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Endoscopic Resection of Craniopharyngiomas

Juan Fernandez-Miranda

June 11, 2017


- Hello, ladies and gentlemen and thank you for joining us for another session of the Grand Rounds. Tonight, we have Dr. Juan Fernandez-Miranda from University of Pittsburgh. He's going to talk to us about endoscopic resection of craniopharyngiomas. Craniopharyngiomas are definitely one pathology, besides pituitary tumors, that are very well fit for the endoscopic approach. Therefore, I appreciate his pearls of technique regarding removal of these lesions. Juan, go ahead please.

- Thanks, Aaron, for having me again here. It's my pleasure to share this time with you, and I appreciate all the work you put together for these seminars that I learn a lot from. So, we're gonna talk, as you said, about craniopharyngiomas, and we talked last time about suprasellar meningiomas, and we are also gonna be in the suprasellar space, but now we're gonna move back into the retrochiasmatic space, which is where most craniopharyngiomas sit. So, if you look at the infundibulum and the CAS, I'm gonna go behind the retroinfundibular, or retrochiasmatic area. We're gonna review first, briefly, the topographic classification of craniopharyngiomas, because this is the basis for the selection of approaches. And then we're gonna focus most of the talking, the important surgical anatomy and technical nuances for removal of these challenging tumors. I'm gonna finish with just a review of other lesions in this area that look like craniopharyngiomas. So, the first concept, as we know, is craniopharyngiomas arise from the pituitary stalk, the infundibulum, somewhere along the hypothalamic axis. And it's actually the difference in the site of origin, what makes the topographic classification of these tumors meaningful. There is a very interesting classification by Steno on craniopharyngiomas, based on the relation of the tumor with the ventricle, with the third ventricle. And there is a category which is extraventricular; and there is a second one that is extra-intraventricular, it is both inside and outside the ventricle; and then there is a third one that is very rare or quite rare, which is the purely intraventricular craniopharyngiomas. And this difference is very relevant for surgical approach selection. For instance, we have here two different tumors. Here we have this type of chraniopharyngioma versus this other one. Similar size, mostly similar location, but the question we always need to ask ourselves is is the floor of the third ventricle intact? You look at this tumor, this tumor has not invaded into the cistern yet, and the floor of the third ventricle appears to be intact. So, this is probably a purely interventricural craniopharyngioma. While this one, you can see that the tumor is occupying the cistern, so this is probably one of those intra-extraventricular craniopharyngiomas. And then the approach for these tumors is going to be different. Basically, the concept is purely intraventricular craniopharyngiomas are not ideal, are not suitable for an endonasal approach. Why? For two reasons mainly. One, because you don't wanna cross a floor of the third ventricle that is probably intact. And, two, because these tumors typically extend above the optic chiasm, and make the resection of this upper portion of the tumor very challenging. But this floor of the third ventricle concept is very important for the selection of approaches. For a tumor like this, you can use a transventricular approach, let's say a lamina terminalis, or a transfrontal, transcallosal, et cetera.

- I wanna add something, Juan, that definitely the retrochiasmatic space is a very difficult place to reach transcranially, through this subfrontal approach. Therefore, the endoscopic expanded approach is really a nice fit, and I think most craniopharyngiomas, unless the ones that are multicompartmental, can be easily approached through this pathway or trajectory, and this is really one pathology that has won the favorability of the endoscopic transnasal approach as part of the non-pituitary lesions. The other idea is that if the floor of the third ventricle is intact, obviously a transcallosal approach, or a translamina teminalis approach would be reasonable. However, the translamina teminalis approach is very narrow, and really not very good approach. I assume, for these that the floor is intact, you approach them transcallosally, is that correct?

- Yes, that is correct, or translamina, one or the other. It depends quite a bit on the , and the frontal horn, and there are multiple variants to decide which approach. But I wanted to start with this case example, because now that endonasal is being used so commonly for these tumors, I think it's very important that we don't use it for the wrong tumor. So, this is the tumor that you don't wanna do an endonasal approach. This is very rare tumor. I have only done two, seen two of these purely intraventricular craniopharyngiomas, among maybe a hundred of others. But it's the one that you don't wanna do endonasal approach.

- Well said.

