Acta Neurochir (2014) 156:123–131 DOI 10.1007/s00701-013-1905-8
CLINICAL ARTICLE - BRAIN TUMORS
Frontobasal interhemispheric approach for large superasellar craniopharyngiomas: do the benefits outweigh the risks? Sheng Han & Xinxin Tie & Xiaofei Qin & Yunjie Wang & Anhua Wu
Received: 16 April 2013 / Accepted: 27 September 2013 / Published online: 19 October 2013 # Springer-Verlag Wien 2013
Abstract Objective Large suprasellar craniopharyngiomas are surgically challenging. The aim of our study was to explore the therapeutic efficacy of the frontobasal interhemispheric approach for these lesions. Methods Twenty-nine consecutive adult patients with large suprasellar craniopharyngiomas (diameter >4 cm) who underwent the frontobasal interhemispheric approach were retrospectively evaluated. Surgical and clinical outcomes were analyzed. Results Gross total removal was achieved in 23 cases (79.3 %) and subtotal removal in 6 cases (20.7 %). The mean follow-up period was 76.5 ± 33.2 months (range, 12-132 months). Twenty-four patients (82.7 %) had improvement of the visual impairment score (VIS) after surgery. VIS was unchanged in five patients (17.3 %), and no patients experienced visual deterioration. Among 23 patients who had preoperative hypopituitarism, 8 (34.8 %) had an improvement. Postoperative new or aggravated hypopituitarism was observed in four patients (13.8 %). Permanent diabetes insipidus was observed in ten patients (34.4 %). Postoperative anosmia occurred in two earlier cases (6.9 %). There was no intracranial infection or cerebrospinal fluid fistula. At last follow-up, >9 % BMI gain was observed in 34.5 % of patients, and 65.5 % of patients returned to work. Four patients (13.8 %) suffered recurrence. Conclusion Although the frontobasal interhemispheric approach has some disadvantages, it provides ideal access to the suprasellar region and the third ventricle with limited brain retraction. The surgically visible angle is adequate; thus, vital structures can be better protected. For large suprasellar S. Han : X. Tie : X. Qin : Y. Wang : A. Wu (*) Department of Neurosurgery, The First Hospital of China Medical University, Nanjing street 155, Heping District, Shenyang 110001, China e-mail: [email protected]
craniopharyngiomas, the benefits of this approach can outweigh its potential risks. Keywords Frontobasa interhemispheric approach . Suprasellar craniopharyngiomas . Third ventricle
Introduction The prognosis of large suprasellar craniopharyngiomas may be unfavorable. This is because of the infiltrative behavior of these lesions towards the pituitary axis and the hypothalamus and the tight adherences of these lesions with the optic pathways and the arteries, which can preclude a radical resection in certain cases. Moreover, lesions extending into the third ventricle and prepontine cistern present peculiar surgical problems because of their deep localization. Surgical removal of these lesions has been associated with a high rate of surgeryrelated morbidity and mortality, while incomplete removal often results in higher recurrence rates [8, 13, 15, 19, 24, 29]. The frontobasal interhemispheric approach for the resection of suprasellar craniopharyngiomas has always been controversial. The surgical procedure for this approach is relatively complicated, involving risks of olfactory nerve injury, interhemispheric blood vessel injury and frontal sinus violation [5]. However, by coming in from a midline projection and orientation, the frontobasal interhemispheric approach can maximize the working corridor and visualize important bilateral structures. In addition, this approach also provides superior access to the top of the third ventricle and inferiorly into the intrasellar region and prepontine cistern with limited brain retraction. Thus, for large suprasellar craniopharyngiomas, this approach has some unique advantages. In this article, we present our experience in the use of this approach and try
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Fig. 1 A 20-year-old woman presented with polydipsia and visual loss, and subsequently underwent the frontobasal interhemispheric approach. a-b: Preoperative MRI revealed suprasellar craniopharyngioma occupying the third ventricle. a T1-WI. b T2-WI. c-d: Postoperative MRI showed total removal of the tumor. c T1-WI. d T2-WI
to demonstrate whether its benefits can outweigh its risks for large suprasellar craniopharyngiomas.
