Extended endoscopic endonasal transsphenoidal approach for residual or recurrent craniopharyngiomas

The role of endoscopic endonasal salvage surgery in recurrent or residual craniopharyngioma after a transcranial approach: a systematic review

BACKGROUND

The management of craniopharyngiomas is challenging due to their high rate of recurrence following resection. Excision of recurrent tumors poses further surgical challenges due to loss of arachnoidal planes and adherence to anatomical structures. The endoscopic endonasal approach (EEA) offers a favorable alternative to transcranial approaches for primary craniopharyngiomas. However, the safety and efficacy of EEA for recurrent tumors, specifically after a prior transcranial approach, needs further investigation.

METHODS

We performed a systematic review using PubMed to develop a database of cases of recurrent craniopharyngiomas previously treated with a transcranial approach.

RESULTS

Fifteen articles were included in this review with a total of 75 cases. There were 50 males and 25 females with a mean age of 38 years (range 2-80). One prior transcranial surgery was done in 80.0% of cases, while 8.0% had two and 12.0% had more than two prior surgeries. Radiotherapy after transcranial resection was given in 18 cases (24.0%). Following EEA, vision improved in 60.0% of cases, and vision worsened in 8.6% of the cases. Of cases, 64.4% had pre-existing anterior hypopituitarism, and 43.8% had diabetes insipidus prior to EEA. New anterior hypopituitarism and diabetes insipidus developed in 24.6% and 21.9% of cases, respectively following EEA. Gross total resection (GTR) was achieved in 64.0%, subtotal resection in 32.0%, and partial resection in 4.0% revision EEA cases. GTR rate was higher in cases with no prior radiotherapy compared to cases with prior radiotherapy (72.0% vs 39.0%, p = 0.0372). The recurrence rate was 17.5% overall but was significantly lower at 10.0% following GTR (p = 0.0019). The average follow-up length was 41.2 months (range, 1-182 months).

CONCLUSION

The EEA can be utilized for resection of recurrent or residual craniopharyngiomas previously managed by a transcranial approach.

Intraoperative ultrasound-assisted endoscopic endonasal transclival marsupialization of an ectopic retrosellar Rathke's cleft cyst: A rare case illustration and systematic review of the literature

Not every Rathke's cleft cyst (RCC) is confined within the sella between the posterior and anterior lobes of the pituitary gland. Intracranial ectopic RCCs are extremely rare, with only seven cases reported in the literature. In this study, the authors presented a rare case of a symptomatic ectopic retrosellar RCC posterior to the pituitary gland, causing extensive clival erosion. The surgical nuances of the wide marsupialization of the cyst through intraoperative ultrasound-assisted endoscopic endonasal transclival approach are described, and a systematic literature review of intracranial ectopic RCCs is conducted.

Endoscopic Supraorbital Translaminar Approach

Surgical selection for third ventricle tumors demands meticulous planning, given the complex anatomic milieu. Traditional open microsurgical approaches may be limited in their access to certain tumors, prompting the exploration of alternative techniques. The endoscopic supraorbital translaminar approach (ESOTLA) has emerged as a promising alternative for managing these tumors. By combining a minimally invasive keyhole approach with endoscopic visualization, the ESOTLA provides enhanced illumination and a wider angle of view within the third ventricle. This unique advantage allows for improved access to retrochiasmatic tumors and reduces the need for frontal lobe and optic chiasm retraction required of microscopic techniques, decreasing the risk of neurocognitive and visual deficits. Complications related to the ESOTLA are rare and primarily pertain to cosmetic issues and potential compromise of the hypothalamus or optic apparatus, which can be minimized through careful subarachnoid dissection. This chapter offers a comprehensive description of the technical aspects of the ESOTLA, providing insights into its application, advantages, and potential limitations. Additionally, a case description highlights the successful surgical extirpation of an intraventricular papillary craniopharyngioma via the ESOTLA followed by targeted therapy. To better illustrate the stepwise dissection through this novel approach, a series of cadaveric and intraoperative photographs are included.

Staged Strategies to Deal with Complex, Giant, Multi-Fossa Skull Base Tumors

Given the complex and multifaceted nature of resecting giant tumors in the anterior, middle, and, to a lesser extent, the posterior fossa, we present two example strategies for navigating the intricacies of such tumors. The foundational premise of these two approaches is based on a two-stage method that aims to improve the visualization and excision of the tumor. In the first case, we utilized a combined endoscopic endonasal approach and a staged modified pterional, pretemporal, with extradural clinoidectomy, and transcavernous approach to successfully remove a giant pituitary adenoma. In the second case, we performed a modified right-sided pterional approach with pretemporal access and extradural clinoidectomy. This was followed by a transcortical, transventricular approach to excise a giant anterior clinoid meningioma. These cases demonstrate the importance of performing staged operations to address the challenges posed by these giant tumors.

Characteristics and Outcomes in Pediatric Versus Adult Craniopharyngiomas: A Systematic Review and Meta-Analysis

BACKGROUND

Craniopharyngiomas account for 1.2% to 4.6% of all intracranial tumors. Although age at presentation is distributed bimodally, with a pediatric peak occurring between 5 and 15 years and an adult peak between 50 and 70 years, presentation, treatment, and outcome differences between these two craniopharyngioma populations have not been thoroughly characterized.

OBJECTIVE

To compare treatments and outcomes between adult and pediatric craniopharyngiomas.

METHODS

This is a systematic review and meta-analysis. Web of Science, MEDLINE, and Scopus databases were searched for primary studies reporting postoperative complications, functional outcomes, recurrence, and overall survival in patients with craniopharyngioma undergoing surgery.

RESULTS

The search yielded 1,202 unique articles, of which 106 (n=4,202 patients) met criteria for qualitative synthesis and 23 (n=735 patients) met criteria for meta-analysis. Compared with adult, pediatric craniopharyngiomas were less likely to present with visual defects (odds ratio [OR] 0.54, 95% CI 0.36-0.80) or cognitive impairment (OR 0.29, 95% CI 0.12-0.71) and more likely with headaches (OR 2.08, 95% CI 1.16-3.73). Children presented with significantly larger tumors compared with adults (standardized mean difference 0.68, 95% CI 0.38-0.97). Comparing functional outcomes, pediatric patients sustained higher rates of permanent diabetes insipidus (OR 1.70, 95% CI 1.13-2.56), obesity (OR 3.15, 95% CI 1.19-8.31), and cranial nerve and/or neurological defects (OR 4.87, 95% CI 1.78-13.31) than adults. No significant differences were found in rates of postoperative cerebrospinal fluid leak, overall or progression-free survival, or recurrence.

CONCLUSION

Adult and pediatric craniopharyngiomas seem to have fundamental differences in clinical presentation and functional outcomes. These patients frequently require multimodality treatment and are best managed with a multidisciplinary team and an individualized approach.

Endoscopic Endonasal Approach in Craniopharyngiomas: Representative Cases and Technical Nuances for the Young Neurosurgeon

Craniopharyngiomas (CPs) are Rathke's cleft-derived benign tumors originating most commonly in the dorsum sellae and representing 2% of intracranial neoplasms. CPs represent one of the more complex intracranial tumors due to their invasive nature, encasing neurovascular structures of the sellar and parasellar regions, making its resection a major challenge for the neurosurgeon with important postoperative morbidity. Nowadays, an endoscopic endonasal approach (EEA) provides an "easier" way for CPs resection allowing a direct route to the tumor with direct visualization of the surrounding structures, diminishing inadvertent injuries, and providing a better outcome for the patient. In this article, we include a comprehensive description of the EEA technique and nuances in CPs resection, including three illustrated clinical cases.

Endoscopic endonasal treatment of craniopharyngiomas: current management strategies and future perspectives

INTRODUCTION

Craniopharyngiomas are locally aggressive disembryogenetic tumors presenting mostly in childhood and late adulthood. They are often burdened by an unfavorable clinical course due to close relationships with nearby critical neurovascular structures and high risk of recurrences. The aim of our paper is to provide a systematic review of the literature regarding current strategies and future perspectives for the treatment of craniopharyngiomas, focusing on the role of endoscopic endonasal surgery.

EVIDENCE ACQUISITION

A comprehensive literature search of three databases (PubMed, Ovid Medline, and Ovid Embase) has been conducted to identify papers addressing the management strategies in adult and pediatric craniopharyngioma patients.

EVIDENCE SYNTHESIS

Twenty-two articles have been included, providing data for 560 adult and 215 pediatric patients. Mean follow-up was 40.29 months for the adult and 58.05 months for pediatric population. GTR rate was 60.97% and 82.52% in adult and pediatric patients, respectively. Adjuvant radiotherapy was delivered in 20.99% of adult and 8.25% of pediatric cases; 89% of adult patients and 94.11% of pediatric patients receiving radiotherapy had previously undergone NTR, STR or partial resection. The recurrence rate was 19.32% and 18.61% for adult and pediatric population, respectively. Recurrences occurred mostly in patients receiving incomplete resection without adjuvant radiotherapy (72.87% in adults and 51.28% in children); 86.69% and 87.12% of adult and pediatric patients reported improvement of their previous ophthalmologic deficit; 40% of the adult population and 41.86%% of pediatric patients worsened or developed endocrinological disturbances. CSF leak rate was 16.4% in adults and 13.95%% in children.

CONCLUSIONS

Modern policy of craniopharyngioma management is represented by the combination of a "maximum safe" allowed surgical removal plus radiotherapy. In this scenario, the endoscopic endonasal technique proved to be a valid approach for removing these lesions, providing satisfactory outcomes with lower morbidity.

