, Rekate H, Schroeder HW, Souweidane MM, Spennato P, Tamburrini G, Teo C, Warf B, Zymberg ST (2008) Application of neuroendoscopy to intraventricular lesions. Neurosurgery 62(Suppl 2):575–597. doi: 10.1227/01.neu.0000316262.74843.dd, discussion 597–578PubMedGoogle Scholar
  8. 8.
    Cappabianca P, de Divitiis E (2004) Endoscopy and transsphenoidal surgery. Neurosurgery 54(5):1043–1048, discussions 1048–1050PubMedCrossRefGoogle Scholar
  9. 9.
    Cappabianca P, Esposito F, Magro F, Cavallo LM, Solari D, Stella L, de Divitiis O (2010) Natura abhorret a vacuo—use of fibrin glue as a filler and sealant in neurosurgical "dead spaces". Technical note. Acta Neurochir (Wien) 152(5):897–904. doi: 10.1007/s00701-009-0580-2 CrossRefGoogle Scholar
  10. 10.
    Cappabianca P, Frank G, Pasquini E, de Divitiis O, Calbucci F (2003) Extended endoscopic endonasal transsphenoidal approaches to the suprasellar region, planum sphenoidale and clivus. In: de Divitiis E, Cappabianca P (eds) Endoscopic endonasal transsphenoidal surgery. Springer, Wien, pp 176–187CrossRefGoogle Scholar
  11. 11.
    Carmel PW (1985) Tumours of the third ventricle. Acta Neurochir (Wien) 75(1–4):136–146CrossRefGoogle Scholar
  12. 12.
    Carrau RL, Jho HD, Ko Y (1996) Transnasal–transsphenoidal endoscopic surgery of the pituitary gland. Laryngoscope 106(7):914–918PubMedCrossRefGoogle Scholar
  13. 13.
    Castelnuovo P, Locatelli D, Mauri S (2003) Extended endoscopic approaches to the skull base. Anterior cranial base CSF leaks. In: de Divitiis E, Cappabianca P (eds) Endoscopic endonasal transsphenoidal surgery. Springer, Wien, pp 137–158CrossRefGoogle Scholar
  14. 14.
    Cavallo LM, de Divitiis O, Aydin S, Messina A, Esposito F, Iaconetta G, Talat K, Cappabianca P, Tschabitscher M (2007) Extended endoscopic endonasal transsphenoidal approach to the suprasellar area: anatomic considerations—part 1. Neurosurgery 61:ONS-24–ONS-34CrossRefGoogle Scholar
  15. 15.
    Cavallo LM, Messina A, Esposito F, de Divitiis O, Dal Fabbro M, de Divitiis E, Cappabianca P (2007) Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions. J Neurosurg 107(4):713–720PubMedCrossRefGoogle Scholar
  16. 16.
    Cinalli G, Cappabianca P, de Falco R, Spennato P, Cianciulli E, Cavallo LM, Esposito F, Ruggiero C, Maggi G, de Divitiis E (2005) Current state and future development of intracranial neuroendoscopic surgery. Expert Rev Med Devices 2(3):351–373PubMedCrossRefGoogle Scholar
  17. 17.
    Couldwell WT, Weiss MH, Rabb C, Liu JK, Apfelbaum RI, Fukushima T (2004) Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases. Neurosurgery 55(3):539–550PubMedCrossRefGoogle Scholar
  18. 18.
    de Divitiis E, Cappabianca P, Cavallo LM, Esposito F, de Divitiis O, Messina A (2007) Extended endoscopic transsphenoidal approach for extrasellar craniopharyngiomas. Neurosurgery 61(5 Suppl 2):219–227. doi: 10.1227/01.neu.0000303220.55393.73, discussion 228PubMedCrossRefGoogle Scholar
  19. 19.
    de Divitiis E, Cavallo LM, Cappabianca P, Esposito F (2007) Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: part 2. Neurosurgery 60(1):46–58, discussion 58-59PubMedGoogle Scholar
  20. 20.
    Delitala A, Brunori A, Chiappetta F (2004) Purely neuroendoscopic transventricular management of cystic craniopharyngiomas. Childs Nerv Syst 20(11–12):858–862. doi: 10.1007/s00381-004-0943-1 PubMedCrossRefGoogle Scholar
  21. 21.
    Fahlbusch R, Honegger J, Paulus W, Huk W, Buchfelder M (1999) Surgical treatment of craniopharyngiomas: experience with 168 patients. J Neurosurg 90(2):237–250PubMedCrossRefGoogle Scholar
  22. 22.