after surgery, 1 year postoperatively and then annually for the remainder of the follow-up period. Visual evaluations
Materials and methods Patient details Between February 2002 and March 2012, in our hospital, 29 consecutive adult patients with suprasellar craniopharyngiomas underwent the frontobasal interhemispheric approach. The group of patients consisted of 20 females (69.0 %) and 9 males (31.0 %) whose age at the time of surgery ranged from 17 to 70 years (mean 35.0±10.7). Symptoms were present 2 months to 6 years before diagnosis. The most common symptoms were visual impairment (29/29), headache (22/29), menstrual disorders (11/29) and diabetes insipidus (10/29). Bitemporal hemianopia was found in 11 patients (37.9 %). (Table 1) Preoperative visual, endocrinological and radiological examinations were performed in all patients. These examinations were routinely repeated the day after surgery, 1 and 3 months
All patients presented with visual loss. Visual examinations included testing the patient’s visual acuity and visual field. The visual impairment score (VIS) was used to analyze the patients’ visual status. This score is used in the guidelines of the German Ophthalmological Society and was applied to the evaluation of visual outcomes of sellar lesions as previously described [9, 13]. A VIS is provided by adding the scores in specific tables given for visual acuity and visual field defects. The sum ranges from 0 (best) to 100 (worst). VIS change was considered an improvement or deterioration of visual function. Endocrinological evaluation Pre- and postoperative hypopituitarism was defined by the development of any mono- or polyhormonal deficiency. Hypoadrenalism was diagnosed in patients with low morning
Acta Neurochir (2014) 156:123–131
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Fig. 2 Surgical views. a Dissection of bilateral olfactory nerve. b Exposure of the retrochiasmatic tumor. c Identification of the anterior communicating artery (AcomA) and bilateral A1, A2. d Total removal of the tumor and exposure of the aqueduct
cortisol levels (
CLINICAL ARTICLE - BRAIN TUMORS
Frontobasal interhemispheric approach for large superasellar craniopharyngiomas: do the benefits outweigh the risks? Sheng Han & Xinxin Tie & Xiaofei Qin & Yunjie Wang & Anhua Wu
Received: 16 April 2013 / Accepted: 27 September 2013 / Published online: 19 October 2013 # Springer-Verlag Wien 2013
Abstract Objective Large suprasellar craniopharyngiomas are surgically challenging. The aim of our study was to explore the therapeutic efficacy of the frontobasal interhemispheric approach for these lesions. Methods Twenty-nine consecutive adult patients with large suprasellar craniopharyngiomas (diameter >4 cm) who underwent the frontobasal interhemispheric approach were retrospectively evaluated. Surgical and clinical outcomes were analyzed. Results Gross total removal was achieved in 23 cases (79.3 %) and subtotal removal in 6 cases (20.7 %). The mean follow-up period was 76.5 ± 33.2 months (range, 12-132 months). Twenty-four patients (82.7 %) had improvement of the visual impairment score (VIS) after surgery. VIS was unchanged in five patients (17.3 %), and no patients experienced visual deterioration. Among 23 patients who had preoperative hypopituitarism, 8 (34.8 %) had an improvement. Postoperative new or aggravated hypopituitarism was observed in four patients (13.8 %). Permanent diabetes insipidus was observed in ten patients (34.4 %). Postoperative anosmia occurred in two earlier cases (6.9 %). There was no intracranial infection or cerebrospinal fluid fistula. At last follow-up, >9 % BMI gain was observed in 34.5 % of patients, and 65.5 % of patients returned to work. Four patients (13.8 %) suffered recurrence. Conclusion Although the frontobasal interhemispheric approach has some disadvantages, it provides ideal access to the suprasellar region and the third ventricle with limited brain retraction. The surgically visible angle is adequate; thus, vital structures can be better protected. For large suprasellar S. Han : X. Tie : X. Qin : Y. Wang : A. Wu (*) Department of Neurosurgery, The First Hospital of China Medical University, Nanjing street 155, Heping District, Shenyang 110001, China e-mail: [email protected]
