Abstract

OBJECTIVE:

Craniopharyngiomas have traditionally represented a challenge for open transcranial or transsphenoidal microscopic neurosurgery because of their anatomical location and proximity to vital neurovascular structures. The extended endoscopic endonasal transsphenoidal approach has been more recently developed as a potentially surgically aggressive, yet minimal access, alternative. To gain a more comprehensive assessment of the benefits and limitations of the various approaches to resection of craniopharyngiomas, we performed a systematic review of the available published reports after endoscope-assisted endonasal approaches and compared their results with transsphenoidal purely microscope-based or transcranial microscope-based techniques.

METHODS:

We performed a MEDLINE search of the modern literature (1995-2010) to identify open and endoscopic surgical series for pediatric and adult craniopharyngiomas. Comparisons were made for patient and tumor characteristics as well as extent of resection, morbidity, and visual outcome. Statistical analyses of categorical variables were undertaken by the use of χ(2) and Fisher exact tests with post-hoc Bonferroni analysis to compare endoscopic, microsurgical transsphenoidal, and transcranial approaches.

RESULTS:

Eighty eight studies, involving 3470 patients, were included. The endoscopic cohort had a significantly greater rate of gross total resection (66.9% vs. 48.3%; P < 0.003) and improved visual outcome (56.2% vs. 33.1%; P < 0.003) compared with the open cohort. The transsphenoidal cohort had similar outcomes to the endoscopic group. The rate of cerebrospinal fluid leakage was greater in the endoscopic (18.4%) and transsphenoidal (9.0%) than in the transcranial group (2.6%; P < 0.003), but the transcranial group had a greater rate of seizure (8.5%), which did not occur in the endonasal or transsphenoidal groups (P < 0.003).

CONCLUSIONS:

The endoscopic endonasal approach is a safe and effective alternative for the treatment of certain craniopharyngiomas. Larger lesions with more lateral extension may be more suitable for an open approach, and further follow-up is needed to assess the long-term efficacy of this minimal access approach.

Copyright © 2012 Elsevier Inc. All rights reserved.

Abstract

Improvement in fiber optics and imaging paved the way for tremendous advancements in neuroendoscopy. These advancements have led to increasingly widespread use of the endoscope in neurosurgical procedures, which in turn incited a technological revolution leading to new approaches, instruments, techniques, and a diverse armamentarium for the treatment of a variety of neurosurgical disorders. Soft-tissue removal is often a rate-limiting aspect to endoscopic procedures, especially when the soft tissue is dense or fibrous. The authors review a series of cases involving patients treated between August 2009 and October 2010 with a new device (the NICO Myriad), a non-heat-generating, oscillating, cutting, and tissue removal instrument that can be used through the working channel of the endoscope as well as in open neurosurgical procedures. They used this device in 14 purely endoscopic intracranial procedures and 1 endoscope-assisted keyhole craniotomy. They report that the device was easy to use and found that tissue resection was more efficient than with other available endoscopic instruments, especially in the resection of fibrotic tissue. There were no observed device-related complications. The authors discuss the technical aspects of using this device in endoscopic resection of pituitary tumors, craniopharyngiomas, and colloid cysts. They also demonstrate its use in hydrocephalus and intraventricular clot removal and discuss its potential use in other neurosurgical disorders.