Endoscopic endonasal approach for infradiaphragmatic craniopharyngiomas: a multicentric Italian study

OBJECTIVE

Infradiaphragmatic craniopharyngiomas (ICs) represent a distinct subtype, harboring a sellar-suprasellar origin and generally growing in the extra-arachnoidal space contained by the diaphragma sellae. They have been considered ideal for surgical removal through the transsphenoidal approach since the 1960s. The authors present a multicentric national study, intending to selectively analyze IC behavior and the impact of the transsphenoidal endoscopic endonasal approach (EEA) on surgical outcomes.

METHODS

Craniopharyngiomas that were intraoperatively recognized as infradiaphragmatic and removed with standard EEA between 2000 and 2021 at 6 Italian neurosurgical departments were included in the study. Clinical, radiological, and surgical findings and outcomes were evaluated and reviewed.

RESULTS

In total, 84 patients were included, with 45.23% identified as pediatric cases and 39.28% as having recurrent tumors. The most common presenting symptoms were endocrine (75%), visual (59.52%), and hypothalamic (26.19%) disorders. ICs were classified as extending below (6 intrasellar and 41 occupying the suprasellar cistern) or above (26 obliterating the anterior recesses of the third ventricle and 11 extending up to the foramina of Monro) the chiasmatic cistern. Gross-total resection (GTR) was achieved in 54 cases (64.28%). Tumor extension above the chiasmatic cistern and calcifications were associated with lower likelihood of GTR. The cumulative rate of postoperative complications was 34.53%, with CSF leak being the most common (14.28%). Endocrine, visual, and hypothalamic functions deteriorated postoperatively in 41/78 patients (52.56%), 5/84 (5.95%), and 14/84 (16.67%), respectively. Twenty-eight patients (33.33%) had recurrence during follow-up (mean 63.51 months), with a mean 5-year progression-free survival (PFS) rate of 58%. PFS was greater in patients who achieved GTR than patients with other extent of resection.

CONCLUSIONS

This is the largest series in the literature to describe ICs removed with standard EEA, without the need for additional bone and dural opening over the planum sphenoidale. EEA provides a direct route to ICs, the opportunity to manage lesions extending up to the third ventricle without breaching the diaphragma, and high rates of GTR and satisfactory clinical outcomes. Increased surgical complexity and morbidity should be expected in patients with extensive suprasellar extension and involvement of the surrounding vital neurovascular structures.

Fatal Fungal Aneurysm Rupture Due to Aspergillosis after Craniopharyngioma Removal via Endoscopic Endonasal Surgery: Case Report and Comparison with Seven Reported Patients

There has been a noted increase in the incidence of intracranial aspergillosis; this is often attributed to the wider use of antibiotics, corticosteroids, and immunosuppressants. Fungal cerebral aneurysms due to aspergillosis after neurosurgery remain extremely rare; in fact, only seven cases have been reported in the literature. In this study, we present a patient with an Aspergillus aneurysm that elicited subarachnoid hemorrhage after endoscopic endonasal surgery (EES) for craniopharyngioma. A 70-year-old woman with recurrent craniopharyngioma and steroid treatment underwent uneventful EES. On the 5th postoperative day, she suffered subarachnoid hemorrhage. As per her computed tomography angiography findings, an aneurysm was detected on the left internal carotid artery (ICA). Subsequent digital subtraction angiography showed occlusion of the ICA and an irregularly shaped wall. The diagnosis was pseudoaneurysm. We then performed craniotomy to place a left high-flow bypass and to trap the pseudoaneurysm. Despite continuous intensive care, she died on the 25th postoperative day of a huge, left cerebral infarct. The final diagnosis was made at autopsy; it revealed destruction of the ICA and Aspergillus invasion of the vessel wall, confirming the presence of a true fungal aneurysm. Perioperatively, patients with potential immunosuppression must be carefully managed. Advanced age is a risk factor. As surgery via the paranasal sinuses raises the risk for aspergillosis, fungal infection must be ruled out in patients whose postoperative course is deemed concerning.

Case report and literature review: Resection of retroinfundibular craniopharyngioma via endoscopic far-lateral supracerebellar infratentorial approach

Introduction

The management of retroinfundibular craniopharyngioma (CP) remains the ultimate challenge for both transsphenoidal and open transcranial surgery because of their anatomical location and proximity to vital neurovascular structures. In this report, we aim to describe the technique and feasibility of a novel approach, the purely endoscopic far-lateral supracerebellar infratentorial approach (EF-SCITA), for resection of retroinfundibular CP.

Case description

A 63-year-old women presented with progressive visual disturbance, polyuria, and spiritlessness of a 3-month duration. Imaging studies revealed a typical retroinfundibular CP containing solid and cystic components with calcification, which extended inferiorly in front of the brainstem and upward into the third ventricle. The EF-SCITA approach was attempted for resection of the tumor. During surgery, lateral prone positioning with upper flexion of the head and early CSF release allowed for download retraction of the cerebellum. This, in combination with tentorium incision, created a working corridor toward retrosellar and suprasellar spaces. This approach required working between neurovascular structures in the crural cistern, with tumor removal permitted in supra-oculomotor and infra-oculomotor spaces. After aspiration of the fluid contents through the supra-oculomotor triangle, the solid lesion was found tightly adhering to the distal part of the pituitary stalk, and subtotal resection was achieved for maintaining the integrity of pituitary function. In the immediate postoperative period, the patients exhibited oculomotor paralysis and was discharged with hormonal replacement therapy three weeks after operation. At her three-month follow-up appointment, she reported obvious vision improvement. Physical examinations showed partial alleviation of oculomotor paralysis. Pathological analyses confirmed the diagnosis of papillary CP.

Discussion

The purely EF-SCITA approach combines the advantages of both the posterolateral approach and endoscopic technique, which offers access to retrosellar and suprasellar spaces with seemingly low risks of postoperative morbidity. It would be a safe and effective alternative for the treatment of retroinfundibular CP, especially those with lateral extension to the temporal lobe or posterolateral extension to the petroclival region. Further observational studies in a larger cohort are urgently needed to assess the long-term efficacy of this minimal access approach.

Advances in Pituitary Surgery

Pituitary surgery has advanced considerably in recent years with the exploration and development of various endoscopic approaches and techniques. Different endoscopic skull base approaches are being applied to access sellar tumors in different locations. Moreover, extracapsular dissection and cavernous sinus exploration have enabled gross total resection of sellar tumors where it could not have been achieved in the past. Techniques for skull base reconstruction have also progressed, allowing surgeons to remove larger and more complicated tumors than before. This review article discusses different endoscopic skull base approaches, surgical techniques for removing pituitary adenomas, and reconstruction methods for repairing postoperative low-flow and high-flow cerebrospinal fluid leakage.

Endoscopic Endonasal Approach to the Third Ventricle Using the Surgical Corridor of the Reverse Third Ventriculostomy: Anatomo-Surgical Nuances

Objective Surgical access to the third ventricle can be achieved through various corridors depending on the location and extent of the lesion; however, traditional transcranial approaches risk damage to multiple critical neural structures.

Methods Endonasal approach similar to corridor of the reverse third ventriculostomy (ERTV) was surgically simulated in eight cadaveric heads. Fiber dissections were additionally performed within the third ventricle along the endoscopic route. Additionally, we present a case of ERTV in a patient with craniopharyngioma extending into the third ventricle.

Results The ERTV allowed adequate intraventricular visualization along the third ventricle. The extracranial step of the surgical corridor included a bony window in the sellar floor, tuberculum sella, and the lower part of the planum sphenoidale. ERTV provided an intraventricular surgical field along the foramen of Monro to expose an area bordered by the fornix anteriorly, thalamus laterally, anterior commissure anterior superiorly, posterior commissure, habenula and pineal gland posteriorly, and aqueduct of Sylvius centered posterior inferiorly.

Conclusion The third ventricle can safely be accessed through ERTV either above or below the pituitary gland. ERTV provides a wide exposure of the third ventricle through the tuber cinereum and offers access to the anterior part as far as the anterior commissure and precommissural part of fornix and the whole length of the posterior part. Endoscopic ERTV may be a suitable alternative to transcranial approaches to access the third ventricle in selected patients.

Endoscopic Endonasal Transsphenoidal Surgery for Recurrent Craniopharyngiomas

Object

Although revision surgery for recurrent craniopharyngiomas is more challenging than primary surgery and often accompanies a higher risk of death and complications, endoscopic endonasal transsphenoidal surgery (EETS) is sometimes still an effective and reliable treatment option. In this study, we introduced the surgical outcomes of EETS for recurrent craniopharyngiomas and summarized the surgical experiences.

Methods

Between 2014 and 2018, 28 patients with recurrent craniopharyngiomas underwent 29 EETS in our department. We regarded the patient undergoing two EETS as two independent patients in statistical analysis. Of the 29 patients, 16 had undergone 1 previous surgery, 10 had undergone 2 previous surgeries, and the remaining 3 patients had undergone 3 surgeries. The extent of resection, visual and endocrine outcomes, and complications of all the patients were collected and analyzed.

