Craniopharyngioma - What is the best approach

30-12-201601.24 am

The whole concept is based on following papers

Microscopic versus endoscopic approaches for craniopharyngiomas: choosing the optimal surgical

corridor for maximizing extent of resection and complication avoidance using a personalized,

tailored approach

Read paper at http://sci-hub.cc/10.3171/2016.9.FOCUS16284

Watch Dr. James K.Liu video – click - https://www.youtube.com/watch?v=A9ffk9jRBKo&index=4&list=PLZquE6mn0cykG3QC6VWDDmPlR4XVsUkVR

Expanded endonasal approach, a fully endoscopic transnasal approach for the resection of midline suprasellar craniopharyngiomas: a new classification based on the infundibulum AMIN B. KASSAM, M.D.,1–4 PAUL A. GARDNER, M.D.,1,4 CARL H. SNYDERMAN, M.D.,1–4 RICARDO L. CARRAU, M.D.,1–4 ARLAN H. MINTZ, M.D.,1,4 AND DANIEL M.

PREVEDELLO, M.D.1,4 - CLICK http://sci-hub.cc/10.3171/JNS/2008/108/4/0715

• MUST READ ARTICLEMUST READ ARTICLEMUST READ ARTICLE

• Whoever wants to deal with sphenoid & skullbase pathologies

• Endoscopic, Endonasal Variability in the Anatomy of the Internal Carotid Artery - excellent article - get it at http://dx.doi.org.sci-hub.cc/10.1016/j.wneu.2014.09.021

• MUST READ ARTICLEMUST READ ARTICLEMUST READ ARTICLE

Explanation video regarding “ Endoscopic, Endonasal Variability in the Anatomy of the Internal Carotid Artery” paper http://dx.doi.org.sci-hub.cc/10.1016/j.wneu.2014.09.021

Is – CLICK

https://www.youtube.com/watch?v=lP4VDWDIqeU

ENDOSCOPIC ENDONASAL PITUITARY TRANSPOSITION FOR A TRANSDORSUM SELLAE APPROACH TO THE INTERPEDUNCULAR CISTERN - Amin B. Kassam, M.D. - CLICK

http://sci-hub.cc/10.1227/01.neu.0000317374.30443.23

Prof. Kassam classfied craniopharyngiomas in to 4 types in paper

http://sci-hub.cc/10.3171/JNS/2008/108/4/0715

1. Type I, preinfundibular ;2. Type II, transinfundibular ; 3. Type III, post- or retroinfundibular , further

subdivided based on 1. Type IIIa - Rostral extension - that is, anterior third

ventricular (infundibular recess, hypothalamic) 2. Type IIIb - caudal extension - interpeduncular fossa

4. Type IV, isolated third ventricular (not well accessed via endonasal routes ).

Type I, preinfundibularSchematic depicting the conceptual

relationship of a Type I preinfundibular craniopharyngioma and the regional anatomy. The tumor (T) can be seen anterior to the infundibulum (S). The tumor may extend superiorly into the prechiasmatic cistern (PC), in which case the ACoA and the A2 segment (A2) will be draped over the dome. The chiasm (C) is elevated, and in the event of extension into the PC, it is often posteriorly displaced. The basilar artery (BA) is found posterior to the infundibulum and is rarely encroached upon in these cases. The tumor is bracketed laterally by the ICA. P = pituitary gland.

Type II, transinfundibularSchematic illustrating the conceptual

relationship of a Type II transinfundibular craniopharyngioma and the regional anatomy. The tumor can be seen within the substance of the pituitary stalk (S), widening the stalk as it courses from the pituitary gland (P) and the hypothalamus. The tumor can be seen extending rostrally into the anterior third ventricle (ATV). The widened stalk containing the tumor runs retrochiasmatically at the junction of the optic nerve (ON) and the optic tract (OT), elevating the posterior portion of the chiasm and displacing the chiasm anteriorly (prefixed chiasm). Again, the tumor is bracketed by the ICA and the ON/OT bilaterally.