- So, that being said, for most of the craniopharyngiomas, the ones that are not purely intraventricular, we have a variety of approaches. And you can see pterional, supraorbital, subfrontal, translamina, and endonasal approach. And, as you said, endonasal is a great approach for, I would say, the vast majority of these tumor. You look at the two other categories; extraventricular, and extra-intraventricular. And the extraventricular one mostly corresponds with the sellar/supraseller kind of craniopharyngioma. These tumors displace the optic chiasm up, typically. They have no hydrocephalus, and the stalk can be usually preserved in surgery, not always, but there's a good chance of preservation of the stalk. And for these tumors, the selection is between endonasal, which is a fantastic approach for these tumors, versus the traditional cisternal approach, let's say pterional-transsylvian, or the modified supraorbital, et cetera. On the other hand, the extra-intraventricular tumor, these are more challenging, because this tumor arise more from the floor of the third ventricle, they grow into the cistern, they go into the ventricle. Some authors say these are not ideal for endonasal, which I would disagree. I think these are ideal tumors for endonasal, but they are more difficult. They are more difficult because the chiasm is displaced forward, so you have less space, so we'll learn how to deal with that. Often this patient has had hydrocephalus, which makes the repair more challenging too, and we'll review that too. And it is not so common that we can actually save the stalk function, because these tumors really invade the whole infundibulum, and it's very difficult to save the function in tumors like this. At least, that's been my experience. Regardless, endonasal approach is a great approach for these tumors. The other alternative is, as you said before, the transventricular, or translamina, or transcallosal approach, which provide not so adequate exposure of the retroinfundibular space. There is another concept that I think is important that Dr. Pascual put together a few years ago, which is this mammillary body angle. This is the angle between the fourth ventricle vertical line and the floor of the third ventricle. Now, this angle is designed to differentiate tumors that are more tubero-infundibular, more, let's say, extra-intraventricular; and those that are more sellar/suprasellar, those that do not really invade the third ventricle. So, those that do not invade the third ventricle, what they do as they grow is they push the floor of the third ventricle up, and then they create a more open angle. And if the tumor actually, on the contrary, what it does is invades into the ventricle, this angle is gonna become more narrow, a closer angle, because it pushes the third ventricle floor down as it goes into the third ventricle, and this is something you can often see in the MRI in sagittal MRI, and did this helps you identify this third ventricular invasion of the tumor, which has some implications for expectations of risk of the operation, et cetera. So, I like to use this trick when I look at the imaging. For the more challenging tumors, tubero-infundibular craniopharyngiomas, those are both inside the ventricle and outside the ventricles, we said, we have a variety of approaches, and I'm gonna show this example to illustrate how endonasal is able to solve this problem. This is a tumor on a young patient that has undergone a transcallosal approach, it's gonna have an outside institution, you see the callosotomy? And the tumor resection is very poor, because this is a fibronous tumor, it's quite vascularized, et cetera. And the patient presents with this tumor, and they propose radiation, actually, and we decided to do an endonasal approach for this. And we can go and remove completely this tumor. And for these, we'll review how we do this, we're doing what we call an inferior transposition of the pituitary gland. What you have to do is increase the working space between the optic chiasm here, and the pituitary gland inferiorly. Now, the expectation for this tumor is to not save the function of the pituitary gland. This patient post-op had panhypopituitarism, improved vision, gross total resection, but panhypopituitarism. That's because of where the tumor comes from. Okay, so just to summarize this first idea. The rationale for an endonasal approach in the case of craniopharyngiomas is mostly for hypothalamic preservation. When we do suprasellar meningiomas, we want to do endonasal to preserve the optic apparatus. It's a better approach because we can decompress the optic apparatus, we can remove the tumor off the optic apparatus more effectively, I believe, than from a transcranial approach. now from a TransCanada approach for comforting UMass is also about vision, but it's also about very importantly, hypothalamic preservation. We can see this plane of dissection better than with any other transplant approach. Yes, because of the nature of our corridor from inferior to superior allows us to see the spinal dissection as we will see. So these are major, very important concept. We talk about surgical exposure. We look how we expose in the past the vertical Solomon in humans, very wide exposure, extend to the optic canals, extend to the planets Winnie valley for curricular Yemen. We don't need these exposure. So extensive. You see the, it doesn't extend to the planet is from the belly and it doesn't extend to the optic canal. And that's something you're different in the exposure. And to me, the anterior limit for our acronym for new exposure, working in the nasally is this a landmark right here, which is what we call the limbus of this suspended. this Lamar you can always define sleep is because the bone has this wet right here. And then you can see it in the dissection. You can see it in SU when I see this little fall, I know that I'm already in the platinum and these full marketed precast magic circles, which on the other side has the superciliary space. If you open the direct here, you you're going to be seen frontal lobe, and there is no need to do that in most there are a few that might extend into the anterior skull-based Dontre falls up, but that's rare most grow into, as we set into the retro in, from the rotor space. So exposing or opening the door in this area has no advantage. When we went to go into the restroom from the risk space to the country is actually not a good idea. You can maybe expose a brain that is exposed to more prone to damage. It can alleviate et cetera. So there is no need to open these direct.

