Aggressive resection and outcomes of primary craniopharyngiomas via an endoscopic endonasal approach based on an anatomical sub-classification

Abstract Objective: The optimal treatment of patients with craniopharyngioma remains controversial. In recent years, we have removed tumors radically via an endoscopic endonasal approach (EEA) in all cases of primary craniopharyngioma. We present here our surgical strategy and outcomes of primary craniopharyngiomas via an EEA.Methods: Between 2015 and 2021, we resected 37 consecutive cases of primary craniopharyngioma via EEA. Aggressive resections had been originally planned in all cases. To help choose the adequate surgical management, we created the five groups included the intrasellar, prechiasmatic, retrochiasmatic, intra-3rd-ventricle and large lobulated type. Bony removal of the dorsum sellae, upper clivus and posterior clinoid process was added in cases with retrochiasmatic or third ventricular lesions, and a combination of EEA and transcranial approach was selected with large multi-lobulated tumors and lateral extension.Results: 16 tumors were classified as retrochiasmatic, 12 tumors as intra-3rd-ventricle, 4 tumors as prechiasmatic, 3 tumors as large lobulated, and 2 tumors as intrasellar type. Gross total resection (GTR) was achieved in 89.2%, near-total resection (NTR) in 8.1%, and subtotal resection (STR) in 2.7%. The pituitary stalk was preserved intraoperatively in 27.0%. Visual improvement was noted in 76.7%. Neuropsychological function status was improved or preserved in all cases. Tumor recurrence was detected 3.0% of GTR, 33.3% of 3 NTR and 100% of STR cases with the mean follow-up period of 32.7 months.Conclusion: Adequate surgical management according to the anatomical location of the lesion via EEA results in good visual and cognitive outcomes with increased extent of resection.