Type III, post- or retroinfundibularSchematic demonstrating the conceptual

relationship of a Type III transinfundibular craniopharyngioma and the regional anatomy. The pituitary gland (P) is seen within the sella, and the tumor (T) lies in the retroinfundibular space while the stalk is being thinned and attenuated, making it difficult to visualize. After entering the retroinfundibular retrochiasmatic space, the tumor can expand rostrally (R, dashed green line) to encroach on the ATV (Type IIIa). The tumor may also run caudally (C, dashed blue line) to enter the interpeduncular fossa below the mammillary bodies (MB) and encroach on the posterior circulation (Type IIIb). In these situations, the tumor is bracketed laterally by the oculomotor nerve (III N) and the PCoA (Pcom) as it bridges the ICA and the PCA.

Type III b Drawing showing a tumor (Tu)

located in the retroinfundibular region of the interpeduncular cistern. Note the complex location of the lesion. The tumor is guarded posteriorly by the brain stem (BS), basilar artery (B), posterior cerebral arteries, and superior cerebellar arteries. Laterally it is surrounded by the optic nerves (ONs) and optic tracts (OT), anterior choroidal arteries, posterior communicating arteries, and III and IV cranial nerves (not shown in the figure). Superiorly the third ventricle (III-v) forms the roof of the region that is occasionally eroded by the lesion. Anteriorly the pituitary gland (PG) with the infundibulum (I) guards the region. The clivus (C) and sphenoid sinus (SS) are shown.

SHA = Superior hypophyseal artery

Prof. Amin kassam says SHA decided into 1. Recurrent optic nerve branch 2. Middle anastamotic branch with opposite SHA 3. Descending infundibular/diaphragmatic

branch & best seen in endoscopic approach than transcranial approach

Prof. Amin kassam says SHA decided into 1. Recurrent optic nerve branch 2. Middle anastamotic branch with opposite SHA 3. Descending infundibular/diaphragmatic branch & best seen in

endoscopic approach than transcranial approach

Prof. Amin kassam says SHA devided into 1. Recurrent optic nerve branch 2. Middle anastamotic branch with opposite SHA 3. Descending

infundibular/diaphragmatic branch & best seen in endoscopic approach. This is one of the reason for choosing endoscopic approach for

craniopharyngioma.

The optic chiasm is referred to as prefixed when it is located above the tuberculum sellae and as a postfixed chiasm when it is situated superior

to the dorsum sellae

Parasagittal cadaveric specimen with a postfixed chiasm. Note the more inclined pituitary stalk (stalk). For reference, note the left and right optic

nerves

Parasagittal cadaveric specimen with a normally positioned opticchiasm. For reference, note the right optic nerve (II)

Subfrontal cadaveric dissection in a specimen found to have aprefixed chiasm. Note the anterior location of the pituitary stalk (arrow).

For reference, note the optic nerves (II) and left internal carotid artery(ICA)

Pituitary transpostion

ENDOSCOPIC ENDONASAL PITUITARYTRANSPOSITION FOR A TRANSDORSUM SELLAE

APPROACH TO THE INTERPEDUNCULAR CISTERN – get the paper at www.sci-hub.cc or www.sci-hub.bz

Intraoperative view with a zero-degreeendoscope showing the face of the sella and the planumsphenoidale after removal of the overlying bone. Notethe critical landmarks: lateral optic–carotid recesses

(LOCR), ICA, the left and right optic nerves (LON,RON), and the middle optic recesses (mOCR). The

dura (D) of the suprasellar compartment was openedabove the SIS, and the arachnoid (A) was preserved.The opening of the sellar dura is initiated under the

SIS, and the pituitary gland (P) is shown.

Intraoperative view with a zero-degree endoscope illustrating the transaction of the previouslycoagulated SIS with endoscissors. The dura (D) of the suprasellar region was opened, and the arachnoid (A) preserved. At this point, the dura of the face of thesella is also incised with the pituitary gland (P) exposed. The bony resection extends laterally to exposethe cavernous sinus (CS).