- The other issue, a horn is that most of these are cystic. And when you open the dura, you only Sue the tumor and he leaves you with this idea that my exposure is limited, but actually the moment you deflated you'll see how much exposure is more than adequate and offer the exposure of the bone. And the Douro is less than the tumor because drainage of the cyst immediately expands your corridor.

- Right? Absolutely. And listen to that. I think what is important is that we expand the approach. Laterally enough, if you do have various small opening like this, that you send them seeing videos around, this is not a, it's very small. This is also small. But if you see is the maximum effective approach, in my opinion, because it goes all the way lateral to expose a bit of the optic nerve prominence and the product on your carotid artery right here. And this is important because it gives you direct access to the optical system, which means when you open the dura, do going to be able to see the optic nerve from the chronic easily. You see, again, it's very important to understand the council of the optic canal, practically, a lot of acid ACA, and I use the optic strap right here as a very important landmark. I go and drill the bone until I see the optical strap. You see a yes, yesterday, the optics struck here, and this is the optic nerve prominent. This is the product model of carotid artery. And then there is no need to remove more bone here. I don't need to expose more optic nerve. I don't need to expose more of the Cardinal Sinose world. There is no need for all this, but actually I do need to see this cord exposed and this optic nerve prominence. And for that, I use the optical star as a landmark. And when I do this exposure, then I can open the dura. And then you see the distal ring right here, and you can see the supraclavicular ICA and you can see the brands of the superior hypophyseal artery. And if you have all this bone here, if you don't remove this bone, then you're going to have a harder time seeing these, as you can see with an angular scope, but you can not have easy access to this. Let's say lateral recess of the suprasellar system. So that's why my opinion is so important to remove this bone of the medial optic carotid recess.

- The other issue is the supra superior or the superior hypophyseal arteries or the perforators to the KSM. They tend to be the main factors that cause post operative visual decline. So you really have to be careful if they're on the capsule, especially the ones that are emphasized. And even if I save them, sometimes just their Manny pollution and vasospasm can lead to visual decline. So I use a piece of gel foam soaked in pep Havering to base them for a few minutes at the time of the closure. Do you do anything else to avoid injury to these important perforators horn?

