Recurrent Craniopharyngioma: Technical Challenges

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Here is resection of a recurrent craniopharyngioma pterional approach. This is a 54 year-old female with progressive mental status decline. She previously had undergone at least two transcranial operations via a right pterional craniotomy for resection of her tumor. And my evaluation reveals is mostly solid tumor with some cystic component, more superiorly and posteriorly. There was evidence of edema within the medial temporal lobe on the right as well as bilateral subfrontal areas. Patient underwent reopening of her right pterional craniotomy. Sylvian fissure, right subfrontal area. She had almost no functional vision in the right eye and minimal functional vision in the left eye. The sub funnel region was entered. The frontal lobe was gently elevated and the right optic nerve was found. Sphenoid wing. Obviously scarring from previous operations, significantly complicates the dissection planes. Here's the right optic nerve, M3 chiasm. Tumors, significantly, affecting the right nerve. Small incision within the chiasm was made to see if I can debulk most of the tumor within this small incision where the tumor reached the more superficial aspect of the pea of the chiasm. Unfortunately further exposure revealed that most of the chiasm on the right side has been destroyed, since there was no functional vision in the right eye. The optic nerve was transected to provide additional operative trajectory toward the tumor. Obviously, this is a technique of last resort. Here's transection of the nerve. I'll enter the chiasm and remove most of the tumor preserving as much of the chiasm as possible to protect the decussating functional fibers from the left optic nerve. Here's the left optic nerve, appears North of the healthy ophthalmic artery, internal quarter artery on the left side, again. Both the ophthalmic artery and the optic nerve are entering the optic canal. Now I continue tumor debulking, where the right optic nerve used to be. Can see the gelatinous tumor of the craniopharyngioma. As I mentioned the scarring here, significant complicates the dissection planes. Here's the left optic nerve, it's not affected by the tumor. Two more debulking continues. Part of the tumor that is growing posteriorly toward the interpeduncular cisterns is also removed. And most of the attention is focused on the area of the right optic nerve, creating the operative corridor into the chiasm to debulk the tumor. Here's the portion of the tumor herniating into the posterior fossa and interpeduncular cistern. Left optic nerve. Ultrasonic aspirator is also used to further remove the tumor that is safely deliverable. Stay away as much as possible from the left side of the chiasm and the optic nerve. Reasonable decompression is achieved. Post operative and MRI revealed reason with the decompression of the optic apparatus. Unfortunately, this tumor recurred month later, despite treatment with radiotherapy, and this patient unfortunately suffered from further consequences from the regrowth of the tumor. Thank you.

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