Results

Gross total resection was accomplished in 16 patients (55.17%), subtotal resection in 11 patients (37.93%), and partial resection in 2 patients (6.9%). Among the 22 patients with preoperative visual acuity and visual field impairment, some degree of vision improvement was observed in 18 patients, 3 patients were without visual change, and perpetual deterioration of vision occurred in one patient. The remaining six patients had normal vision before and after surgery. Postoperative endocrine tests showed that, among five patients with normal preoperative pituitary hormone function, only one patient still had normal pituitary hormone function and the other four patients had one or more hypothalamic-pituitary axes involved. None of the patients with preoperative endocrine dysfunction had endocrine function improved. Diabetes insipidus was observed in six new cases postoperatively. Cerebrospinal fluid (CSF) leakage occurred in 1 patient. One patient had bacterial meningitis, which was cured with antibiotics and a lumbar drain. No serious morbidity and mortality occurred in all patients.

Conclusions

For recurrent craniopharyngiomas, a personalized treatment plan should be developed according to the tumor characteristics and the patient's situation. There is no omnipotent method to be used for all patients. The EETS still is a safe and effective way to treat recurrent craniopharyngiomas in appropriate patients.

Endoscopic Endonasal Approach to the Third Ventricle using the Corridor of the Reverse Third Ventriculostomy: anatomo-surgical nuances

Objective: Surgical access to the third ventricle can be achieved through various corridors depending on the location and extent of the lesion; however, traditional transcranial approaches risk damage to multiple critical neural structures. Methods: Endonasal approach similar to corridor of the reverse third ventriculostomy (ERTV) was surgically simulated in eight cadaveric heads. Fiber dissections were additionally performed within the third ventricle along the endoscopic route. Additionally, we present a case of ERTV in a patient with craniopharyngioma extending into the third ventricle. Results: The ERTV allowed adequate intraventricular visualization along the third ventricle. The extracranial step of the surgical corridor included a bony window in the sellar floor, tuberculum sella and the lower part of the planum sphenoidale. ERTV provided an intraventricular surgical field along the foramen of Monro to expose an area bordered by the fornix anteriorly, thalamus laterally, anterior commissure anterior superiorly, posterior commissure, habenula and pineal gland posteriorly, and aqueduct of Sylvius centered posterior inferiorly. Conclusion: The third ventricle can safely be accessed through ERTV either above or below the pituitary gland. ERTV provides a wide exposure of the third ventricle through the tuber cinereum and offers access to the anterior part as far as the anterior commissure and pre-commissural part of fornix and the whole length of the posterior part. Endoscopic ERTV may be a suitable alternative to transcranial approaches to access the third ventricle in selected patients.

Current Advances in the Management of Adult Craniopharyngiomas

Craniopharyngiomas (CPs) are slow growing, histologically benign intracranial tumors located in the sellar–suprasellar region. Although known to have low mortality, their location and relationship to the adjacent neural structures results in patients having significant neurologic, endocrine, and visual comorbidities. The invasive nature of this tumor makes complete resection a challenge and contributes to its recurrence. Additionally, these tumors are bimodally distributed, being treated with surgery, and are followed by other adjuncts, such as focused radiation therapy, e.g., Gamma knife. Advances in surgical techniques, imaging tools, and instrumentations have resulted in the evolution of surgery using endoscopic techniques, with residual components being treated by radiotherapy to target the residual tumor. Advances in molecular biology have elucidated the main pathways involved in tumor development and recurrence, but presently, no other treatments are offered to patients, besides surgery, radiation, and endocrine management, as the disease and tumor evolve. We review the contemporary management of these tumors, from the evolution of surgical treatments, utilizing standard open microscopic approaches to the more recent endoscopic surgery, and discuss the current recommendations for care of these patients. We discuss the developments in radiation therapy, such as radiosurgery, being used as treatment strategies for craniopharyngioma, highlighting their beneficial effects on tumor resections while decreasing the rates of adverse outcomes. We also outline the recent chemotherapy modalities, which help control tumor growth, and the immune landscape on craniopharyngiomas that allow the development of novel immunotherapies.

The clinical application of intraoperative visual evoked potential in recurrent craniopharyngiomas resected by extended endoscopic endonasal surgery

OBJECTIVE

The protection of visual function is a major challenge for recurrent craniopharyngioma due to the interface between tumor and surrounding structure (esp. optic nerve) is more unclear. Intraoperative visual evoked potential (VEP) has been integrated into transsphenoidal surgery for pituitary adenomas and primary craniopharyngiomas in the prediction of postoperative visual outcome. In the present study, we firstly analyzed the clinical value of the VEP in the prediction of postoperative visual outcome for recurrent craniopharyngiomas by extended endoscopic endonasal surgery (EEES).

METHODS

Thirty-six patients with recurrent craniopharyngiomas who underwent EEES with intraoperative VEP monitoring were retrospectively reviewed. The association between the changes in the VEP amplitude and postoperative visual outcome was determined. In addition, other potential prognostic factors with regard to postoperative visual outcomes were also included in the analysis.

RESULTS

Gross total resection (GTR) was achieved in 32 patients (88.9%). Reproducible and stable VEP was recorded in 72 eyes. We recorded that there were 29 eyes remained stable VEP amplitude intraoperation, 4 (13.8%) of which suffered new visual acuity (VA) and 5 (17.2%) suffered new visual field (VF) defects after surgery. A transient VEP decrease was recorded in 41 eyes, 8 (19.5%) of which suffered from visual deterioration. Of 2 eyes with a permanent VEP decrease, 2 (100%) experienced postoperative visual impairment. Clinical variable analyses revealed a significant correlation between recurrent craniopharyngioma and age, adhesion with optic nerve, postoperative VA, and intraoperative VEP amplitude. Unstable VEP amplitude during operation and tight adhesion were independent risk factors for postoperative VA. Tight adhesion and a larger tumor volume were independent risk factors for postoperative VF defects.

CONCLUSIONS

EEES provides a unique view for the lesions under and behind the chiasm and achieve higher rates of GTR with improved visual outcomes. Tight adhesion and unstable VEP amplitude were strong predictors of postoperative visual impairment. Recurrent craniopharyngiomas are more likely to adhere to the optic nerve, VEP is more likely to be unstable during operation, and the improvement rate of postoperative visual function is lower than primary craniopharyngiomas. So intraoperative VEP is more necessary for recurrent craniopharyngiomas.

Endoscopic transsphenoidal surgery for resection of pituitary macroadenoma: A retrospective study

BACKGROUND

The endoscopic transsphenoidal approach is an efficient minimally invasive procedure for removal of pituitary tumors that can be accomplished through a one-hand or two-hand approach. The one-hand procedure through one nostril is more intuitive for surgeons, but maneuvering the instruments can be restrictive. The two-hand procedure using a one-and-half nostril approach provides more precise manipulation. This study aimed to compare the surgical outcomes of one-hand/mono-nostril and two-hand/one-and-half nostril surgeries for resection of large pituitary tumors by a single neurosurgeon.

MATERIALS AND METHODS

The surgical data of 78 consecutive cases with pituitary macroadenoma (diameter >1 cm) were reviewed retrospectively. Altogether, 30 cases received one-hand/mono-nostril surgery, while 48 cases received two-hand/one-and-half nostril surgery. Postoperative outcomes of the two operations were compared.

RESULTS

The operative time, hospital stay, residual rate of pituitary macroadenoma, visual field, surgical complications, and re-operative rates were slightly improved in the two-hand/one-and-half nostril surgery group compared with that in the one-hand/mono-nostril surgery group (all p>0.05). However, postoperative hypopituitarism was less frequent (1/48; 2.0%) with the two-hand/one-and-half nostril approach than with the mono-nostril approach (p = 0.004). Similar surgical outcomes were found in all patients with either small or large pituitary tumors, except that the difference in postoperative improvement in visual field change reached statistical significance (p = 0.044).

CONCLUSION

A single-surgeon endoscopic endonasal transsphenoidal surgery with two-hand/one-and-half nostril approach is an effective and safe procedure for removal of large pituitary tumors.

Basilar Artery Injury During Endonasal Surgery: Stepwise to Control Bleeding

BACKGROUND

Intraoperative injury during endoscopic endonasal surgery of the carotid artery has been previously described in the literature. However, the accidental damage of the basilar artery in such scenario is not defined.

OBJECTIVE

To define the protocol of action for massive bleeding from an artery in the posterior fossa.

METHODS

The reported patient was diagnosed with a partially calcified clival chordoma featured by a huge intradural component. An endoscopic endonasal transpterygoid transclival approach was selected for the treatment of this tumor. During the surgical procedure, the basilar artery injury was injured, causing intense bleeding. We present and discuss the surgical maneuvers that could save a patient's life after this dramatic complication.

RESULTS

Different techniques were performed in order to control the massive bleeding, including injection of hemotastic matrix with thrombin (Floseal©), bipolar coagulation, and vessel reconstruction by means of a vascular clip. Finally, an autologous muscle graft reinforced with an overlying fibrin sealant patch (Tachosil©) was chosen and was an effective technique. Afterwards, the patient was treated with a flow diverter device to occlude an iatrogenic pseudoaneurysm. A monoplegia of the right upper limb was the only remarkable sequel 6 mo after surgery.

CONCLUSION

The muscle graft together with the coordinated action with interventional neuroradiology for the reconstruction of the vessel are possibly the best options to try to preserve the neurological function. In such a scenario, the assumption of potential ischemic events prevails over the intraoperative death of the patient.

Reconstruction of skull base bone defects using an in situ bone flap after endoscopic endonasal transplanum-transtuberculum approaches

PURPOSE

The creation of bone flaps which can be later repositioned and fixed in situ for repairing the bone defects during the endoscopic endonasal approaches (EEAs)-similar to transcranial craniotomies-is still a challenge. We present an in situ bone flap (ISBF) closure for the repair of bone defects after endoscopic endonasal transplanum-transtuberculum approaches (EETAs).