- Yes, I do. I have a couple of slides dealing with that, but it's a very important point. I liked your trick of the, you know, gel foam or the Patty with a pattern because these are women who believe that they can get into a spasm often. But yes, I do have some tricks. I'm going to serve with you on the super hypophyseal galleries and the brands is how the recommend the bronzes and all that. So I'm gonna just show you the first video. And this is just to illustrate this concept of the exposure. How do we do the exposure? So we are gesturing the seller here. So always expose the seller. I'd like to see the due to the pituitary gland. And then this is taking the bone of the tubercle sella. And this bone is all fin. And this is the one of the precast medic soldiers. You see that I start seeing the dural fall right there as a precast medic, the liberals of this unit right here. And now you see this, the dural followed by there and now extended bone in drilling laterally. And do we see the optic nerve prominence, the prominence, the medial OCR. And this is the dural fall of the plan on the LIMU story of this phenotype. So this is the type of exposure now, how do you open the dura the different ways of doing it? But I like to open a little bit in the supraciliary space and then we open a little bit in the cellar and I often actually opened these during the cellar wildly. So I have more flexibility in the pituitary gland or the, it depends on the case. And then we quietly on the cap, we cut through the little, the tuberculum super in their carbon of sinus and the beauty of this, you can cut the dura, the diaphragm. And did you find that between the stock and this allows you to early visualize the pituitary stock, and that's another beauty of the endonasal approach, the ability to see repeated three stock very early in the operation. So as we set the super-heavy MCL already, this is a very important topic for these kind of funny maturity. So this are, is, are displaced for an upward TPV for, by kind of running GMs. This is different than tuberculum Solomon and UMass because, it displays those artists backwards in the arachnoid, but displays them and terrier and app. And often I just said, when the first thing you see when you open the dura and you see arachnoid, then you open that arachnoid and then you see the artists within the arachnoid. And then you see like this picture here, then you have cure the tumor and you have the artists and then you need to preserve the art is going to the optic nerves. But at the same time, you do take a tumor now. So how do you do that? So it's always very important to be very selective on the Brian says, did you cooperate? And the brands that you preserve and for that, you know, we studied the branches of the superhero of Gerard, and hopefully we'll have a publication coming out soon where we study more than 30 of these cases. And the classical partners will be called the candelabra. Pardon? But it has three branches. There is a branch, there's a common stem, obviously right here that actually often arises from this chronic cave area. And then this brand's bifurcates try for kids story in three branches is, and then there is one that goes to the optic apparatus to the optic nerve itself. That is the central one. Let's say that goes to the infundibulum and a third one that goes down. So the one that goes down, we call this the descending branch. We can call it also the diaphragmatic branch because he often goes to the diaphragm. Although we have seen that also it goes to the pituitary gland, but these descending brands is often in your way. And actually it often is vascular supply to the kind of friend you are a capsule itself. So these brands here, I often, if you see my way and is your paradise in the other main stem on the other branches, I just cooperate these brides because it doesn't go to the optic apparatus. You go to the dura or to the pituitary gland. Now I always say to preserve this one, it goes to the infundibulum. And importantly, it has a very robust anastomoses in most cases with the contralateral one. So you look at this and ask the Moses is even possible to injure these, manage them on the other side, but this will probably still receive vast supplies. So looking at this and as to what is another very important point. And then the one that probably is mostly responsible for visual iteration is this one, these brands are going to the optic nerve. It supplies the optic nerve just before the optic canal, just before the atomic RA. And it can arise directly from this super have zeal and sometimes directly from the carotid. So there are multiple variations there, but bottom line, these two brands has optic nerve and inform DVR Bryant. Do you want to preserve, you want to look at the anastomosis, this descending branch you may sacrifice, or I do sacrifice, I don't see any increased risk of these sort of iteration from these one. Now let's take a look at a video that illustrates this concept of on, on the brands, on their super high velocity and the sacrifice of these brands. So these are kind of fun in your market is a calcified portion, and this is the stock is the gland. And now I see it. This is the superior hypophyseal right here, the main stem and you see there is a branch going down that I'm cooperating selectly because this brands goes down and I cannot mobilize this rock here without, you know, quoting them brands like privately the braches, but I still preserve the main stem of the superhero because you had already, and that way you can present the brands is going to the optic apparatus. Now, in addition to the super high popularity, the other very important vascular structure, the ones in the retro cosmetic region and, and undos, the one that is at the highest risk is typically this one, the poster you're communicating are the pecan. The pcan is usually at the lateral edge of the tumor, it taxes or adheres to the lateral aspect of the capsule of the tumor. You also have these all other periphery branches that are between the pickle and the super heavy RA, and then Costilla, you have of course, ambassador bifurcation the P one segment. And then also remember the third nerve on the corner. Now this