craniopharyngiomas, the benefits of this approach can outweigh its potential risks. Keywords Frontobasa interhemispheric approach . Suprasellar craniopharyngiomas . Third ventricle
Introduction The prognosis of large suprasellar craniopharyngiomas may be unfavorable. This is because of the infiltrative behavior of these lesions towards the pituitary axis and the hypothalamus and the tight adherences of these lesions with the optic pathways and the arteries, which can preclude a radical resection in certain cases. Moreover, lesions extending into the third ventricle and prepontine cistern present peculiar surgical problems because of their deep localization. Surgical removal of these lesions has been associated with a high rate of surgeryrelated morbidity and mortality, while incomplete removal often results in higher recurrence rates [8, 13, 15, 19, 24, 29]. The frontobasal interhemispheric approach for the resection of suprasellar craniopharyngiomas has always been controversial. The surgical procedure for this approach is relatively complicated, involving risks of olfactory nerve injury, interhemispheric blood vessel injury and frontal sinus violation [5]. However, by coming in from a midline projection and orientation, the frontobasal interhemispheric approach can maximize the working corridor and visualize important bilateral structures. In addition, this approach also provides superior access to the top of the third ventricle and inferiorly into the intrasellar region and prepontine cistern with limited brain retraction. Thus, for large suprasellar craniopharyngiomas, this approach has some unique advantages. In this article, we present our experience in the use of this approach and try
124
Acta Neurochir (2014) 156:123–131
Fig. 1 A 20-year-old woman presented with polydipsia and visual loss, and subsequently underwent the frontobasal interhemispheric approach. a-b: Preoperative MRI revealed suprasellar craniopharyngioma occupying the third ventricle. a T1-WI. b T2-WI. c-d: Postoperative MRI showed total removal of the tumor. c T1-WI. d T2-WI
to demonstrate whether its benefits can outweigh its risks for large suprasellar craniopharyngiomas.
after surgery, 1 year postoperatively and then annually for the remainder of the follow-up period. Visual evaluations
Materials and methods Patient details Between February 2002 and March 2012, in our hospital, 29 consecutive adult patients with suprasellar craniopharyngiomas underwent the frontobasal interhemispheric approach. The group of patients consisted of 20 females (69.0 %) and 9 males (31.0 %) whose age at the time of surgery ranged from 17 to 70 years (mean 35.0±10.7). Symptoms were present 2 months to 6 years before diagnosis. The most common symptoms were visual impairment (29/29), headache (22/29), menstrual disorders (11/29) and diabetes insipidus (10/29). Bitemporal hemianopia was found in 11 patients (37.9 %). (Table 1) Preoperative visual, endocrinological and radiological examinations were performed in all patients. These examinations were routinely repeated the day after surgery, 1 and 3 months
All patients presented with visual loss. Visual examinations included testing the patient’s visual acuity and visual field. The visual impairment score (VIS) was used to analyze the patients’ visual status. This score is used in the guidelines of the German Ophthalmological Society and was applied to the evaluation of visual outcomes of sellar lesions as previously described [9, 13]. A VIS is provided by adding the scores in specific tables given for visual acuity and visual field defects. The sum ranges from 0 (best) to 100 (worst). VIS change was considered an improvement or deterioration of visual function. Endocrinological evaluation Pre- and postoperative hypopituitarism was defined by the development of any mono- or polyhormonal deficiency. Hypoadrenalism was diagnosed in patients with low morning
Acta Neurochir (2014) 156:123–131
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Fig. 2 Surgical views. a Dissection of bilateral olfactory nerve. b Exposure of the retrochiasmatic tumor. c Identification of the anterior communicating artery (AcomA) and bilateral A1, A2. d Total removal of the tumor and exposure of the aqueduct
cortisol levels (