METHODS

A retrospective analysis of consecutive patients who underwent the EETAs between January 2016 and February 2019 was performed. According to whether or not to use ISBF for skull base reconstruction, these patients were divided into the ISBF group or the non-ISBF group.

RESULTS

Of 47 patients in the ISBF group, only one patient (2.1%) developed postoperative cerebrospinal fluid (CSF) leakage, yielding a significantly lower leakage rate in the ISBF group than in the non-ISBF group (6 of 38, 15.8%, P = 0.042). Besides, when only comparing cases of hydrocephalus in the two groups, the CSF leakage rate in the ISBF group was 8.3% (1/12), which was still significantly lower than that in the non-ISBF group (62.5%, 6/8) (P = 0.018). Postoperative CSF leakages in both groups were successfully treated with lumbar drainage alone, and no cases of injury to the internal carotid arteries or optic nerves occurred in either group.

CONCLUSIONS

An ISBF closure similar to transcranial craniotomies with repositioning bone flap in situ-is feasible, safe, and reliable. The ISBF closure combining with a pedicled nasoseptal flap (PNSF) provides the cranial base surgeon with an additional repair method that has demonstrated effectiveness at facilitating a more stable and durable reconstruction and reducing CSF leaks.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Surgical management of craniopharyngiomas in adult patients: a systematic review and consensus statement on behalf of the EANS skull base section

BACKGROUND AND OBJECTIVE

Craniopharyngiomas are locally aggressive neuroepithelial tumors infiltrating nearby critical neurovascular structures. The majority of published surgical series deal with childhood-onset craniopharyngiomas, while the optimal surgical management for adult-onset tumors remains unclear. The aim of this paper is to summarize the main principles defining the surgical strategy for the management of craniopharyngiomas in adult patients through an extensive systematic literature review in order to formulate a series of recommendations.

MATERIAL AND METHODS

The MEDLINE database was systematically reviewed (January 1970-February 2019) to identify pertinent articles dealing with the surgical management of adult-onset craniopharyngiomas. A summary of literature evidence was proposed after discussion within the EANS skull base section.

RESULTS

The EANS task force formulated 13 recommendations and 4 suggestions. Treatment of these patients should be performed in tertiary referral centers. The endonasal approach is presently recommended for midline craniopharyngiomas because of the improved GTR and superior endocrinological and visual outcomes. The rate of CSF leak has strongly diminished with the use of the multilayer reconstruction technique. Transcranial approaches are recommended for tumors presenting lateral extensions or purely intraventricular. Independent of the technique, a maximal but hypothalamic-sparing resection should be performed to limit the occurrence of postoperative hypothalamic syndromes and metabolic complications. Similar principles should also be applied for tumor recurrences. Radiotherapy or intracystic agents are alternative treatments when no further surgery is possible. A multidisciplinary long-term follow-up is necessary.

Neurological and neuropsychological outcome after resection of craniopharyngiomas

OBJECTIVE

Craniopharyngiomas are rare and benign tumors of the sellar and/or parasellar region. Primary treatment involves resection followed by adjuvant radiotherapy. While the grade of resection was frequently analyzed following surgery, the neurological outcome and especially neuropsychological deficits and quality of life have been neglected for many decades. Therefore, the authors retrospectively analyzed their patient series and prospectively assessed neuropsychological outcome and quality of life following resection of craniopharyngiomas in adults.

METHODS

In total, 71 patients (39 men and 32 women) with a mean age of 49 years were enrolled in the retrospective analysis. In addition, 36 of the 71 patients were included in the prospective arm of the study and underwent neurological and neuropsychological testing as well as quality of life (36-Item Short-Form Health Survey; SF-36) assessment. Factors influencing outcome were identified and correlations calculated.

RESULTS

Resection was performed mostly using a pterional (41.6%, 47/113 surgical procedures) or bifrontal translamina terminalis (30.1%, 34/113 surgical procedures) approach. Following surgery, visual acuity was significantly improved (> 0.2 diopters) in 32.4% (23/71) of patients, or remained stable in 45.1% (32/71) of patients. During long-term follow up, 80.3% (57/71) of patients developed pituitary insufficiency, particularly involving the corticotropic and thyrotrophic axes. In total, 75% (27/36) of patients showed neuropsychological deviations in at least 1 test item. In particular, attentiveness, cognitive speed, and short-term memory were affected. Referring to the SF-36 score, quality of life was affected in both the mental and physical score in 19.4% (7/36) and 33.3% (12/36), respectively. The risk factors that were identified were a tumor volume larger than 9 cm3, tumor extension toward/into the third ventricle or the brainstem, and resection using a bifrontal translamina terminalis or left-sided approach.

CONCLUSIONS

This study demonstrated that resection of craniopharyngiomas is frequently associated with postoperative neuropsychological deficits and hence an impaired quality of life. In addition to tumor size and extension toward/into the third ventricle or the brainstem, selection of the surgical approach may play a crucial role in the patient's neuropsychological outcome and quality of life.

Endoscopic endonasal transsphenoidal approach for pediatric craniopharyngiomas: A case series

OBJECTIVES

This study aims to analyze our series of pediatric patients who underwent craniopharyngioma resection using the endoscopic endonasal transsphenoidal approach (EETA).

METHODS

We collected clinical and surgical data from the charts of 20 children who underwent craniopharyngioma removal surgery using the EETA from 2007 to 2017. From the charts, we collected demographic information, results of imaging tests (size and extension of the tumor), and information regarding the surgical procedure and postoperative complications.

RESULTS

From the 20 patients included in this series (12 women and eight men), 17 underwent EETA as a primary procedure, and the remaining three underwent EETA as a secondary procedure due to a relapsing tumor following previous transcranial surgery. The mean age of the patients at the time of the surgical procedure was 7.5 years (range 3-18 years). Regarding their location, 12 tumors were in the sellar and suprasellar regions, three extended into the third ventricle, and five were exclusively intrasellar. We achieved a gross total resection (GTR) of the tumor in 14 patients (70%), subtotal in five (25%), and partial in one (5%). One patient (5%) developed a cerebrospinal fluid fistula after the surgical procedure. In the postoperative follow-up period (mean time = 5.3 years; range = 2-9 years), 11 (55%) patients developed panhypopituitarism, and a relapsing tumor was later found in three (15%) patients. Regarding visual impairment, four patients had visual abnormalities preoperatively (amaurosis, n = 2; bilateral visual acuity decrease, n = 1; bilateral visual field defect, n = 1), and those did not improve or worsened postoperatively. None of the patients who did not have vision problems before the surgery developed those postoperatively.

CONCLUSION

Our results showed that the EETA is a safe and effective approach for removing craniopharyngiomas in children, as it associated with low operative morbidity and complication rates. Also, our data demonstrated that the EETA may be performed regardless of the size of the nasal cavity, pneumatization of the sphenoid sinuses, and location or extension of the tumors.

Craniopharyngiomas in children - experience of consecutive 152 operated cases

CONTEXT

Craniopharyngiomas (CPH) are benign tumors, rarely encountered in children, representing 5-6% of all intracranial tumors.

OBJECTIVE

This study aimed to analyze the surgical management and quality of life in a series of CPH pediatric cases.

DESIGN

This was a multicenter study performed over a 25-year period (1994 - 2019) in Bucharest.

SUBJECTS AND METHODS

152 children (0-17 years old) were treated for CPH. Preoperative manifestations were intracranial hypertension, endocrine dysfunction, visual impairment, ataxia, intellectual performance decrease.

RESULTS

Considering all surgical approaches used, we advocate for pterional approach to best fit in CPH. We achieved gross-total removal (GTR) in 83 cases (54.4%), near-total resection (NTR) in 13 cases (9%), partial resection (PTR) in 51 cases (33.3%). 5 cases were biopsies (3.2%). Gamma Knife Surgery was performed in 10 cases (6.5%), all recurrences. At 6 months GOS revealed: Good Recovery 70 cases (46.2%), Moderate Disability 62 cases (40.7%), Severe Disability 13 (8.5%), Vegetative State 2 cases (1.3%), Deceased 5 cases (3.2%). Complications were: diabetes insipidus (89.3%); hypopituitarism (66.4%); hypothalamic damage (17.7%); visual deterioration (18.4%).

CONCLUSIONS

Surgery remains the main option, but GTR complications prove the necessity for a multidisciplinary approach. Outcome predicting factors are: age, tumor size, hydrocephalus degree, hypothalamic dysfunction.

Pediatric craniopharyngioma

BACKGROUND

Craniopharyngioma has historically been recognized to be a formidable pathology primarily due to its proximity to critical neurovascular structures and the challenging surgical corridors that surgeons have tried to reach this lesion.

FOCUS OF REVIEW

In this work, we review the medical and surgical management of these tumors with a focus on clinical presentation, diagnostic identification, surgical approach, and associated adjuvant therapies. We will also discuss our current treatment paradigm using endoscopic, open, and combined approaches to craniopharyngiomas. The management of craniopharyngiomas requires a multidisciplinary team of surgeons, endocrinologists, and neuroanesthesiologists as well as neurocritical care specialists to deliver the most comprehensive and safest surgical resection with minimal postoperative morbidity.