is the endonasal view and is the view of the basis of the brain just to compare the abusive is a basilar bifurcation, is that P one. And some of you have this fetal pig comes very large pick and break here. So again, pecan is the artery that is, I believe at the highest risk when the loop is kind of for a Uma resection is just, it runs the aspirator to the third nerve, as you, as you know, and you remember, or BW from a transcript perspective or unless the Activia on approach is this one here, we have the curatory, this is our peak. And right here, this is the anterior Croix, the lottery, this optic track, and for kind of continuing resection from this window, we work within the third nerve and the good auditor within the corridor on the optic nerve. And we often have to deal with a pickup, but we seen our way we need to move it between P com Brontez to get into the tumor when we work endonasal, however, we work from inside out, and the peak coming is going to be on our side. So always very important to remember the come to avoid pulling on the tumor because you can evolve that already. So this is an example of a crane offering Uma solid portion, cystic portion. We don't see the pickle in the imaging is not so easy to see sometimes because often it has small brunch. So let me guess. So this clip that illustrate this council of the pecan, and you see here, this is the corroding supra, claimable corroded. And then this is the peak come right here. And this is the capsule of the much and carefully. They second Iraqi with bands that attach the capsule, the tumor to the pecan, and the same time we preserve all the periphery in branches around it so carefully. They second, the pcan is a very important concept in [Indistinct]. Massoud you want to do it under direct visualization, no pulling could, you can risk injury. It's not only the pecan. We have the other brands. So for example, these are two more what I actually had. So this case, so this very calcified craniopharyngioma, where the sect in this P one, this is a fetal of communicating already. And while they second, this perfectly investors, we avulsed an already from the hypoplastic P one that we cooperate directly. Now, in this particular case, we were lucky to avoid any stroke because this hypoplastic P one was irrelevant. But this shows how complex sometimes is the dissection of these tumors. And how important is to, you know, preserve all the small perforating vessels we could do can get a, a significant stroke in patients in this area. Now let's review. Now these council that the pituitary mobilization, as we said at the beginning, sometimes we face these tumors where you see this, the optic apparatus right here, and this is the pituitary gland, the window, the space between these various small, how do you deal with this? Can you still do endonasal? And yes, you can, but you have to learn how to mobilize the pituitary gland. And this is very gentle mobilization is just, you can K it's not really a transposition. It's just about opening Durham nicely and let the Glen fall some to increase your space as opposed to retract the optical apparatus. What'd you do is you retract the pituitary gland down. So you increase these work in a space by moving the pituitary gland down, as opposed to moving their optic chiasm app, as you would do with a transparent approach, would you often have to manipulate the optic apparatus here, you manipulate the pituitary gland, which I believe is much better tolerated. So also this concept of the pituitary mobilization with this video, you see, can you see the pituitary gland that has been all nicely exposed to the red has been open and they have even by dissect to the pituitary gland off the wall of the cabin of sign-ups. So this dura, this dural dissection allows me to bring the Glen down Sam, it's just a matter of a few millimeters, but enough to increase my working chorionic here. It's between the optical products and the pituitary gland St comes concept in this other case, calcified portion, optical parameters up here between three Glenn, see how the is being displaced inferiorly, and they can mobilize it because at the second, the glam off the Walnut color, the carbon of sinus I've opened the dura of the pituitary gland all around. So I can actually bring the Glen out of a cell a little bit, so I can mobilize it and increase my working quality within the optic apparatus on the pituitary gland. Now I can nicely see the undersurface of the optic chiasm, and you see how all the time this section is opening this window within optic apparatus and pituitary gland. And lastly, another very important anatomical concept is the anatomy of the third ventricle, because we see these intranasally. We just often see these marvelous view of the third brand to go from an endonasal perspective. One key landmark in here is what we call the hypothalamic sulcus. This will cause we can often recognize it's within the thalamus itself and the hypothalamus and other anatomy we need to recognize. And second, third ventricle is the mass intermedia or. You can often see the posture of Cami showed the aqueduct is the eventual ganglion and the structures in the roof for disease and the Telecordia within internal studio mates. And in this case, this patient had had, has had a surgery in the past and he C had an injury to the fornix. So we're looking into the third ventricle. You see the both for Eminem and row here. Look at the difference in the furnaces. This is an, a traffic for chronic atrophy of the phonics in this side. And again, you see the internal civil veins, the roof of the third ventricle, the thalamus, and then you see the hypotheticals right here. You see a date in, but Marcy transition within the thalamus and hypothalamus. Okay, now I'm going to get, so a few examples of the different categories of kernel for indium, as we discussed at the beginning, yes. To yes. Put all the concepts of the anatomy review together. This first case, there are deeply easy case men in their fifties or something with these suprasellar mass visual loss. this is a complete extra integral kind of for, in your mind. You see, it's not even in the third ventricle, there is no question about it. So