Endoscopic Endonasal Transplanum Transtuberculum Approach for the Resection of a Large Suprasellar Craniopharyngioma.

Objectives  To demonstrate an endoscopic endonasal transplanum transtuberculum approach for the resection of a large suprasellar craniopharyngioma. Design  Single-case-based operative video. Setting  Tertiary center with dedicated skull base team. Participants  A 72-year-old male patient diagnosed with a suprasellar craniopharyngioma. Main Outcomes Measured  Surgical resection of the tumor and preservation of the normal surrounding neurovascular structures. Results  A 72-year-old male patient presented with a 1-year history of progressive bitemporal visual loss. He also referred symptoms suggestive of hypogonadism. Neurological examination was unremarkable and endocrine workup demonstrated mildly elevated prolactin levels. Magnetic resonance images demonstrated a large solid-cystic suprasellar lesion, consistent with the diagnosis of craniopharyngioma. The lesion was retrochiasmatic, compressed the optic chiasm, and extended into the interpeduncular cistern ( Fig. 1 ). Because of that, the patient underwent an endoscopic endonasal transplanum transtuberculum approach. 1 2 3 The nasal stage consisted of a transnasal transseptal approach, with complete preservation of the patient's left nasal cavity. 4 The cystic component of the tumor was decompressed and its solid part was resected. It was possible to preserve the surrounding normal neurovascular structures ( Fig. 2 ). Skull base reconstruction was performed with a dural substitute, a fascia lata graft, and a right nasoseptal flap ( Video 1 ). The patient did well after surgery and referred complete visual improvement. However, he also presented pan-hypopituitarism on long-term follow-up. Conclusions  The endoscopic endonasal route is a good alternative for the resection of suprasellar lesions. It permits tumor resection and preservation of the surrounding neurovascular structures while avoiding external incisions and brain retraction. The link to the video can be found at: https://youtu.be/zmgxQe8w-JQ .

Preoperative magnetic resonance images of a 72-year-old male patient with a large suprasellar craniopharyngioma. The lesion compressed was retrochiasmatic and compressed the optic chiasm from posterior to anterior. It also extended posteriorly into the interpeduncular cistern. ( A ) Coronal and ( B ) sagittal image.

An endoscopic endonasal transtuberculum transplanum approach was performed for the resection of the large suprasellar craniopharyngioma. Intraoperative picture demonstrating the relevant anatomy. Abbreviations: SHA, left superior hypophyseal artery; br., branch; ICA, left internal carotid artery; PCA, left posterior communicating artery.

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