    Fortes FS, Carrau RL, Snyderman CH, Kassam A, Prevedello D, Vescan A, Mintz A, Gardner P (2007) Transpterygoid transposition of a temporoparietal fascia flap: a new method for skull base reconstruction after endoscopic expanded endonasal approaches. Laryngoscope 117(6):970–976. doi: 10.1097/MLG.0b013e3180471482 PubMedCrossRefGoogle Scholar
  23. 23.
    Fraioli B, Pastore FS, Floris R, Vagnozzi R, Simonetti G, Liccardo G, Giuffre R (1997) Computed tomography-guided transsphenoidal closure of postsurgical cerebrospinal fluid fistula: a transmucosal needle technique. Surg Neurol 48(4):409–412, discussion 412-403PubMedCrossRefGoogle Scholar
  24. 24.
    Frank G, Pasquini E, Doglietto F, Mazzatenta D, Sciaretta V, Farneti G, Calbucci F (2006) The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery 59(suppl 1):ONS75–ONS83PubMedGoogle Scholar
  25. 25.
    Fukushima T, Hirakawa K, Kimura M, Tomonaga M (1990) Intraventricular craniopharyngioma: its characteristics in magnetic resonance imaging and successful total removal. Surg Neurol 33(1):22–27PubMedCrossRefGoogle Scholar
  26. 26.
    Fukushima T, Ishijima B, Hirakawa K, Nakamura N, Sano K (1973) Ventriculofiberscope: a new technique for endoscopic diagnosis and operation. Technical note. J Neurosurg 38(2):251–256. doi: 10.3171/jns.1973.38.2.0251 PubMedCrossRefGoogle Scholar
  27. 27.
    Gardner PA, Kassam AB, Snyderman CH, Carrau RL, Mintz AH, Grahovac S, Stefko S (2008) Outcomes following endoscopic, expanded endonasal resection of suprasellar craniopharyngiomas: a case series. J Neurosurg 109(1):6–16. doi: 10.3171/JNS/2008/109/7/0006 PubMedCrossRefGoogle Scholar
  28. 28.
    Gardner PA, Prevedello DM, Kassam AB, Snyderman CH, Carrau RL, Mintz AH (2008) The evolution of the endonasal approach for craniopharyngiomas. J Neurosurg 108(5):1043–1047. doi: 10.3171/JNS/2008/108/5/1043 PubMedCrossRefGoogle Scholar
  29. 29.
    Geffen G, Walsh A, Simpson D, Jeeves M (1980) Comparison of the effects of transcortical and transcallosal removal of intraventricular tumours. Brain 103(4):773–788PubMedCrossRefGoogle Scholar
  30. 30.
    Gore PA, Nakaji P, Deshmukh V, Rekate HL (2006) Synchronous endoscopy and microsurgery: a novel strategy to approach complex ventricular lesions. Report of three cases. J Neurosurg 105(6 Suppl):485–489. doi: 10.3171/ped.2006.105.6.485 PubMedGoogle Scholar
  31. 31.
    Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, Mintz A (2006) A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 116(10):1882–1886PubMedCrossRefGoogle Scholar
  32. 32.
    Harris AE, Hadjipanayis CG, Lunsford LD, Lunsford AK, Kassam AB (2005) Microsurgical removal of intraventricular lesions using endoscopic visualization and stereotactic guidance. Neurosurgery 56(1 Suppl):125–132, discussion 125-132PubMedCrossRefGoogle Scholar
  33. 33.
    Hori T, Kawamata T, Amano K, Aihara Y, Ono M, Miki N (2010) Anterior interhemispheric approach for 100 tumors in and around the anterior third ventricle. Neurosurgery 66(3 Suppl Operative):65–74. doi: 10.1227/01.NEU.0000365550.84124.BB PubMedGoogle Scholar
  34. 34.
    Jane JA Jr, Prevedello DM, Alden TD, Laws ER Jr (2010) The transsphenoidal resection of pediatric craniopharyngiomas: a case series. J Neurosurg Pediatr 5(1):49–60. doi: 10.3171/2009.7.PEDS09252 PubMedCrossRefGoogle Scholar
  35. 35.
    Jho HD (2001) The expanding role of endoscopy in skull-base surgery. Indications and instruments. Clin Neurosurg 48:287–305PubMedGoogle Scholar
  36. 36.
    Kasowski HJ, Nahed BV, Piepmeier JM (2005) Transcallosal transchoroidal approach to tumors of the third ventricle. Neurosurgery 57(4 Suppl):361–366, discussion 361-366PubMedCrossRefGoogle Scholar
  37. 37.
    Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL (2005) Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus 19(1):E3:1–E3:12Google Scholar
  38. 38.
