Comparative analysis on microsurgical removal of craniopharyngioma via lateral supraorbital approach and standard pterional approach

Orbitozygomatic Transsylvian Resection of a Craniopharyngioma: A Step-by-Step Guide

Adamantinomatous craniopharyngioma (ACP) is a rare sellar region tumor seen in 0.5-2 cases per million persons each year,1 presenting a bimodal distribution that peaks at 5-15 years in children and 45-60 years in adults.2 Arising from embryonic remnants of the Rathke pouch epithelium, ACPs are associated with calcifications in 90% of cases and grow cranially toward the floor of the diencephalon.1 Craniopharyngiomas are benign but locally aggressive tumors, with microsurgery being the best chance of cure.3 The natural history is to compress the optic apparatus and hypothalamic-pituitary axis as they expand, with a propensity to encase the carotids. Endoscopic transbasal approaches have gained wide acceptance in the management of these tumors.4-6 However, open microsurgical approaches via pterional and orbitozygomatic craniotomies afford wider visualization of different corridors that help mitigate the surgical risks.7-9 The orbitozygomatic craniotomy allows lesions that extend above the optic chiasm to be safely approached from an inferior-to-superior corridor.9 The wide exposure of the basal arachnoid cisterns allows protection of the lenticulostriate perforators during resection.8-11 We demonstrate a step-by-step orbitozygomatic approach with dissection of the sylvian, carotid, carotid-oculomotor, chiasmatic, and lamina terminalis cisterns that allowed safe resection of a third ventricular ACP. The patient was a male in his 70s, who presented with progressive headaches and visual impairment. Magnetic resonance imaging showed a multicystic suprasellar lesion extending through the third ventricle. The surgery was performed with no complication (Video 1). Postoperative vision stabilized, and magnetic resonance imaging showed complete resection.

Comparing Surgical Approaches for Craniopharyngioma Resection Among Adults and Children: A Meta-analysis and Systematic Review

BACKGROUND

Craniopharyngioma treatment often necessitates surgical resection. Conventional approaches, such as transcranial and transsphenoidal approaches, are predominantly used. However, a recently adopted supraorbital approach may be more efficacious. Thus, this meta-analysis and systematic review aimed to compare the efficacy of the transcranial, transsphenoidal, and supraorbital approaches for resection and treatment of craniopharyngiomas.

METHODS

This study was performed following PRISMA guidelines. Analyses were performed according to study design: (1) analyses for studies comparing several surgical approaches; and (2) analyses of all included studies. Random effects meta-analysis models were used to pool odds ratios among studies comparing several approaches. Similarly, categorical meta-regression models were used to examine the effect of surgical approach as a covariate of outcome data for all studies. Statistics were performed using Comprehensive Meta-Analysis software (CMA 3.3, Biostat, Englewood, NJ) (significance set at P < 0.05).

RESULTS

Patients were well-matched for age, sex, and preoperative comorbidities between groups stratified by surgical approach. Analyses including 22 studies that compared several approaches demonstrated that the transsphenoidal group had a greater occurrence of postoperative visual improvement (P < 0.0001), lesser occurrence of visual deterioration (P < 0.0001), and lower tumor recurrence rate (P = 0.015) compared with the transcranial group. Only 2 studies compared the supraorbital approach to another approach, limiting analyses. Analyses including all studies demonstrated that the supraorbital group did not differ to either the transcranial or transsphenoidal group for any examined variables.

CONCLUSIONS

The present study suggests that the transsphenoidal approach is associated with improved clinical outcomes for craniopharyngioma resection. There are limited data regarding the supraorbital approach, warranting future investigation.