Intraoperative view using a zero-degreeendoscope demonstrating coagulation of the SIS withan endobipolar. The bipolars can be seen straddlingthe SIS located between the sella (S) below and thesuprasellar cistern (A) above. Note the dura (D) overlyingthe cistern was opened without transgressingthe arachnoid (A).

3 layers anteriorly, posteriorly, and inferiorly along the sellar floor

1. periosteal dura [ PD ]2. meningeal dura [ MD ] 3. pituitary capsule [ PC ]

Intraoperative view with a zero-degree endoscope showing the two components of the dura mater located along the face and floor of the sella. The dura here is formed by an inner meningeal dura (MD) and an outer periosteal dura (PD). The intercavernous sinuses run in between both layers as the IIS shown in the picture. Once these layers reach the cavernous sinus, they bifurcate and only the meningeal layer forms the medial wall of the cavernous sinus (CS) along the lateral border of the sella. The pituitary gland is shown with a preserved pituitary capsule (PC).

Ds= Dorsum Sellae after removing the pituitary mass in craniopharyngioma case

“pituitary ligaments”are analogous to the dentate ligamentsthat attach the lateral portion of the spinal cord to the dura.

Pituitary ligaments starts from pituitary capsule to meningeal layer

of dura over cavernous sinus .

A, schematic drawing showing the sellarregion in a frontal view. The pituitary gland (P) isdemonstrated in the center attached to the medial wall of the cavernous sinus (CS) by the pituitary ligaments(PLs). The anterior dura covering the pituitary glandwas removed, and the pituitary stalk was freed underthe chiasm (Ch). The internal carotid arteries areshown on both sides. The inferior hypophyseal arteries(IHa) originate from the meningohypophyseal trunk ofthe ICA within the CS, and they travel medially andposteriorly to vascularize the inferior posterior third ofthe gland. The inferior hypophyseal arteries are ligatedand cut along with the IIS and the PLs to allowthe gland to be mobilized superiorly. The superiorhypophyseal arteries (SHa) are preserved, and careshould be taken when opening the dural fold of theaperture to avoid injuring them.

B, endonasal cadavericdissection using a zero-degree endoscope afterreleasing the pituitary gland from the dural fold (DF)that forms the aperture is shown. The SHa runs abovethe DF, and care should be taken at

the last cut whenopening the sellar aperture to avoid damaging theSHa. The CS, the IHa, the dorsum sellae (DS), and theclivus (C) are shown. The pituitary stalk (S) can beseen moved to the right side with the pituitary gland(PG) still being tethered by several PLs, preventingcomplete mobilization.

A, endonasal cadaveric dissection througha zero-degree endoscope demonstrating a pituitarytransposition. The left inferior hypophyseal artery(IHa) was transected. The pituitary gland (PG) isbeing rotated medially away from the cavernous sinus(CS). The pituitary capsule can be seen covering theunderlying pituitary gland (PG). Soft tissue attachments“pituitary ligaments” (PL) can be seen connectingthe PC to the CS. Endoscissors are showntransecting the PL along the left side of the sella. Theclivus (C) is labeled along the midline for orientationproposes.

B, correlative intraoperative endonasal viewdemonstrating mobilizing the right side of the PG.Note the PL tethering the gland to the CS are identifiedand released.

intraoperative suprasellar view with a zero-degree endoscopeshowing the pituitary gland (PG) and the pituitary stalk (S) after the opening

of the suprasellar and sellar dura, ligation of the SIS, and complete excision ofthe anterior dural fold (DF) that forms the pituitary aperture. The chiasm (Ch)is visualized superiorly and anteriorly. A small subchiasmatic perforator (SP)

branch of the superior hypophyseal artery is shown.

endonasal cadaveric dissection view using a zero-degree endoscope during a pituitary transposition is shown. At this point, the left lateral aspect of the pituitary gland covered by its capsule (PC) is totally disconnected from the

cavernous sinus (CS) and the superior soft tissue adherence (AI) between the gland and the DF that forms the pituitary aperture is demonstrated.