Indonesia is the, is the best option. This is the type of team or where we can preserve often the function of the pituitary gland. I would have a good expectation of preserving this function. So in this case, you'll see the pituitary gland. We have removed most of the tumor already. And then the last portion of the tumor, this is the peculiar stock. We can separate the tumor that is invading the stock. And we'd go to the source of origin of this or an actor. We remove the last piece of it. This, as we would say, a tune that arise law in the pituitary stop, it, doesn't get to the third ventricle, this a complete resection of a tumor. And this patient has a preservation of the pituitary function. You can see the post with a stock, so we can do this precipitation, the function because of the type of kind of friend Gemma we're dealing with. Of course we do a careful technique, but at the same time is a tool that allows you to do this. Another example. This one is what we could call an extra ventricular, but also we could say tumor because it seems that he's going to the third ventricle, but actually you will see is not. And if you see it's pushing the angle for the third ventricle superiorly, and in this case, the third ventricle has been seen out there in the gold floor by the tumor. So at the end of the resection, or by the end of the section we see here is the liquid membrane. Here is the stock and not what we're doing is we'd die. Second, the capsule of the tumor, the capsule of the car in front of him, all the, of the third ventricle to see what is the relationship. And I keep dissecting and delight fine, no real plane here. So which means all these capsule here belongs to the kind of, and to the stock. So then you need to decide how much of this capsule you cap, how much of the capsule you leave. And at the end remove part of the capsule until this looks like more normal tissue right here. The four, the theoretical is still intact. It's very thin, but it's not open. And this is the stock completely brochure it's theme, but it's completely preserved and going to the third ventricle that is not open yet. You see your white exposure grow it optic nerve. In this case, the functional stability glamour has been preserved also, this talk has been preserved. You can see post-op Mr. Kassem here in this talk, but again, we can preserve this talk in this situation, on the function of the Glen, because a tumor allows us to the second from the stock. This other case, or whatever is different. These patient had ha has had had a tailored approach 30 years before Breda, surely three times progressive visual loss severity has bumpy. And he would be to tourism. She's developing new SIS that is causing these via, there are crossing these visual loss. And in this one we've got for surely we have no expectation of ability of, of function of the clan has gone on. He's been gone for a long time. So in this case, we can see how these intra extra ventricular tumor is a rising from the floor of the third ventricle. And we are separating this for the third ventricle, from the tumor in that star with the survey section right here. There's two more. There's the four, the third ventricle, this calcified portion. This is actually one that has the third ventricle floor around it. And we have completely separated. There is no way you can sort the function of the pituitary gland tumor. Like this is you remove it completely, obviously. And that is the calcified portion of the tumor. And this is the inside on the third ventricle, again, as the Enron ganglion and the aqueduct author of CommInsure and all day knives, anatomy, the third ventricle, and this is the post-op. And sometimes we deal with very large tumor like this heavily calcified, but we're also rings the bell here. This patient presented with psych captive kind of symptoms like severe amnesia confusion. These pieces had actually been there for a few weeks in a psychiatric institution until they did a CT scan and they found a mass and then see what the patient was sent to the, to us. And then she has this large tumor. This is, has multiple cysts and all that, but we can deal with these in the nasally when you are experienced. And the nice thing you see occupies the whole super solar systems. You haven't going to have a lot of space to work and take the tumor out and into this of course is a tumor that is extra intervention is one where I have really no hope of pursuing the pituitary gland function. Even if it's partially intact. And this one, we open the dura, you see the pituitary gland. This is the stock here. Let's talk is somewhere in this area. I try always to preserve the stock if possible, and this is the capital of the tumor, where the stock could be. And then I'm going inside the tumor. Now I'm going outside. This is the peak come right here, separating the, pick them from the capsule. And that is the optical apparatus, trying to find a plane between the optical parameters and the tumor. This is the shipper type of CRE. Sometimes it's very challenging to preserve these vessels as you work posteriorly. And at the end, I guess, cut they stop. But I see there is no meaningful. I don't see any real tissue I'm preserved. So I just transected makes the dissection much easier, more effective, and they follow it all the way to the third ventricle. And then I'm now inside the third ventricle, trying to find this critical step of the operation, where you need to decide, why does he prefer animals? What is wall a third ventricle and what is tumor and where to transect this tumor. And you see this, the remaining portion of tumor, and I'm going to transect. You don't want to go off there, all this calcification that is irrelevant, but you want to see the last piece of teamwork here. And at the end, the inside of the third ventricle here, and you see the bassinet bifurcation and the third one degrees, why the open and in a case like this, and we'll talk about reconstruction. I would probably put an external event sequence rain, just because I'm worried about hydrocephalus postop and the risk of leakage, even the risk of hemorrhage. So you have a hemorrhage in a case like this, he would cause a acute hydrocephalus and.

