Revisiting the combined approach of Yaşargil for microsurgical removal of intra-extraventricular and pure intraventricular craniopharyngiomas.

OBJECTIVE

Craniopharyngiomas originate from squamous epithelium in the pituitary stalk, tend to expand into surrounding tissues, and have high recurrence rates when residual tumor remains. Therefore, gross total resection should be the goal at initial surgery. Yaşargil described the combined approach, involving both anterior interhemispheric transcallosal transforaminal and pterional transsylvian approaches in the same session for intra-extraventricular and pure intraventricular craniopharyngiomas. This study presents our series, the first since Yaşargil's publications, of patients operated on with this approach.

METHODS

Data were prospectively collected (September 2006-August 2024) from patients undergoing endoscope-assisted combined craniopharyngioma surgery. First, parasagittal craniotomy was performed, and the tumor was resected microsurgically via the anterior interhemispheric transcallosal transforaminal route. Then, the residual tumor in the parachiasmatic area was removed via the pterional craniotomy and transsylvian route. Since January 2018, intraoperative MRI has been used to confirm gross total resection.

RESULTS

During the study period, 67 craniopharyngioma patients underwent surgery, and combined approach was performed in 12 cases. Gross total resection was achieved in 11 of the 12 patients who underwent the combined approach, while one had a near-total resection. The patient who underwent near-total resection had a history of two prior surgeries and radiotherapy and was the only case of recurrence (mean follow-up: 97 months). The stalk was resected in all patients and hormone replacement therapy was required.

CONCLUSION

The basic principle in the treatment of craniopharyngiomas, which have high recurrence rates in the presence of residual tumor and locally aggressive behavior, is gross total resection in the initial surgery. Gross total resection offers the opportunity for cure and is critical in the course of the disease. The combined approach is an effective and safe technique to achieve gross total resection in the initial surgery for patients with intra-extraventricular and pure intraventricular craniopharyngiomas.