Outcomes following endoscopic endonasal resection of sellar and supresellar lesions in pediatric patients

PURPOSE

The endoscopic endonasal approach (EEA) is a credible surgical alternative for the resection of sellar and suprasellar lesions such as pituitary adenomas, craniopharyngiomas, and Rathke cleft cysts. However, its application to pediatric patients poses several unique challenges that have not yet been well evaluated. The authors evaluate the safety, efficacy, and outcomes associated with the use of the EEA for treatment of these pathologic entities in pediatric patients.

METHODS

Retrospective review of 30 patients between the ages of two and 24 who underwent endoscopic endonasal resection of sellar or suprasellar lesions between January 2010 and December 2015. Endocrinological and ophthalmological outcomes, as well as extent of resection and complications were all evaluated.

RESULTS

Gross total resection was achieved in eight of the nine pituitary adenomas, nine of the 12 craniopharyngiomas, and six of the nine Rathke cleft cysts. Of the 30 patients, 22 remained disease free at last follow-up. A total of six patients developed hypopituitarism and five developed diabetes insipidus. Eleven patients experienced improved vision, sixteen experienced no change, and one patient experienced visual worsening. Postoperative cerebrospinal fluid leak was seen in a single case and later resolved, vasospasm/stroke was experienced by 10% of patients, and new obesity was recorded in 10% of patients. There were no perioperative deaths.

CONCLUSIONS

Endoscopic endonasal resection is a safe and effective surgical alternative for the management of sellar and suprasellar pathologies in pediatric populations with excellent outcomes, minimal complications, and a low risk of morbidity.

Endoscopic endonasal skull base surgery for pediatric brain tumors

PURPOSE

The utility of endoscopic endonasal skull base surgery (EES) in various pathologic entities in adults has been published in the literature. However, the role of EES in children has not been clearly elucidated. We evaluated the feasibility of EES in children with brain tumors.

METHODS

We retrospectively reviewed clinical features, surgical outcomes, and complications in children who underwent EES for intracranial and skull base tumors at a single institution from July 2010 to October 2018.

RESULTS

A total of 82 patients underwent EESs for 77 intracranial and 5 skull base bony tumors. The mean age at diagnosis was 11.4 years (range 4-18 years), and the mean follow-up period was 46.8 months. The most common tumors were craniopharyngioma in the intracranial tumor and chordoma in the skull base. Gross total resection was the goal of surgery in 55 patients and achieved in 90.9%. The vision was improved in 76.1% of patients with visual impairments. Preoperatively, various endocrinological deficiencies were revealed in 73.7% of 76 patients with hypothalamus-pituitary lesions, and the hyposomatotropism was most common. Endocrinological status was improved only in 10. Aseptic or bacterial meningitis (7.3%) was the most common surgical complication, and the cerebrospinal fluid leakage rate was 2.4%.

CONCLUSIONS

EES provides favorable neurological outcomes with acceptable risk for children with brain tumors. The high incidence of endocrinological deficits in cases with hypothalamus-pituitary lesions emphasizes the importance of judicious pre- and postoperative evaluation.

Endonasal endoscopic transsphenoidal resection of intrinsic third ventricular craniopharyngioma: surgical results

OBJECTIVE

Intrinsic third ventricular craniopharyngiomas (IVCs) have been reported by some authors to "pose the greatest surgical challenge" of all craniopharyngiomas (CPAs). A variety of open microsurgical approaches have historically been used for resection of these tumors. Despite increased utilization of the endoscopic endonasal approach (EEA) for resection of CPAs in recent years, many authors continue to recommend against use of the EEA for resection of IVCs. In this paper, the authors present the largest series to date utilizing the EEA to remove IVCs.

METHODS

The authors reviewed a prospectively acquired database of the EEA for resection of IVCs over 14 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital. Preoperative MR images were examined independently by two neurosurgeons and a neuroradiologist to identify IVCs. Pre- and postoperative endocrinological, ophthalmological, radiographic, and other morbidities were determined from retrospective chart review and volumetric radiographic analysis.

RESULTS

Between January 2006 and August 2017, 10 patients (4 men, 6 women) ranging in age from 26 to 67 years old, underwent resection of an IVC utilizing the EEA. Preoperative endocrinopathy was present in 70% and visual deterioration in 60%. Gross-total resection (GTR) was achieved in 9 (90%) of 10 patients, with achievement of near-total (98%) resection in the remaining patient. Pathology was papillary in 30%. Closure incorporated a "gasket-seal" technique with nasoseptal flap coverage and either lumbar drainage (9 patients) or a ventricular drain (1 patient). Postoperatively, complete anterior and posterior pituitary insufficiency was present in 90% and 70% of patients, respectively. In 4 patients with normal vision prior to surgery, 3 had stable vision following tumor resection. One patient noted a new, incongruous, left inferior homonymous quadrantanopsia postoperatively. In the 6 patients who presented with compromised vision, 2 reported stable vision following surgery. Each of the remaining 4 patients noted significant improvement in vision after tumor resection, with complete restoration of normal vision in 1 patient. Aside from the single case (10%) of visual deterioration referenced above, there were no instances of postoperative neurological decline. Postoperative CSF leakage occurred in 1 morbidly obese patient who required reoperation for revision of closure. After a mean follow-up of 46.8 months (range 4-131 months), tumor recurrence was observed in 2 patients (20%), one of whom was treated with radiation and the other with chemotherapy. Both of these patients had previously undergone GTR of the IVC.

CONCLUSIONS

The 10 patients described in this report represent the largest number of patients with IVC treated using EEA for resection to date. EEA for resection of IVC is a safe and efficacious operative strategy that should be considered a surgical option in the treatment of this challenging subset of tumors.

The extended endoscopic approach to perisellar and skull base lesions: is one nostril enough?

The extended endonasal endoscopic approach to the skull base is still under investigation. The main advantage of using this technique is to approach lesions in a minimally invasive manner resulting without brain retraction. Here, the authors present the results of extended endonasal endoscopic surgery via one nostril. All skull base procedures performed via an endonasal approach at the author's Department between January 2011 and May 2017 were analysed prospectively. Special attention was paid to complications, radicality, advantages and disadvantages of the endoscopic technique. Additionally, the application of various telescopes and the technique of dural closure were analysed. Sixty-two patients were operated on various pathologies of the skull base via an extended endonasal approach. Seven pathologies were resected via binostril technique. All other pathologies could be exposed by the mononostril technique. In 2 of 62 cases, the authors had to switch to binostril technique. MRI revealed radical gross total resection in 93% of all cases when intended. Overall complication rate was 16% (9/55) in the mononostril and 57% (4/7) in the binostril cohort. Seven patients in the mononostril cohort (13%) versus three patients in the binostril cohort (43%) complained of postoperative nasal congestion. This clinical report shows that many extended skull base lesions can be treated by a mononostril endonasal approach. In selected cases, this technique might represent an alternative to the binostril approach. Nevertheless, the binostril technique offers a better range of manipulation and exposure and should be preferred in difficult and very extended cases.

A regional Australasian experience of extended endoscopic transsphenoidal surgery for craniopharyngioma: Progression of the mentoring model

Endoscopic endonasal transsphenoidal approaches to craniopharyngioma has become increasingly popular over the last 15 years. We present the results of our retrospective series of craniopharyngiomata resected by an endoscopic, endonasal approach at a low-volume service in Australasia. Between the years of 2009 and 2017, 11 patients underwent pure endoscopic endonasal transsphenoidal resection for a craniopharyngioma at our institutions. The medical records, histopathology, intraoperative findings and patient imaging were retrospectively assessed. 11 patients were included with 5 male and 6 female patients. The mean age was 32.0 years (range 14-68 years). Of this patient series a gross total resection of the tumour was achieved in 8 of 11 patients (73%). In the immediate postoperative phase, 10 of the 11 patients developed diabetes insipidus (91%). The pituitary stalk was formally not seen in 4 patients and all were treated with vasopressin. Of the 7 patients where the pituitary stalk was identified it was formally divided in 6 and preserved in 1 patient where the tumour was separate to the stalk. The endoscopic endonasal transsphenoidal approach for excision of craniopharyngioma, utilising and progressing the surgical mentoring model, can achieve adequate decompression of critical structures. Furthermore, our aggressive approach to divide and remove the involved pituitary stalk results in high rates of gross macroscopic resection with excellent long-term disease control with a greater risk of postoperative diabetes insipidus and panhypopituitarism.

Endoscopic Resection of Pediatric Skull Base Tumors: An Evidence-Based Review

Objectives  To perform a systematic review examining experiences with endoscopic resection of skull base lesions in the pediatric population, with a focus on outcomes, recurrence, and surgical morbidities. Methods  PubMed/MEDLINE, Cochrane Library, Embase, and Web of Science databases were evaluated. Studies were assessed for level of evidence. Bias risk was evaluated using the Cochrane Bias tool, Grades of Recommendation, Assessment, Development and Evaluation (GRADE), and Methodological Index for Non-Randomized Studies (MINORS) criteria. Patient characteristics, pathology, site of primary disease, presenting symptoms, stage, procedure specific details, and complications were evaluated. Results were reported using the Preferred Reporting Systems for Systematic Reviews and Meta-Analysis guidelines. Results  Ninety-three studies met criteria for inclusion, encompassing 574 patients with skull base tumors. The GRADE and MINORS criteria determined the overall evidence to be moderate quality. The most common benign and malignant pathologies included juvenile nasopharyngeal angiofibromas ( n  = 239) and chondrosarcomas ( n  = 11) at 41.6 and 1.9%, respectively. Of all juvenile nasopharyngeal angiofibroma tumors, most presented at stage IIIa and IIIb (25.8 and 27.3%, respectively). Nasal obstruction (16.5%) and headache (16.0%) were common symptoms at initial presentation. Surgical approaches included endoscopic endonasal ( n  = 193, 41.2%) and endoscopic extended transsphenoidal ( n  = 155, 33.1%). Early (< 6 weeks) and late (>6 weeks) complications included cerebrospinal fluid leak ( n  = 36, 17.3%) and endocrinopathy ( n  = 43, 20.7%). Mean follow-up time was 37 months (0.5-180 months), with 86.5% showing no evidence of disease and 2.1% having died from disease at last follow-up. Conclusion  Endoscopic skull base surgery has been shown to be a safe and effective method of treating a variety of pediatric skull base tumors. If appropriately employed, the minimally invasive approach can provide optimal results in the pediatric population.