endonasal cadaveric dissection using a zero-degree endoscope is shown after releasing the pituitary gland from the DF that forms the aperture. It allows for a suprasellar view. The PG and

the S after the opening of the suprasellar and sellar dura are shown. The Ch isvisualized superiorly. The location of the left CS and the dorsum sellae (DS) are shown.

schematic drawing showing the sellar region after the pituitary gland (PG) is transposed superiorly. Before detaching the posterior clinoid process (PC), the dorsum

sellae (DS) is drilled. The ICA is retracted laterally within the cavernous sinus (CS), allowing the surgeon to drill the carotid canal with a high-speed drill using a 1-mm

diamond drill bit. The ligated IIS is shown.

intraoperative viewusing a zero-degree endoscope showing the PC beingthinned with a high-speed drill in between the DS and

the medial wall of the cavernous sinus (RCS) at thelevel of the carotid canal. The pituitary gland (P) is

transposed superiorly

Intraoperative view with a zero-degreeendoscope showing the pituitary gland (P) transposedsuperiorly to expose the dorsum sellae (DS). The right

posterior clinoid process (PC) is resected after detachmentfrom the posterior carotid canal. The laterally

retracted medial wall of the right cavernous sinus (CS)is shown.

Intraoperative view using a 45-degree endoscope showing the contents of the interpeduncularcistern after the opening of the retrosellar dura. The basilar artery (B) can be seen at its upper

level bifurcating into both posterior cerebral arteries (P1). The superior cerebellar arteries (SCA) originating immediately before the bifurcation. The right third cranial nerve (III) is seen at its

origin in between the right P1 and SCA. The tumor (Tu) was invading thefloor of the third ventricle. Some small perforators (SP) are seen originating from the left P1

Schematic drawing showing the direct view of the tumor (Tu) in the interpeduncular cisternthat is obtained after the pituitary transposition. Note that the pituitary gland (PG) is elevated and fixed in

place with fibrin glue. The dotted lines represent the bone that was removed during the approach (transplanum, transsellar, transclival approaches). The optic nerves (ONs), left optic tract (OT), third ventricle

(III-v), brainstem (BS), basilar artery (B), clivus (C), and sphenoid sinus (SS) are shown.

Intraoperative view using a 45-degree endoscope showing the contents of the interpeduncular cistern after the opening of the retrosellar dura. The basilar artery (B)

can be seen at its upper level bifurcating into both posterior cerebral arteries (P1).The superior cerebellar arteries (SCA) originating immediately before the bifurcation.

The right third cranial nerve (III) is seen at its origin in between theright P1 and SCA. The tumor (Tu) was invading thefloor of the third ventricle. Some

small perforators (SP)are seen originating from the left P1

Intraoperative view using a 45-degree endoscope showing the lateral border of the interpeduncularcistern on the left side. ICA subchiasmatic perforators that vascularize the left optic nerve (LON)

and optic chiasm (Ch) are seen. The left posterior communicating artery (Pcomm) is seen joining the posteriorcerebral artery (P1/P2 junction). A small perforator (SP) from Pcomm that supplies the left optic tract

(LOT) is shown. After the origin of the anterior choroidal artery (covered by Pcomm), the ICA bifurcatesinto the middle and anterior cerebral arteries. The first segment of the anterior cerebral artery (A1) is seenas it travels over the genu of the left optic nerve/tract.Inferiorly, the basilar artery can be seen with the left

superior cerebellar artery (SCA). The left third cranial nerve is seen in between the left SCA and P1.

Intraoperative view with a 45-degreeendoscope positioned in the lower aspect of the sphenoid

sinus where a clivectomy was performed aimingsuperiorly and showing the pituitary gland (PG)

transposed. The tumor (Tu) is being resected usingthe two-suction technique. The right cavernous sinus

(CS) is shown.

