Extended endonasal endoscopic approach for the resection of craniopharyngioma - an analysis of 40 cases

Background:

Extended endonasal endoscopic approach for the non-pituitary lesions of the sellar and suprasellar regions are not new in the field of neurosurgery. Traditional transsphenoidal approach gives exposure to the pituitary fossa, whereas extended approach provides exposure to the optic nerve, chiasm, A-com complex, basal frontal lobe, mammillary body, midbrain, 3^rd cranial nerve, basilar artery, Circle of Willis and laterally to the cavernous sinuses.

Methods and Materials:

From November 2007 to February 2016,there were 40 cases of craniopharyngiomaoperated by the extended endonasalendoscopic approach. Patient’s history, clinical findings, pre-operative &post-operative visual acuity, visual field analysis and radiological data were collected and analyzed.

Results:

Age group of the patients varied from 10 to 60 yrs. Male were 19 (47.5%), female were 21 (52.5%).Gross total removal was achieved in 22 cases (55.0%) and subtotal in 10 (25.0%) cases. Visual acuity and visual field improved in all cases. One case (2.5%) had prolonged period of unconsciousness, probably from hypothalamic disturbance. Cerebrospinal fluid leak developed in 10 (25.0%) cases. All patients required thyroxin and cortisol for replacement. Permanent diabetes insipidusdeveloped in 10 cases (25.0%). No cases required traditional, open approaches following endoscopic resection. Three patients required permanent CSF diversion via a ventriculo-peritoneal shunt after documentation of post-operative hydrocephalus.

Conclusion:Extendedtransspehnoidal approach is an excellent alternative of skull base approach for the removal of most of the craniopharyngiomas.It gives better visualization, improved postoperative visual outcome for less manipulation and lower complicationrate than craniotomy. However,CSF leak and DI are known common complications which shouldbe managed promptly and appropriately.

Keywords:

Craniopharyngioma, Extended endoscopic, transnasal, transphenoidal

Hyperdense Appearance in Active Epidural and Subdural Hematoma: Serial Case Report

Many of traumatic brain injured patients come to the emergency department with active intracranial bleeding, either Epidural Hematoma (EDH) or Subdural Hematoma (SDH). The most common source of bleeding in EDH cases might be either from the oozed bleeding from fracture of adjacent bone or tear of medial meningeal vessel branches. The classic appearance usually found in non-contrast head CT, which formed a biconvex lesion. The active bleeding, usually from blood vessels tearing origin, could also be found in CT imaging. There is hypodense mixed within the hyperdense lesion, sometimes formed a whirlpool-like appearance, which later known as “Swirl Sign”³. The acute subdural hematoma, by its process, is different with EDH. It is usually caused by clot accumulation of adjacent cortical laceration or tearing of bridging veins. The crescent-like appearance is the classical CT image shown in acute SDH. However, up to now, the active bleeding in subdural hematoma is not widely explained. We report 12 cases of epidural and subdural hematoma which indicate active bleeding from imaging study.All of the cases revealed the active bleeding during the surgery.We suggest that hypodense lesion in acute TBI imaging should be considered as active bleeding not only for EDH but also for SDH cases. Thus, more attention must be taken carefully during the surgery.

Keyword: Swirl sign, Subdural Hematoma, SDH, active bleeding