Optic nerve mobilization to enhance the exposure of the pituitary stalk during craniopharyngioma resection: early experience

OBJECT Preservation of the pituitary stalk and its vasculature is a key step in good postoperative endocrinological outcome in patients with craniopharyngiomas. In this article, the authors describe the surgical technique of medial optic nerve mobilization for better inspection and preservation of the pituitary stalk. METHODS This operative technique has been applied in 3 patients. Following tumor exposure via a frontolateral approach, the pituitary stalk could be seen partially hidden under the optic nerve and the optic chiasm. The subchiasmatic and opticocarotid spaces were narrow, and tumor dissection from the pituitary stalk under direct vision was not possible. The optic canal was therefore unroofed, the falciform ligament was incised, and the lateral part of the tuberculum sellae was drilled medial to the optic nerve. The optic nerve could be mobilized medially to widen the opticocarotid triangle, which enhanced visualization of and access to the pituitary stalk. RESULTS By using the optic nerve mobilization technique, the tumor could be removed completely, and the pituitary stalk and its vasculature were preserved in all patients. In 2 patients, vision improved after surgery, while in 1 patient it remained normal, as it was before surgery. The hormonal status remained normal after surgery in 2 patients. In the patient with preoperative hormonal deficiencies, improvement occurred early after surgery and hormonal levels were normal after 3 months. No approach-related complications occurred. CONCLUSIONS This early experience shows that this technique is safe and could be used as a complementary step during microsurgery of craniopharyngiomas. It allows for tumor dissection from the pituitary stalk under direct vision. The pituitary stalk can thus be preserved without jeopardizing the optic nerve.

Microsurgical resection of extensive craniopharyngiomas using a frontolateral approach: operative technique and outcome

Object An extensive craniopharyngioma is a tumor that extends into multiple compartments (subarachnoid spaces) and attains a size larger than 4 cm. A wide spectrum of approaches and strategies has been used for resection of such craniopharyngiomas. In this report the authors focused on the feasibility and efficacy of microsurgical resection of extensive craniopharyngiomas using a frontolateral approach. Methods A retrospective analysis was performed on 16 patients with extensive craniopharyngiomas who underwent operations using a frontolateral approach at one institution. The preoperative and postoperative clinical and radiological data, as well as the operative videos, were reviewed. The main focus of the review was the extent of radical tumor removal, early postoperative outcome, and approach-related complications. Results Gross-total resection of craniopharyngioma was achieved in 14 (87.5%) of 16 cases. Early after surgery (within 3 months), 1 patient showed improvement in hormonal status, while in the remaining 15 patients it worsened. No major neurological morbidity was observed. Two patients experienced temporary psychotic disorders. Visual function improved in 6 patients and remained unchanged in 9. One patient experienced a new bitemporal hemianopsia. Three patients with features of short-term memory disturbances at presentation did show improvement after surgery. There were no deaths or significant approach-related morbidity in this patient series. Only 1 patient required revision surgery for a CSF leak. Conclusions The safe and simple frontolateral approach provides adequate access even to extensive craniopharyngiomas and enables their complete removal with a reasonable morbidity and approach-related complication rate.

Microsurgical Excision of Olfactory Groove Meningeomas, Comparative Studies of Different Surgical Approaches

To review the surgical approaches, techniques, outcomes, and recurrence rates in a series of 6 olfactory groove meningioma (OGM) patients operated from January 2010 to April 2011.Methods: Six patients underwent craniotomy and micro-neurosurgical removal of olfactory groove meningioma maximum. Tumor diameter varied from 5 to 8.5 cm among six cases, 2 cases underwent glabellar mini craniotomy another 2 by bifrontal approach and rest of them were by frontolateral approach. Result: Total removal was possible in all cases. Histopathology revealed typical meningioma (WHO grade 1). there was no operative mortality and no permanent focal neurological deficit except anosmia. One patient developed leak and two cases meningitis which was resolved by lumber drain and antibiotic therapy. No tumor recurrence within six months of followup. For the removal of large olfactory groove meningiomas we used three different surgical approaches: frontolateral approaches, bifrontal approach and glabellar mini craniotomy. We consider the frontolateral approach is an alternative, if not superior, to standard bifrontal approaches. DOI: http://dx.doi.org/10.3329/medtoday.v24i1.13942 Medicine TODAY Vol.24(1) 2012 pp.5-7