    Kassam A, Thomas AJ, Snyderman C, Carrau R, Gardner P, Mintz A, Kanaan H, Horowitz M, Pollack IF (2007) Fully endoscopic expanded endonasal approach treating skull base lesions in pediatric patients. J Neurosurg 106(2 Suppl):75–86PubMedGoogle Scholar
  39. 39.
    Kassam AB, Gardner PA, Snyderman CH, Carrau RL, Mintz AH, Prevedello DM (2008) Expanded endonasal approach, a fully endoscopic transnasal approach for the resection of midline suprasellar craniopharyngiomas: a new classification based on the infundibulum. J Neurosurg 108(4):715–728. doi: 10.3171/JNS/2008/108/4/0715 PubMedCrossRefGoogle Scholar
  40. 40.
    Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P, Zanation A, Duz B, Stefko ST, Byers K, Horowitz MB (2011) Endoscopic endonasal skull base surgery: analysis of complications in the authors' initial 800 patients. J Neurosurg 114(6):1544–1568. doi: 10.3171/2010.10.JNS09406 PubMedCrossRefGoogle Scholar
  41. 41.
    Kassam AB, Prevedello DM, Thomas A, Gardner P, Mintz A, Snyderman C, Carrau R (2008) Endoscopic endonasal pituitary transposition for a transdorsum sellae approach to the interpeduncular cistern. Neurosurgery 62(3 Suppl 1):57–72. doi: 10.1227/01.neu.0000317374.30443.23, discussion 72–74PubMedCrossRefGoogle Scholar
  42. 42.
    Kassam AB, Thomas A, Carrau RL, Snyderman CH, Vescan A, Prevedello D, Mintz A, Gardner P (2008) Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 63(1 Suppl 1):ONS44–ONS52. doi: 10.1227/01.neu.0000335010.53122.75, discussion ONS52–ONS53PubMedCrossRefGoogle Scholar
  43. 43.
    Konovalov AN, Gorelyshev SK (1992) Surgical treatment of anterior third ventricle tumours. Acta Neurochir (Wien) 118(1–2):33–39CrossRefGoogle Scholar
  44. 44.
    Kunwar S (2003) Endoscopic adjuncts to intraventricular surgery. Neurosurg Clin N Am 14(4):547–557PubMedCrossRefGoogle Scholar
  45. 45.
    Laws ER Jr (1994) Transsphenoidal removal of craniopharyngioma. Pediatr Neurosurg 21(Suppl 1):57–63PubMedCrossRefGoogle Scholar
  46. 46.
    Laws ER, Kanter AS, Jane JA Jr, Dumont AS (2005) Extended transsphenoidal approach. J Neurosurg 102(5):825–827, discussion 827-828PubMedCrossRefGoogle Scholar
  47. 47.
    Leng LZ, Brown S, Anand VK, Schwartz TH (2008) "Gasket-seal" watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery 62(5 Suppl 2):ONSE342–ONSE343. doi: 10.1227/01.neu.0000326017.84315.1f, discussion ONSE343PubMedCrossRefGoogle Scholar
  48. 48.
    Lewis AI, Crone KR, Taha J, van Loveren HR, Yeh HS, Tew JM Jr (1994) Surgical resection of third ventricle colloid cysts. Preliminary results comparing transcallosal microsurgery with endoscopy. J Neurosurg 81(2):174–178. doi: 10.3171/jns.1994.81.2.0174 PubMedCrossRefGoogle Scholar
  49. 49.
    Locatelli D, Massimi L, Rigante M, Custodi V, Paludetti G, Castelnuovo P, Di Rocco C (2010) Endoscopic endonasal transsphenoidal surgery for sellar tumors in children. Int J Pediatr Otorhinolaryngol 74(11):1298–1302. doi: 10.1016/j.ijporl.2010.08.009 PubMedCrossRefGoogle Scholar
  50. 50.
    Maira G, Anile C, Albanese A, Cabezas D, Pardi F, Vignati A (2004) The role of transsphenoidal surgery in the treatment of craniopharyngiomas. J Neurosurg 100(3):445–451PubMedCrossRefGoogle Scholar
  51. 51.
    Prevedello DM, Doglietto F, Jane JA Jr, Jagannathan J, Han J, Laws ER Jr (2007) History of endoscopic skull base surgery: its evolution and current reality. J Neurosurg 107(1):206–213PubMedCrossRefGoogle Scholar
  52. 52.
    Rhoton AL Jr (2002) The lateral and third ventricles. Neurosurgery 51(4 Suppl):S207–S271PubMedGoogle Scholar
  53. 53.