- You know, you know, horn, don't you worry about sucking Arab backwards. In other words, sucking her from the nose into the event to call causing ventriculitis. I usually don't use EVD for that reason, because I've heard reports of the reverse suctioning of the air from the nose into the ventral cop. What, what do you think of that?

- That's an interesting, I don't think I've seen that, but it's an interesting concept. I would, I would not drain it aggressively. I would probably yes, they drain at about 15 centimeters or so, but certainly if your reconstruction is not robust and you are draining aggressively, I think that can happen. Yes. It's a risk. No question.

- Obviously these patients don't have a longboard drain.

- Yes, yes. I prefer not to.

- And you don't use lumbar drain for most of your craniopharyngiomas.

- That, that is correct. Actually here is where we talk about reconstruction and yes, I do not use a lumbar dream for most. you have a good flap. I don't use lumbar drain. I don't use multilayer. I just use dura again. And then the flap and sometimes an EVD when a patient has hydrocephalus, especially all the theoretical is widely open post-op. I typically use on DVD just for precaution and for drainage for two, three days, but I try to avoid a lumbar drain in these cases. And yeah, so this very quick clip on the reconstruction technique, because what I typically do is I typically just put a piece of durian ELA, make sure it's nicely placed. And then the simple flat, the beautiful thing is that the septal flap is a very large piece of tissue and the dural defect it's actually quite narrow. If I go back, you see, this is a defect and that's our septal flap. So there is redundant septal flap. There is probably a centimeter extra, so they'll flap around the dural defect. And I think that's what makes these reconstruction very successful. Illegal rates nowadays, they used to be very high noise are about 5% for tumors in the supraciliary space, even lower than that, to the point that we don't use lumbar drains in this case anymore, because the septal flap is so robust that, and the dual defect is smaller than a flap. And that makes it very effective.

- You know, I, I use lumbar drain routinely for credit fringe yamas, and I used the guests get a seal technique, describe our shorts. It works very well for us sometimes, you know, do we really need a lumbar drain if we're using gasket a CLT technique that's questionable. But I think that solid construct, if you can do it is a very useful, but remember the acute angle between the plaintiff and the pituitary can make it difficult to do that. So again, you have to see what fits geometrically for your requests.

- Right? I mean, I would have a hard time myself putting a rigid construct here because this is, this is caloric here, I'm here and this optic nerve optic nerve. So I cannot put it in this area. I would have to tag it underneath this bone, or maybe put some work here in the floor of the cellar. I don't have much bone because I extended my exposure all the way lateral. I, I am actually, you know, very satisfied with the liquid on the super center space, I think is a place where the leak rate is, is very low, regardless of your technique of reconstruction. I think the septal flap is in my opinion, the key for successful reconstruction, this area. When you say gasket seal, you probably use the gasket seal plastic septal flap on top.

- Correct? You do the guests get seal and then use it in as a set of lab.

- Yeah. I, I honestly think in this area, what person I think makes the difference. It's actually the simple flap as the key step you have, you don't have a set flat. There is when you are in travel then is when we start thinking about using faster ladder and a lumbar drain and everything you can do, and then like ask it to maybe a good option. You don't have a good flap. Alright. So just to conclude the part on kind of the, you know, th this we published recently a few years ago, and now we're recently, we are doing our re the re review of four series with now a hundred and something patients and updated results, which I don't, I don't have yet, but this was published in the past, and this is available. But in general, the resection rate is very good for these students about, you know, 70% or more, you get a complete or near complete resection of these tumors. The clinical results are in general, good is especially in terms of visual recovery, most patients, two thirds to 80%, they get better. And just a few, my good, worse after surgery, always a major issue is there between the dysfunction. And as we discussed, that depends very much on the type of tumor that you're dealing with. Some of them, there is no way I can personally preserve their function. Some others is you actually can. It depends on that type of tumor. And in the last minutes, I guess when I review a few different tumors that are cases that I've encountered that are, they look like kind of funny angiomas, but they are not. And also to send a message that not always shoot is necessarily for the steamer. Sometimes observation is, is appropriate for too much like this, this, for example, a 39 year old with him, fertility, this tumor, I thought it was kind of funny. Gamer went after resection and ended up being an all-star astrocytoma are piloted the cancer sites on my gray one. So very interesting. I had to move the pituitary gland app to take the tumor because he was behind the stock. So the stock was all in front of the tumor, and this patient has partial hypopituitarism post pre-op and ended up having panic, but be to do some post-op not the I and the da recover, but C needs to be on a staircase after. So, so always in to think about that when pieces are intact before she really would, you want to do or not unusual in case I did recently epidermoid cyst on the pituitary stock. It looks kind of funny, but he was actually at an epidermoid cyst. And in this case, and the trick that I used here is not only to go above super cetera, to get the tumor behind the stock, but also you combine this with opening image in the anterior and the postural gland right here to get this portion of the tumor. It was very difficult to come from here down, but relatively easy to just open it in the ante, on the poster of glam and get these part of the team when there was in between the two logos or the clan. So that was a tricky.

- Christine, as you can see, this tumor has divided anterior and posterior pituitary. So you really work between just behind and anterior to the gland. But one has to always remember the risk to the pituitary gland itself. Devascularizing it? When you really mobilize it, some of the pituitary's can be extremely sensitive and get devascularized. I'm sure you have experienced that before. So anytime you can avoid significant manipulation. It's great. Go ahead.

