Acta Neurochirurgica 32, 297--301 (t975) 9 by Springer-Verlag 1975
Division of Neurological Surgery, University of Southern California, Los Angeles, California.
Total Removal of a Craniopharyngioma Teehr~ical
Note
By
A. Talalla With 4 Figures
Summary A technique is described for dealing with large solid calcified fragments of eraniopharyngiomas whose size would ordinarily render such a lesion inoperable. The advent of the surgical microscope, the use of self retaining brain retractors and the improved techniques for reducing intracranial volume have all contributed to an era of neurosurgery which necessitates the reevaluation of intracranial lesions hitherto thought to be "inoperable". A striking example of the effects of these adjuncts to neurosurgery is in the legitimate expectations of direct treatmer~t of intracranial aneurysms, the preservation of neurovaseular structures during the removal of strategically placed turnouts and in the safe accessibility to even the deepest intracranial structures. Although the eraniopharyngioma is not a neoplasm, its life-threatening propensities are allied to the recurrences that can be associated with such simple procedures as evacuating the cystic component of such ~tumours~', The magnification and light afforded by the surgical microscope coupled with the ease of approach to the optic chiasma has made the eraniopharyngioma a tempting target for total excision. The difficulty encountered in such an operation mostly concerns itself with ghe solid component of the lesion which when densely calcified can constitute a mass whose size can restrict its mobility and whose
298
A. Ta~alla: Total Removal of a Craniopharyngioma
solidity can d e f y a t t e m p t s to reduce its bulk. W h e n such b u l k disbars its safe r e m o v a l t h r o u g h t h e limited space b e t w e e n t h e optic nerves, one m a y t h e n i n d e e d be t e m p t e d to a b a n d o n t h e exercise a n d confirm earlier a d m o n i t i o n s on t h e i n o p e r a b l e n a t u r e of such lesions.
Fig. 1. Tomogram of sella showing shar p projections of the calcified mass Such a challenge p r e s e n t e d itself t o t h e a u t h o r a n d t h e m a n n e r in which it was successfully m e t forms t h e basis of this brief c o m m u n i c a t i o n which h o p e f u l l y can be of help to others who m a y be faced w i t h similar circumstances.
Case Report A 26 year old y o u t h was a d m i t t e d as an emergency following an apparently unprovoked episode of systemic hypotension. I n pursuit of the cause of this disturbance skull X-rays were taken. This showed the intrasellar calcification characteristic of a craniopharyngioma whose supraseilar
Fig. "2. Operative photograph of untouched cyst
]~ig. 3. Operative photograph of high speed drill being used
300
A. Talalla:
c o m p o n e n t was disclosed b y a n air e n e c p h a l o g r a m . P e r i m e t r y s h o w e d a b i t e m p o r a l h e m i a n o p i a i~ t h i s s m a l l - s t a t u r e d p a t i e n t w h o also e x h i b i t e d the stlgmata of pituitary deficiency. In view of the ehiasmal syndrome and what was thought to be a cystic suprasellar extension, surgical exploration was decided.
Fig. 4. Postoperative
lateral skull X-ray showing sellar component
total removal
of intra-
Operation: T h e c h i a s m a was r e a c h e d w i t h ease a n d it was seen t h a t both optic nerves were splayed out by the cystic component of the mass. Needling of the cyst allowed a prompt collapse of the sac and decompression of the optic apparatus. The capsule was then excised and from within the depths of the sella soft friable tumor was removed until a rock hard calcified mass remained. The dimensions of this solid remnant were such that, although it was mobilised within the sella, it could not be negotiated through the space between the optic nerves without damaging these structures. Furthermore, the heaviest pituitary rongeurs were of no avail in "breaking up" the mass. As a last resort, a high speed drill was employed and with a steady flow of saline to restrict the radiation of the ensuing heat the single large fragment of calcified tumor was bisected. The two halves were easily and safely removed. The patient made an uneventful r e c o v e r y s h o w i n g a r e s o l u t i o n of his field defect b u t c o n t i n u i n g to r e q u i r e replacement steroid therapy.
T o t a l R e m o v a l of a C r a n i o p h a r y n g i o m a T h e r e q u i r e m e n t s for comparable circumstances r e t r a c t o r s a n d t h e use of o p e r a t i n g a t a d i s t a n c e of
301
t h e safe use of t h i s t e c h n i q u e m similar or are a d e q u a t e m a g n i f i c a t i o n , self r e t a i n i n g b r a i n b o t h h a n d s to m a n i p u l a t e t h e h i g h s p e e d drill a few m i l l i m e t e r s f r o m t h e optic nerves.