Pure Endoscopic Lateral Orbitotomy Approach to the Cavernous Sinus, Posterior, and Infratemporal Fossae: Anatomic Study

Objective  The aim of this anatomic study is to describe a fully endoscopic lateral orbitotomy extradural approach to the cavernous sinus, posterior, and infratemporal fossae. Material and Methods  Three prefixed latex-injected head specimens (six orbital exposures) were used in the study. Before and after dissection, a computed tomography scan was performed on each cadaver head and a neuronavigation system was used to guide the approach. The extent of bone removal and the area of exposure of the targeted corridor were evaluated with the aid of OsiriX software (Pixmeo, Bernex, Switzerland). Results  The lateral orbital approach offers four main endoscopic extradural routes: the anteromedial, posteromedial, posterior, and inferior. The anteromedial route allows a direct route to the optic canal by removal of the anterior clinoid process, whereas the posteromedial route allows for exposure of the lateral wall of the cavernous sinus. The posterior route is targeted to Meckel's cave and provides access to the posterior cranial fossa by exposure and drilling of the petrous apex, whereas the inferior route gives access to the pterygopalatine and infratemporal fossae by drilling the floor of the middle cranial fossa and the bone between the second and third branches of the trigeminal nerve. Conclusion  The lateral orbitotomy endoscopic approach provides direct access to the cavernous sinus, posterior, and infratemporal fossae. Advantages of the approach include a favorable angle of attack, minimal brain retraction, and the possibility of dissection within the two dural layers of the cavernous sinus without entering its neurovascular compartment.

Impact of neutrophil-lymphocyte ratio on long-term outcome in patients with craniopharyngioma

Neutrophil-lymphocyte ratio (NLR) is a poor prognostic factor in many tumors including glioblastoma multiforme (GBM), colorectal, and prostate cancer. The aim of this study was to investigate the prognostic value of preoperative NLR in patients with craniopharyngioma.Around 149 patients of craniopharyngioma surgically were treated at the Department of Neurosurgery, West China Hospital from January 2008 to December 2010, including 84 males and 65 females aged from 6 to 70 years were retrospectively reviewed, and preoperative NLR was analyzed. Overall survival (OS), progression free survival (PFS), and quality of life (QOL) were evaluated.The 5-year OS and PFS rates were 81.21% and 75.84%. Preoperative NLR was significantly correlated with OS (HR = 1.44, 95% CI 1.16-1.79, P = .001) and PFS (HR = 1.46, 95% CI 1.22-1.74, P < .001). The best cut-off value of NLR was found to be 4 based on the receiver operator characteristics (ROC) curve. Patients with NLR ≥4 had a significantly worse QOL (P = .039), lower OS rate (P = .009), and PFS rate (P < .001).Preoperative NLR may be a simple, readily available, and valid predictor of long-term outcome in craniopharyngioma. We suggest that the NLR can provide effective guidance to neurosurgeons for more information about the tumor and prognostic evaluation.

Quality of life outcomes after endoscopic approaches to intracranial tumors

PURPOSE OF REVIEW

To review the literature on quality of life (QOL) in endoscopic approaches to anterior and central intracranial skull-base disease. As endoscopic surgical techniques have gained widespread acceptance and complications and morbidity remain low and comparable with microscopic and open approaches, a shift to focusing on patients' perception of their own well being as an important outcome parameter has been made. In addition to the traditional measurements of surgical outcomes (extent of resection, recurrence rate, morbidity, survival, and complication rate), the success of a surgery can now be assessed using QOL measures.

RECENT FINDINGS

The main tools for assessing QOL in endoscopic skull-base surgery (anterior skull-base questionnaire and 22-item sinonasal outcome test) were not specifically designed for endoscopic skull-base approaches, and recently, a new tool was introduced and validated, the skull-base inventory, adding to our armamentarium, but it has not yet been widely employed. Endoscopic skull-base surgery leads to improved or sustained long-term QOL overall but it is significantly influenced by tumor disease. Specific endoscopic surgical technique (such as nasoseptal flap closure) appears to have less impact on QOL.

SUMMARY

It is becoming critical to assess therapeutic interventions in terms of impact on a patient's QOL. QOL can be useful in comparing efficacy of surgical interventions, and in the future, it will likely become a reportable indicator of surgical outcome and guide our surgical technique recommendations. Large-scale prospective multicenter trials would be beneficial.

Radiation therapy rather than prior surgery reduces extent of resection during endonasal endoscopic reoperation for craniopharyngioma

OBJECTIVE

Radiation therapy is often advocated for residual or recurrent craniopharyngioma following surgical resection to prevent local recurrence. However, radiation therapy is not always effective and may render tumors more difficult to remove. If this is the case, patients may benefit more from reoperation if gross total resection can be achieved. Nevertheless, there is little data on the impact of radiation on reoperations for craniopharyngioma. In this study, we sought to analyze whether a history of previous radiation therapy (RT) affected extent of resection in patients with recurrent craniopharyngiomas subsequently treated with reoperation via endoscopic endonasal approach (EEA).

METHODS

The authors reviewed a prospectively acquired database of EEA reoperations of craniopharyngiomas over 13 years at Weill Cornell, NewYork-Presbyterian Hospital. All procedures were performed by the senior author. The operations were separated into two groups based on whether the patient had surgery alone (group A) or surgery and RT (group B) prior to recurrence.

RESULTS

A total of 24 patients (16 male, 8 female) who underwent surgery for recurrent craniopharyngioma were identified. The average time to recurrence was 7.64 ± 4.34 months (range 3-16 months) for group A and 16.62 ± 12.1 months (range 6-45 months) for group B (p < 0.05). The average tumor size at recurrence was smaller in group A (1.85 ± 0.72 cm; range 0.5-3.2) than group B (2.59 ± 0.91 cm; range 1.5-4.6; p = 0.00017). Gross total resection (GTR) was achieved in 91% (10/11) of patients in group A and 54% (7/13) of patients in group B (p = 0.047). There was a near significant trend for higher average Karnofsky performance status (KPS) score at last follow-up for group A (83 ± 10.6) compared with group B (70 ± 16.3, p = 0.056).

CONCLUSIONS

While RT for residual or recurrent craniopharyngioma may delay time to recurrence, ability to achieve GTR with additional surgery is reduced. In the case of recurrent craniopharyngioma, if GTR can be achieved, consideration should be given to endonasal reoperation prior to the decision to irradiate residual or recurrent tumor.

From above or from below? That is the question. Comparison of the supraorbital approach with the endonasal approach. A cadaveric study

BACKGROUND

Nowadays the endoscopic endonasal approach is increasingly being used to remove craniopharyngiomas, tuberculum sellae meningiomas and other presellar and parasellar lesions and its value in anterior skull base surgery is undisputed. Herein, we assess the relative advantages, disadvantages and feasibility of the keyhole eyebrow approach and the endonasal endoscopic approach in four cadaveric heads for the removal of presellar and parasellar lesions.

METHODS

We used four cadaveric heads for 12 surgical dissections. The specimens were embalmed with two different techniques. Two bilateral supraorbital endoscopic assisted approaches and one transnasal expanded endonasal approach were performed for each head. We evaluated the feasibility, maneuverability and safety of each approach. We measured the operating room obtained with each approach and the distance from the main structures we reached.

RESULTS

The technical feasibility of the endoscopic endonasal transphenoidal approach and the supraorbital eyebrow approach was reproduced in all four cadaveric heads. The transnasal approach gave us a good operating field medial to the two optic nerves and the two carotid arteries anteriorly until the frontal sinus and, posteriorly, the basilar artery, the emergence of the superior cerebellar arteries and posterior cerebral arteries. After performing the supraorbital approach, we viewed a wider field of the anterior skull base and we were able to reach the ipsilateral carotid artery, the optico-carotid recess, the pituitary stalk, the lamina terminalis until the contra lateral optic nerve and carotid artery, keeping a wider angle of maneuverability.

CONCLUSIONS

Although the endoscopic transnasal approach has developed in leaps and bounds in the last decade, other transcranial approaches maintain their value. The supraorbital endoscopic approach is a minimally invasive approach and seems to be optimal for those lesions wider than 2 cm in the lateral extension and for all the paramedian lesions.