A and B, intraoperative views with a 45- degree endoscope positioned in the lower aspect of thesphenoid sinus where a clivectomy was performed aiming superiorly and showing the third ventricle of twodifferent patients at the end of the tumor resection. Various anatomic structures can be seen in both images

as such as the foramen of Monro (FM), the column of the fornix (CF), the anterior commissure (AC), the thalamic mass intermedia (MI), the choroid plexus (CP), and the walls of the hypothalamus (H). The patient inFigure 13 had hydrocephalus preoperatively; body of the fornix (F) is also identified at the level of the septum

pellucidum. The internal cerebral veins (ICV) are also prominent and can be easily seen.

http://www.ncbi.nlm.nih.gov/pubmed/18424968 - get paper at www.sci-hub.io

Hemitransposition of pituitary

For better understanding of hemitransposition of pituitary see this video by Dr. Janakiram https://

www.youtube.com/watch?v=CqM6qJE12Fw

ICA various positions & ICA relation to pituitary

Endoscopic view of the internal carotid artery showing 3 types of angles (black lines) between the posterior ascending and horizontal portions of the C4 segment. (A) angle <80; (B) angle >100; and (C) angle between 80 and 100. PG, pituitary gland; ON, optic nerve. *C4 bend. (Printed with permission from Mayfield Clinic.)

See video lecture at https://www.youtube.com/watch?v=4tiRfPLYkBo

Transnasal transsphenoidal endoscopic view of the parasellar region illustrate that types I- III are symmetric and type IV is asymmetric. (A) Type I angle between the posterior ascending and

horizontal portions of C4 segment is <80, resulting in direct contact between the pituitary gland and the internal carotid artery (ICA) and a tortuous ICA configuration. (B) Type II angle between

the posterior ascending and the horizontal portions of the C4 segment is between 80 and 100. (C) Type III angle between the posterior ascending and the horizontal portions of the C4 segment is >100. ICA appears slightly curvilinear and less tortuous than the type I or the type II. (D) Type IV angles of the left and right ICAs are asymmetric. PG, pituitary gland; ON, optic nerve. *C4 bend.

(Printed withpermission from Mayfield Clinic.)

Authors speculate that type I presents the highest risk for vascular injury based on its contact between the ICA and

pituitary gland. In 50% of our specimens, the C4 bend was behind the pituitary gland (Figure 4A). Risk of potential vascular

injury decreases in types II and III. – Get paper at http://dx.doi.org.sci-hub.cc/10.1016/j.wneu.2014.09.021

Transnasal transsphenoidal endoscopic view of a type II angle (between 80 and 100) that has no contact with the pituitary gland. Angle allows a corridor

to the posterior aspect of the cavernous sinus and the oculomotor nerve without retraction of the internal carotid artery or the pituitary

gland. CN III, oculomotor nerve; CS, cavernous sinus; PG, pituitary gland. (Printed with permission from Mayfield Clinic.)

Transnasal transsphenoidal endoscopic view between the C3 and the C4 segments of the internal carotid artery at the lacerum and clivus levels. Two distinct shapes (green) were identified as trapezoid (A) in

80%or hourglass (B) in20%of specimens. (Printed with permission from Mayfield Clinic.)

Conceptual illustration of the endoscopic perspective depicts the various internal carotid artery (ICA) classifications. (Left) Bouthillier et al. (2) used 7 segments: C1 ¼ cervical, C2 ¼ petrous, C3 ¼ lacerum, C4 ¼ cavernous, C5 ¼ clinoid, C6 ¼ ophthalmic,

and C7 ¼ communicating. (Right) De Powell et al. (5) modification includes C3-C4 bend, C4 bend, and C4-C5 bend. Depending on the angle of the C4 bend (green plane),

a potential corridor between the ICA and the pituitary allows access to the posterior cavernous sinus (yellow arrow). SOF, superior orbital fissure; OS, optic strut; OCR,

opticocarotid recess; TS, tuberculum sellae. (Printed with permission Mayfield Clinic.)

Anatomic measurements between the internal carotid arteries and the pituitary gland in 20 specimens. (A) (aee) Intercarotid distances between the left and right ICAs. (B) Measurements (a’, b’, c’) of the space between the ICA and the pituitary gland at 3

levels (cephalic, middle, caudal). (Printed with permission from Mayfield Clinic.)