- That goes along with, with diesel or type of team or what we call general cell team, or these are also very rare. Do you also the stock and you see, these are tumors we did in the past. And, you know, in retrospect, this had that you can, yes. Often watch if they are asymptomatic, they are not clearly growing. You can just watch the students because removing these tumors, all, there's a nice surgical exercise that is often not good for the functioning of the pituitary gland or the function of the stock. So these patients often get the eye or panhypopituitarism and observation. If they see a tool like this in my clinic, I would, yes. Observe it. If it's symptomatic, if it grows, then I'll do a surgery or radiation is an option to.

- Vascular to, so they are social with a lot of bleeding at times. So it's hard to them from other tumors, but surely if you see a solid tumor, very much at social with his superior pituitary stalk, and it's not causing symptoms, and it doesn't look like a craniopharyngioma, if a symptomatic it's best to just follow.

- Completely agree. No question about it. Now, then we have extreme cases. This was a P P two se Toma had a type of tumor. The post-program is a giant one. These patients had multiple symptoms. This one, of course, it's sturdy. And even though the tumor is very large, it's a tumor that you can do in the nasally. And this will be, you know, adjusted last clip to so quickly this case, but you see very large exposure. And usually the pituitary gland is down here and all this is the dura that we are exposing. And we extended the exposure laterally and include, you know, all the way to the crude on optic nerve. And then we, we joined inside the tumor. And as you mentioned, these tumors might be very vascular. The nice thing of is an exchange of being very vascular is that they are very suckable and that makes the tumor resection quite easy because they aspirate very easily, but they are very vascular and that's completely inside the third ventricle. But, you know, that's the optical problems right here where they say adopt the optical Parado, sapele the third nerve. And at the end, you get this picture of the third ventricle, completely open look at the massive thing on the thalamus is the thalamus mass and the media, and this will be forming a Monroe. And, and you get an, a computer section of, of tomorrow, such as like this, this person knew that the patient, you know, long-standing hydrocephalus and, you know, be patient for a post-op management. And long-term so just to conclude, I'm not questioning the endonasal, Suli provides an ideal approach for most gonna fund in your minds. You have to remember the purely internal tickler are not ideal. The rest are ideal for endonasal to be inform the recommend framers are more difficult, more challenging, more risk for complications, but it's still, when you're experienced are good for endonasal surgery, versus suprasellar kind of for given gamers are easier, perhaps ideal for less experienced use to start with because they are, you know, less challenging. It provides visual and purely function outcome advantageous. If you compare it with open approaches, I believe, especially because decreases manipulation of the optic apparatus and all that, the Twitter you stop, you can see early and avoid. It's a disruption early on the case, and very important for me, because you always worry about these hypothalamic damage. And these view of the cosmetic hypothalamic dissection plane is something that the endonasal approach provides. The Knoll that approach provides a view like that. Remember all the key anatomy review, the middle OCR or the limbus hypophyseal already comfort ventricle. And this three of them mobilizing the pituitary inferior to gain more space. I'm finally, I would express the importance of the septal flap and sometimes externally into grand drain when Tim was really embedding today into the third ventricle. Well, I just want to say, thank you are on for another fun session, how it wasn't too long ago.

- It's great. You're on a horn. You have done pioneering work and other scopic surgery, both in anatomy and a gifted surgeon that you are. And at such a young age who have contributed so much. And I have no doubt that we'll hear a lot more from you in the near future. And we're happy to see a neurosurgery is happy to see somebody of your caliber at such a young age, make so much progress. And it's good to have you for us for many years to come. I personally look forward to it and I know many others well, I closed this idea of this session by adding that I think craniopharyngioma is the first tumor besides pituitary tumors, obviously that has proven itself to be a better fit for the endonasal approach. Then the transcranial approach, we did a paper recently in neurosurgical focus in that regard that the outcome of craniopharyngioma resection through the nose are superior. There is obviously slight increase of pituitary function sacrifice, but that probably relates to the fact that the resections are more aggressive, more thorough, and therefore the rest of the stock is higher. The stock is much more in their blind spot when you come in trans cranially and as we expected, the visual outcomes were slightly worse by other sub front of approach. So I think more and more, we'll see people that will believe that craniopharyngiomas are one non pituitary lesion that is very fit for the endoscopic transducer approach. And with that, thank you. Thank you. And thank you, Horner. We look forward to having with us in another session soon.

- Excellent. Thanks so much.

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