Neuro-endoscope for skull base tumors

The endoscope has traditionally been used in neurosurgery to access a lesion within a natural body cavity. The challenge has been to access and resect deep-seated intraparenchymal lesions using a minimally invasive endoscopic technique. Endoscopic endonasal trans-sphenoidal surgery has gained increasing acceptance by otolaryngologists and neurosurgeons. Surgical procedures of the skull base include exposure, resection, and base reconstruction. These approaches start at the sphenoid sinus, which provides a reference point to important vascular and neural structures. The endoscopic endonasal approach is optimal in paramedian ventral skull base tumors, allowing wide access to the ventral skull base regions and allowing early devascularization of the tumor without retraction of the brain. Limited exposure results in limited "injury" to surrounding tissue and consequently reduced post-operative pain, a shorter length of hospital stay, a reduction in the time to return to work, and decreased overall cost.

Is Low-Lying Optic Chiasm an Obstacle to an Endoscopic Endonasal Approach for Retrochiasmatic Craniopharyngiomas? (Korean Society of Endoscopic Neurosurgery -003)

OBJECTIVE

Despite advances in endoscopic techniques, retrochiasmatic craniopharyngiomas (CPs) are difficult to remove completely, because the low-lying optic chiasm often provides an obstacle to an endoscopic endonasal approach. This study aimed to identify the endoscopic surgical outcomes of the retrochiasmatic CP and resolve the issues related to low-lying optic chiasm.

METHODS

We reviewed 154 consecutive patients with CP who underwent endonasal endoscopic resection from February 2009 to April 2017 at 2 independent institutions. The topographic relationship of the tumor with the third ventricle, stalk, and optic chiasm and clinical outcomes were investigated.

RESULTS

Retrochiasmatic CPs were found in 142 of 154 patients (92.2%). The median follow-up time was 25 months. Gross total resection and near-total resection were achieved in 113 patients (79.6%) and 21 patients (13.8%), respectively. Postoperative cerebrospinal fluid leaks were found in 16 patients (11.3%). Low-lying and high-lying chiasms were found in 44 patients (31.0%) and 98 patients (69.0%), respectively. Low-lying chiasm did not affect clinical outcomes including the extent of resection. Patients with low-lying chiasm showed a marginal trend for postoperative visual deterioration. The ventricular growth pattern representing the origin of the tumor and previous surgery were significantly associated with the position of the optic chiasm (P = 0.007 and 0.001, respectively).

CONCLUSIONS

An endoscopic endonasal approach is an effective surgical approach for retrochiasmatic CP, even in tumors with low-lying chiasm. However, a thorough and careful dissection is necessary to prevent visual deterioration.

Extended endoscopic endonasal approach for recurrent or residual symptomatic craniopharyngiomas

OBJECTIVES

Removal of recurrent or residual symptomatic craniopharyngiomas is more challenging than the primary surgery. The extended endoscopic endonasal (EEE) approach has been proposed an alternative surgical route for removal of various suprasellar tumors including craniopharyngiomas currently. In this study, we summarized the operative experience and described the feasibility and advantages of this technique in recurrent or residual symptomatic craniopharyngiomas.

PATIENTS AND METHODS

A retrospective review of 15 patients (9 males and 6 females) whom underwent EEE approach between April 2012 and February 2017, were included in this study. The lesions included 8 purely suprasellar craniopharyngiomas (2 extraventricular, 6 intraextraventricular), 3 both intra- and suprasellar craniopharyngiomas, and 4 intrasellar craniopharyngiomas. The mean preoperative (that is, EEE approach) tumor volume was 10.54 cm³. The mean follow-up period was 23.1 months (range, 8-54). All patients were analyzed in terms of the treatment effect, complictions and follow-up results.

RESULTS

Total removal of tumors was achieved in 12 patients (80.0%) and subtotal removal in 3 cases (20.0%). The pituitary stalks were identified in 11 patients during operations and secured in 8 patients. Postoperative visual acuity was improved in 10 cases, and normalization of the impairment was achieved in 3 patients. There were no significant differences between pre and postoperative endocrine function, except in one patient with normal preoperative pituitary hormone function who suffered postoperative hypopituitarism. Postoperative diabetes insipidus (DI) occurred in 14 patients including 6 patients who had long-term DI and others reporting transient postoperative DI. No cerebrospinal fluid (CSF) leak was identified. There were no deaths or major complications. Obesity developed in 2 patients, with no deaths and recurrent cases during follow-up period.

CONCLUSION

The pure EEE approach is a safe, effective alternative for treatment of recurrent or residual symptomatic craniopharyngiomas owing to its advantages including wide-angle view, close observation and elimination of brain retraction. Larger studies with further follow-up is needed to assess the long-term efficacy of this minimal access approach.

Pediatric Craniopharyngiomas: A Primer for the Skull Base Surgeon

Pediatric craniopharyngioma is a rare sellar-region epithelial tumor that, in spite of its typically benign pathology, has the potential to be clinically devastating, and presents a host of formidable management challenges for the skull base surgeon. Strategies in craniopharyngioma care have been the cause of considerable controversy, with respect to both philosophical and technical issues. Key questions remain unresolved, and include optimizing extent-of-resection goals; the ideal radiation modality and its role as an alternative, adjuvant, or salvage treatment; appropriate indications for expanded endoscopic endonasal surgery as an alternative to transcranial microsurgery; risks and benefits of skull base techniques in a pediatric population; benefits of and indications for intracavitary therapies; and the preferred management of common treatment complications. Correspondingly, we sought to review the preceding basic science and clinical outcomes literature on pediatric craniopharyngioma, so as to synthesize overarching recommendations, highlight major points of evidence and their conflicts, and assemble a general algorithm for skull base surgeons to use in tailoring treatment plans to the individual patient, tumor, and clinical course. In general terms, we concluded that safe, maximal, hypothalamic-sparing resection provides very good tumor control while minimizing severe deficits. Endoscopic endonasal, intraventricular, and transcranial skull base technique all have clear roles in the armamentarium, alongside standard craniotomies; these roles frequently overlap, and may be further optimized by using the approaches in adaptive combinations. Where aggressive subtotal resection is achieved, patients should be closely followed, with radiation initiated at the time of progression or recurrence-ideally via proton beam therapy, although three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, and stereotactic radiosurgery are very appropriate in a range of circumstances, governed by access, patient age, disease architecture, and character of the recurrence. Perhaps most importantly, outcomes appear to be optimized by consolidated, multidisciplinary care. As such, we recommend treatment in highly experienced centers wherever possible, and emphasize the importance of longitudinal follow-up-particularly given the high incidence of recurrences and complications in a benign disease that effects a young patient population at risk of severe morbidity from hypothalamic or pituitary injury in childhood.

Is the chiasm-pituitary corridor size important for achieving gross-total resection during endonasal endoscopic resection of craniopharyngiomas?

OBJECTIVE Craniopharyngiomas arise from the pituitary stalk, and in adults they are generally located posterior to the chiasm extending up into the third ventricle. The extended endonasal approach (EEA) can provide an ideal corridor between the bottom of the optic chiasm and the top of the pituitary gland (chiasm-pituitary corridor [CPC]) for their removal. A narrow CPC in patients with a prefixed chiasm and a large tumor extending up and behind the chiasm has been considered a contraindication to EEA, with a high risk of visual deterioration and subtotal resection. METHODS A database of all patients treated in the authors' center (Weill Cornell Medical College, NewYork-Presbyterian Hospital) between July 2004 and August 2016 was reviewed. Patients with craniopharyngiomas who underwent EEA with the goal of gross-total resection (GTR) were included in the study. Patients with postfixed chiasm or limited available preoperative imaging were excluded. Using preoperative contrast-enhanced T1-weighted sagittal midline MR images, the authors calculated the CPC as well as the distance from the chiasm to the top of the tumor (CTOT). From these numbers, they calculated a ratio of the CPC to the CTOT as a measure of difficulty in removing the tumors through the EEA and called this ratio the corridor index (CI). The relationship between the CI and the ability to achieve GTR and visual outcome were measured. RESULTS Thirty-four patients were included in the study. The mean CPC was 10.1 mm (range 5.2-19.1 mm). The mean CTOT was 12.8 mm (range 0-28.3 mm). The median CI was 0.8; the CI ranged from 0.4 to infinity (for tumors with a CTOT of 0). Thirty-two patients had GTR (94.1%) and 2 had subtotal resection. The CPC value had no relationship with our ability to achieve GTR and no effect on visual or endocrine outcome. CONCLUSIONS EEA for craniopharyngioma is generally considered the first-line surgical approach. Although a narrow corridor between the top of the pituitary gland and the bottom of the chiasm may seem to be a relative contraindication to surgery for larger tumors, the authors' data do not bear this out. EEA appears to be a successful technique for the majority of midline craniopharyngiomas.

Can recurrences be predicted in craniopharyngiomas? β-catenin coexisting with stem cells markers and p-ATM in a clinicopathologic study of 45cases

Background

Recurrence is a common feature of craniopharyngiomas, benign tumors that origin from squamous epithelial remnants of Rathke’s pouch- arising at any segment of its whole course. There are two histotypes, showing different morphology and clinical behavior: adamantinomatous(adaCP) and papillary (papCP). An univocal strategy of management has not yet been defined, being considered the combination of surgery and radiotherapy the most effective, especially in case of incomplete resection. Therefore, the identification of factors influencing the biological and clinical behaviour is of paramount importance.

β-catenin is a cell-cell adhesion protein, whose nuclear localization has been linked to the pathogenesis of adaCP: its nuclear accumulation is associated to the presence of a tumor stem cell subpopulation. The latter is made of cells capable of self-renewal, hence believed to be responsible of recurrence, metastases and resistance to therapy in all tumors.

