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Craniopharyngioma: Transcallosal Route

March 04, 2014

Transcript

More recently, within the past five years, I have primarily used the endonasal transsphenoidal approach for a section of suprasellar craniopharyngiomas; even of a large size. However, the transcallosal approach may be used by some of our colleagues, and therefore this procedure will be described here. This video is one of the ones from earlier in my career, where I used fixed retractors, and used a transcallosal approach for removal of craniopharyngiomas. This is a 41 year old male with visual dysfunction. MRI evaluation revealed a suprasellar, primarily cystic mass, with an enhancing nodule involving the pituitary stock. Most of the cyst is filling the third ventricle. Endoscopic transnasal approach is an excellent option for resection of this mass. No matter which trajectory is used, transcranial versus transnasal, the risk to the pituitary stock is significant for this tumor. The patient was placed in the supine position. Head is neutral; supine as well. Here is the superior sagittal sinus, right-sided parasagittal frontal craniotomy. Interhemispheric fissure was entered, the single eye where it disconnected, and the pericallosal arteries were found, mobilized, and a small callosotomy was completed to enter the right ventricle. Using the cottonoid patties, to hold the pericallosal arteries out of harm's way, staying on the right side of the arteries, to enter the right ventricle. Neuro-navigation was employed during this operation. A very minimal callosotomy would be more than adequate. A centimeter and half, and the ependymal of the ventricle is this connected area. You can see CSF, after opening up the ventricle. Brain relaxation will be very helpful. Here's the foramen of Monro. The septal vein was disconnected, so that the foramen of Monro can be extended and expanded, via a minimal anterior transcroidal approach. Here you can see the cyst wall, after it was decompressed, through the framing. Here's the thalamus dried vein. After the cyst was decompressed, it was disconnected from the floor of the third ventricle and the surrounding structures. After circumferential disconnection of the cyst, the entire wall of the cyst was extracted gently in fragments. Unfortunately, using this operative trajectory, adequate visualization of the pituitary stock is not readily available. Here's the calcifications within the craniopharyngioma. Small amount of venous bleeding was encountered that was readily controlled. Here you can see the operative space into their suprasellar area. In entry into this suprasellar area, via the floor of the third ventricle, no residual tumor is apparent. You can see part of the optic nerves. Hemostasis is secured, an external ventricular drain is placed tentatively, and for a short period of time, post-operatively. And the postoperative scan revealed gross total resection of the mass without any complicating features. This patient did suffer from diabetes insipidus after surgery. However, his vision improved significantly. Thank you.

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