    Rosenfeld JV (2011) The evolution of treatment for hypothalamic hamartoma: a personal odyssey. Neurosurg Focus 30(2):E1PubMedCrossRefGoogle Scholar
  54. 54.
    Rutka JT (2008) Endonasal resection of craniopharyngiomas. J Neurosurg 109(1):1. doi: 10.3171/JNS/2008/109/7/0001, reply 3–5PubMedGoogle Scholar
  55. 55.
    Sainte-Rose C, Puget S, Wray A, Zerah M, Grill J, Brauner R, Boddaert N, Pierre-Kahn A (2005) Craniopharyngioma: the pendulum of surgical management. Childs Nerv Syst 21(8–9):691–695. doi: 10.1007/s00381-005-1209-2 PubMedCrossRefGoogle Scholar
  56. 56.
    Samii M, Bini W (1991) Surgical treatment of craniopharyngiomas. Zentralbl Neurochir 52(1):17–23PubMedGoogle Scholar
  57. 57.
    Samii M, Samii A (2000) Surgical management of craniopharyngiomas. In: Schmidek HH (ed) Schmidek & Sweet operative neurosurgical techniques. Indications, methods and results, vol 1. WB Saunders, Philadelphia, pp 489–502Google Scholar
  58. 58.
    Seeger W (2006) Endoscopic anatomy of the third ventricle. Microsurgical and endoscopic approaches. Springer, WienGoogle Scholar
  59. 59.
    Souweidane MM, Sandberg DI, Bilsky MH, Gutin PH (2000) Endoscopic biopsy for tumors of the third ventricle. Pediatr Neurosurg 33(3):132–137PubMedCrossRefGoogle Scholar
  60. 60.
    Spaziante R, de Divitiis E (1997) Drainage techniques for cystic craniopharyngiomas. Neurosurg Quart 7:183–208CrossRefGoogle Scholar
  61. 61.
    Steno J, Malacek M, Bizik I (2004) Tumor-third ventricular relationships in supradiaphragmatic craniopharyngiomas: correlation of morphological, magnetic resonance imaging, and operative findings. Neurosurgery 54(5):1051–1058, discussion 1058-1060PubMedCrossRefGoogle Scholar
  62. 62.
    Wait SD, Abla AA, Killory BD, Nakaji P, Rekate HL (2011) Surgical approaches to hypothalamic hamartomas. Neurosurg Focus 30(2):E2PubMedCrossRefGoogle Scholar
  63. 63.
    Weiss MH (1987) The transnasal transsphenoidal approach. In: Apuzzo MLJ (ed) Surgery of the third ventricle. Williams & Wilkins, Baltimore, pp 476–494Google Scholar
  64. 64.
    Wen HT, Rhoton AL Jr, de Oliveira E (1998) Transchoroidal approach to the third ventricle: an anatomic study of the choroidal fissure and its clinical application. Neurosurgery 42(6):1205–1217, discussion 1217–1209PubMedCrossRefGoogle Scholar
  65. 65.
    Winkler PA, Ilmberger J, Krishnan KG, Reulen HJ (2000) Transcallosal interforniceal-transforaminal approach for removing lesions occupying the third ventricular space: clinical and neuropsychological results. Neurosurgery 46(4):879–888, discussion 888-890PubMedGoogle Scholar
  66. 66.
    Winkler PA, Weis S, Buttner A, Raabe A, Amiridze N, Reulen HJ (1997) The transcallosal interforniceal approach to the third ventricle: anatomic and microsurgical aspects. Neurosurgery 40(5):973–981, discussion 981–972PubMedCrossRefGoogle Scholar
  67. 67.
    Woiciechowsky C, Vogel S, Lehmann R, Staudt J (1995) Transcallosal removal of lesions affecting the third ventricle: an anatomic and clinical study. Neurosurgery 36(1):117–122, discussion 122-113PubMedCrossRefGoogle Scholar
  68. 68.
    Yasargil MG (1996) Craniopharyngiomas. In: Yasargil MG (ed) Microneurosurgery: microneurosurgery of CNS tumors, vol IV B. Thieme, StuttgartGoogle Scholar
  69. 69.
    Yasargil MG, Abdulrauf SI (2008) Surgery of intraventricular tumors. Neurosurgery 62(6 Suppl 3):1029–1040. doi: 10.1227/01.neu.0000333768.12951.9a, discussion 1040-1021PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Luigi Maria Cavallo
    • 1
  • Domenico Solari
    • 1
  • Felice Esposito
    • 1
  • Paolo Cappabianca
    • 1
  1. 1.Department of Neurological Sciences, Division of NeurosurgeryUniversità degli Studi di Napoli Federico IINaplesItaly

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