ATM is a kinase activated by autophosphorylation (p-ATM) upon DNA double-strand breaks. It is involved not only in DNA repair, but also in tumor migration and invasiveness. Its expression may have prognostic implications in many neoplastic diseases.

Methods

In this study, we measured the immunohistochemical expression of β-catenin, stem cell markers (CD133, CD166), Ki67 and pATMin 45 craniopharyngiomas and correlated it with clinicopathologic features.

Results

Statistical analysis revealed strong correlation of β-catenin with recurrence (p = 0.0039), Ki67 (p = 0.0011, r = 0.4903) and CD166 (p = 0.0002, r = 0.6218). A slight tendency to a higher expression of β-catenin was recorded for adaCP rather than papCP (p = 0.0895).Fisher’s exact test showed that CD166 was significantlyrelated with recurrence (p = 0.0040). Furthermore, cytoplasmic pATM was more expressed in adaCPs (p = 0.0470), compared to papCPs that displayed a more evident nuclear signal (p = 0.0313) instead.

Conclusions

Backing upon these data, we could weigh in on the need of identifying β-catenin and CD166 as prognostic markersthat could be useful in predicting thebiologicalbehavior, as recurrence risk incraniopharyngiomas. The final goal is to drew up a prognostic algorithm to be of aid in the planning of an appropriate treatment strategy. Furthermore, our findings demonstrate that pATM could be used as additional distinction-marker between the two histotypes.

Learning curve for the endoscopic endonasal approach for suprasellar craniopharyngiomas

The endoscopic endonasal approach is considered an alternative minimally invasive approach for suprasellar craniopharyngiomas. However, the complicated surgical manipulations required by this approach have limited its application. We evaluate whether the approach features a learning curve. Thirty-three patients were retrospectively reviewed and grouped as early (17 patients) and late (16 patient) groups. The operation time, extent of removal, ophthalmology, endocrinology, reconstruction and modifications of standard technique were evaluated. Between the two groups, the operation time decreased from 201.1±105.3min in the early group to 107.6±90.0min in the late group (p<0.05). Regarding clinical outcomes, non-significantly increasing trends toward the rate of gross total resection, visual improvement and (from 76.5% to 87.5%, 73.3% to 93.3%), significantly decreasing trends toward the rate of tumor recurrence (from 23.5% to 0% p<0.05) and non-significantly decreasing trends toward the rate of hypopituitarism recovery (26.7% to 0%) were observed between the two groups. With respect to complications, non-statistically significant decreasing trends toward transient cranial nerve paralysis (from 5.9% to 0%) and non-statistically significant increasing trends toward rate of CSF leakage, meningitis and new hypothyroidism (from 11.8% to 25%, 11.8% to 31.3%, 0 to 3%) were observed. We identified a learning curve for the endoscopic endonasal approach for suprasellar craniopharyngiomas. The exact number of patients necessary to establish a significant improvement in the clinical outcomes and decrease in the complications warrants further investigation. The outcomes of tumor recurrence may be associated with duration of follow-up. The CSF leakage represented the most common complication.

Clinical Outcome After Extended Endoscopic Endonasal Resection of Craniopharyngiomas: Two-Institution Experience

BACKGROUND

The extended endoscopic endonasal approach (EEA) to the anterior cranial base is used for the resection of craniopharyngiomas.

OBJECTIVE

We present clinical experience and outcomes of using EEA for craniopharyngiomas.

METHODS

A total of 116 patients in 2 remote institutions were enrolled in this retrospective study. Surgical, endocrinologic, and ophthalmologic outcomes were assessed.

RESULTS

The mean follow-up was 35 months (range, 1-115). Gross total resection (GTR), near total resection (NTR, >95%), and subtotal resection (STR) were achieved in 46%, 39%, and 15% of the patients, respectively. Surgery performed after 2010 was the only variable significantly associated with greater extent of resection, which might be explained by the learning curve. Overall tumor recurrence rate was 15.5%, with a median interval until recurrence of 14.5 months (range, 3-58). Extent of resection was significantly associated with recurrence-free survival (P = 0.0116). Those who underwent NTR/STR followed by adjuvant radiotherapy had a similar median recurrence-free survival rate compared with those who underwent GTR (26.5 vs. 20 months, P = 0.167). Endocrinologic examination revealed that 47.4% of patients experienced worsening of anterior pituitary function following surgery while 25.5% developed new-onset diabetes insipidus. Of the 89 patients with preoperative visual deficits, 68 (76.4%) experienced improvement in visual field assessment.

CONCLUSION

EEA is effective for the surgical resection of craniopharyngiomas, resulting in high rates of visual improvement and low complication rates. Adjuvant radiotherapy is a useful method for tumor control after incomplete resection.

Endoscopic endonasal versus open transcranial resection of craniopharyngiomas: a case-matched single-institution analysis

OBJECTIVE The authors compared clinical and radiological outcomes after resection of midline craniopharyngiomas via an endoscopic endonasal approach (EEA) versus an open transcranial approach (TCA) at a single institution in a series in which the tumors were selected to be equally amenable to gross-total resection (GTR) with either approach. METHODS A single-institution retrospective review of previously untreated adult midline craniopharyngiomas was performed. Lesions were evaluated by 4 neurosurgeons blinded to the actual approach used to identify cases that were equally amenable to GTR using either an EEA or TCA. Radiological and clinical outcome data were assessed. RESULTS Twenty-six cases amenable to either approach were identified, 21 EEA and 5 TCA. Cases involving tumors that were resected via a TCA had a trend toward larger diameter (p = 0.10) but were otherwise equivalent in preoperative clinical and radiological characteristics. GTR was achieved in a greater proportion of cases removed with an EEA than a TCA (90% vs 40%, respectively; p = 0.009). Endoscopic resection was associated with superior visual restoration (63% vs 0%; p < 0.05), a decreased incidence of recurrence (p < 0.001), lower increase in FLAIR signal postoperatively (-0.16 ± 4.6 cm³ vs 14.4 ± 14.0 cm³; p < 0.001), and fewer complications (20% vs 80% of patients; p < 0.001). Significantly more TCA patients suffered postoperative cognitive loss (80% vs 0; p < 0.0001). CONCLUSIONS An EEA is a safe and effective approach to suprasellar craniopharyngiomas amenable to GTR. For this select group of cases, the EEA may provide higher rates of GTR and visual improvement with fewer complications compared with a TCA.

Microscopic versus endoscopic approaches for craniopharyngiomas: choosing the optimal surgical corridor for maximizing extent of resection and complication avoidance using a personalized, tailored approach

Resection remains the mainstay of treatment for craniopharyngiomas with the goal of radical resection, if safely possible, to minimize the rate of recurrence. Endoscopic endonasal and microscopic transcranial surgical approaches have both become standard methods for the treatment for craniopharyngiomas. However, the approach selection paradigm for craniopharyngiomas is still a point of discussion. Choosing the optimal surgical approach can play a significant role in maximizing the extent of resection and surgical outcome while minimizing the risks of potential complications. Craniopharyngiomas can present with a variety of different sizes, locations, and tumor consistencies, and each individual tumor has distinct features that favor one specific approach over another. The authors review standard cranial base techniques applied to craniopharyngioma surgery, using both the endoscopic endonasal approach and traditional open microsurgical approaches, and analyze factors involved in approach selection. They discuss their philosophy of approach selection based on the location and extent of the tumor on preoperative imaging as well as the advantages and limitations of each surgical corridor, and they describe the operative nuances of each technique, using a personalized, tailored approach to the individual patient with illustrative cases and videos.

Management and outcome of recurrent adult craniopharyngiomas: an analysis of 42 cases with long-term follow-up

OBJECTIVE The treatment of recurrent and residual craniopharyngiomas is challenging. In this study the authors describe their experience with these tumors and make recommendations on their management. METHODS The authors performed an observational study of adult patients (≥ 18 years) with recurrent or residual craniopharyngiomas that were managed at their tertiary center. Retrospective data were collected on demographics and clinical, imaging, and treatment characteristics from patients who had a minimum 2-year follow-up. Descriptive statistics were used and the data were analyzed. RESULTS There were 42 patients (27 male, 15 female) with a mean age of 46.3 ± 14.3 years. The average tumor size was 3.1 ± 1.1 cm. The average time to first recurrence was 3.6 ± 5.5 years (range 0.2-27 years). One in 5 patients (8/42) with residual/recurrent tumors did not require any active treatment. Of the 34 patients who underwent repeat treatment, 12 (35.3%) had surgery only (transcranial, endoscopic, or both), 9 (26.5%) underwent surgery followed by adjuvant radiation therapy (RT), and 13 (38.2%) received RT alone. Eighty-six percent (18/21) had a gross-total (n = 4) or near-total (n = 14) resection of the recurrent/residual tumors and had good local control at last follow-up. One of 5 patients (7/34) who underwent repeat treatment had further treatment for a second recurrence. The total duration of follow-up was 8.6 ± 7.1 years. The average Karnofsky Performance Scale score at last follow-up was 80 (range 40-90). There was 1 death. CONCLUSIONS Based on this experience and in the absence of guidelines, the authors recommend an individualized approach for the treatment of symptomatic or growing tumors. This study has shown that 1 in 5 patients does not require repeat treatment of their recurrent/residual disease and can be managed with a "scan and watch" approach. On the other hand, 1 in 5 patients who had repeat treatment for their recurrence in the form of surgery and/or radiation will require further additional treatment. More studies are needed to best characterize these patients and predict the natural history of this disease and response to treatment.