Author's address: A. Talalla, M,D., Clinical Neurosciences, MeMaster IJniversity Medical Centre, IKamilton, Ontario, Canada, L8S 4J9,
Division of Neurological Surgery, University of Southern California, Los Angeles, California.
Total Removal of a Craniopharyngioma Teehr~ical
Note
By
A. Talalla With 4 Figures
Summary A technique is described for dealing with large solid calcified fragments of eraniopharyngiomas whose size would ordinarily render such a lesion inoperable. The advent of the surgical microscope, the use of self retaining brain retractors and the improved techniques for reducing intracranial volume have all contributed to an era of neurosurgery which necessitates the reevaluation of intracranial lesions hitherto thought to be "inoperable". A striking example of the effects of these adjuncts to neurosurgery is in the legitimate expectations of direct treatmer~t of intracranial aneurysms, the preservation of neurovaseular structures during the removal of strategically placed turnouts and in the safe accessibility to even the deepest intracranial structures. Although the eraniopharyngioma is not a neoplasm, its life-threatening propensities are allied to the recurrences that can be associated with such simple procedures as evacuating the cystic component of such ~tumours~', The magnification and light afforded by the surgical microscope coupled with the ease of approach to the optic chiasma has made the eraniopharyngioma a tempting target for total excision. The difficulty encountered in such an operation mostly concerns itself with ghe solid component of the lesion which when densely calcified can constitute a mass whose size can restrict its mobility and whose
298
A. Ta~alla: Total Removal of a Craniopharyngioma
solidity can d e f y a t t e m p t s to reduce its bulk. W h e n such b u l k disbars its safe r e m o v a l t h r o u g h t h e limited space b e t w e e n t h e optic nerves, one m a y t h e n i n d e e d be t e m p t e d to a b a n d o n t h e exercise a n d confirm earlier a d m o n i t i o n s on t h e i n o p e r a b l e n a t u r e of such lesions.
Fig. 1. Tomogram of sella showing shar p projections of the calcified mass Such a challenge p r e s e n t e d itself t o t h e a u t h o r a n d t h e m a n n e r in which it was successfully m e t forms t h e basis of this brief c o m m u n i c a t i o n which h o p e f u l l y can be of help to others who m a y be faced w i t h similar circumstances.
Case Report A 26 year old y o u t h was a d m i t t e d as an emergency following an apparently unprovoked episode of systemic hypotension. I n pursuit of the cause of this disturbance skull X-rays were taken. This showed the intrasellar calcification characteristic of a craniopharyngioma whose supraseilar
Fig. "2. Operative photograph of untouched cyst
]~ig. 3. Operative photograph of high speed drill being used
300
A. Talalla:
c o m p o n e n t was disclosed b y a n air e n e c p h a l o g r a m . P e r i m e t r y s h o w e d a b i t e m p o r a l h e m i a n o p i a i~ t h i s s m a l l - s t a t u r e d p a t i e n t w h o also e x h i b i t e d the stlgmata of pituitary deficiency. In view of the ehiasmal syndrome and what was thought to be a cystic suprasellar extension, surgical exploration was decided.
Fig. 4. Postoperative
lateral skull X-ray showing sellar component
total removal
of intra-
Operation: T h e c h i a s m a was r e a c h e d w i t h ease a n d it was seen t h a t both optic nerves were splayed out by the cystic component of the mass. Needling of the cyst allowed a prompt collapse of the sac and decompression of the optic apparatus. The capsule was then excised and from within the depths of the sella soft friable tumor was removed until a rock hard calcified mass remained. The dimensions of this solid remnant were such that, although it was mobilised within the sella, it could not be negotiated through the space between the optic nerves without damaging these structures. Furthermore, the heaviest pituitary rongeurs were of no avail in "breaking up" the mass. As a last resort, a high speed drill was employed and with a steady flow of saline to restrict the radiation of the ensuing heat the single large fragment of calcified tumor was bisected. The two halves were easily and safely removed. The patient made an uneventful r e c o v e r y s h o w i n g a r e s o l u t i o n of his field defect b u t c o n t i n u i n g to r e q u i r e replacement steroid therapy.
T o t a l R e m o v a l of a C r a n i o p h a r y n g i o m a T h e r e q u i r e m e n t s for comparable circumstances r e t r a c t o r s a n d t h e use of o p e r a t i n g a t a d i s t a n c e of
301
t h e safe use of t h i s t e c h n i q u e m similar or are a d e q u a t e m a g n i f i c a t i o n , self r e t a i n i n g b r a i n b o t h h a n d s to m a n i p u l a t e t h e h i g h s p e e d drill a few m i l l i m e t e r s f r o m t h e optic nerves.
Author's address: A. Talalla, M,D., Clinical Neurosciences, MeMaster IJniversity Medical Centre, IKamilton, Ontario, Canada, L8S 4J9,
