Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Oper Neurosurg . 2025 Aug 8;30(5):692–702. doi: 10.1227/ons.0000000000001687 Search in PMC Search in PubMed View in NLM Catalog Add to search Endoscopic Endonasal Approach for Craniopharyngiomas With Intraventricular Extension: Anatomic-Clinical Considerations and Surgical Outcomes in a Series of 61 Patients Ilaria Bove Ilaria Bove , MD * Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita' degli Studi di Napoli Federico II, Naples, Italy; Find articles by Ilaria Bove * , Domenico Solari Domenico Solari , MD, PhD * Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita' degli Studi di Napoli Federico II, Naples, Italy; Find articles by Domenico Solari *, ✉ , Teresa Somma Teresa Somma , MD, PhD * Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita' degli Studi di Napoli Federico II, Naples, Italy; Find articles by Teresa Somma * , Riccardo Nocini Riccardo Nocini , MD, PhD ‡ Unit of Otolaryngology, Head and Neck Department, University of Verona, Verona, Italy Find articles by Riccardo Nocini ‡ , Carmela Palmiero Carmela Palmiero , MD * Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita' degli Studi di Napoli Federico II, Naples, Italy; Find articles by Carmela Palmiero * , Felice Esposito Felice Esposito , MD, PhD * Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita' degli Studi di Napoli Federico II, Naples, Italy; Find articles by Felice Esposito * , Paolo Cappabianca Paolo Cappabianca , MD * Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita' degli Studi di Napoli Federico II, Naples, Italy; Find articles by Paolo Cappabianca * , Luigi Maria Cavallo Luigi Maria Cavallo , MD, PhD * Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita' degli Studi di Napoli Federico II, Naples, Italy; Find articles by Luigi Maria Cavallo * Author information Article notes Copyright and License information * Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita' degli Studi di Napoli Federico II, Naples, Italy; ‡ Unit of Otolaryngology, Head and Neck Department, University of Verona, Verona, Italy ✉ Correspondence: Domenico Solari, MD, PhD, Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Via Sergio Pansini, 5, Napoli 80131, Italy. Email: [email protected] ✉ Corresponding author. Received 2024 Nov 22; Accepted 2025 Apr 3; Issue date 2026 May. Copyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc on behalf of Congress of Neurological Surgeons. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY) , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. PMC Copyright notice PMCID: PMC13068443 PMID: 40778761 Abstract BACKGROUND AND OBJECTIVES: Craniopharyngiomas (CPs) with intraventricular extension has required often a difficult surgical management. These injuries involve a high degree of endocrinological, visual, and neuropsychological morbidities, which have a huge impact on the patient's quality of life. The advancements of visualization instruments along with development of minimally invasive techniques as the endoscopic endonasal have granted reduction of morbidity and mortality rates. The aim of this retrospective study was to report our experience with the endoscopic endonasal approach in the management of a series of patients affected by CPs with intraventricular extension. METHODS: The authors reviewed data of 61 cases from a series of 164 patients, who underwent an endoscopic endonasal transtuberculum/transplanum approach for the removal of a CP involving the third ventricle between January 2001 and March 2023. Four main third ventricular growth patterns were identified: stalk-infundibulum, infundibulum-ventricular chamber, stalk-infundibulum-ventricular chamber, and ventricular chamber. RESULTS: Sixty-one patients (34 men, 27 women), with mean age of 51.87 years (range 10-79 years ± 13.66 SD), underwent extended endoscopic endonasal approach. Gross total resection was obtained in 65.6% of cases and resulted significantly influenced by the sex (95% CI, 0.080-0.60; P = .02), previous treatment (95% CI, 0.08-0.31; P = .04), and tumor location (95% CI, 0.44-0.10; P = .05). Postoperatively, visual improvement was observed in 40 patients (76.9%). The hypothalamic functions were improved in 6 cases (20%), remained stable in 9 (45%), instead a new-onset of hypothalamic functions disturbances were registered in 5 cases on 31 patients (16.1%). Six postoperative cerebrospinal fluid leaks (9.8%) occurred. CONCLUSION: The different topographies of intraventricular CPs affect the outcomes of resection. However, the extension of CP in the third ventricle does not represent a limit of the endonasal route; the good outcomes and limited complications confirm that. KEY WORDS: Endoscopic endonasal approach, Craniopharyngioma, Third ventricle, Transtuberculum/transplanum endoscopic endonasal approach, Hypothalamus ABBREVIATIONS: CP craniopharyngioma DI diabetes insipidus EEA endoscopic endonasal approach EOR extent of resection GTR gross total resection NTR near-total resection SI stalk-infundibulum STR subtotal resection. The resection of craniopharyngiomas (CPs) involving the third ventricle can result in injury to the hypothalamus, infundibulum, pituitary gland, and optic apparatus. Maximum safe surgical resection is the primary goal according to current treatment policy, but it is often difficult to accomplish. 1 - 5 Transcranial microsurgery has traditionally been the standard operative option. 6 - 9 Trans-sphenoidal approaches were limited to intrasellar, infradiaphragmatic CPs. In the last decades, the evolution of transtuberculum/transplanum endoscopic endonasal approach (EEA) has given new opportunity of management for supradiaphragmatic CPs. 10 - 17 According to the relationships between the tumor and the infundibulum, Kassam et al 18 developed a classification to guide the endonasal resection of CPs. Type I to III can be surgically approached by EEA. Type IV or purely third ventricular lesions, although being amenable to EEA, should be accessed by transchoroidal or translaminar terminalis approach. Other classification schemes have been reported. 19 , 20 In the “QST” type, Fan et al 21 describe the largest surgical experience with CPs in the modern era. The authors classify CPs in 3 types according to their origin: infrasellar/subdiaphragmatic, subarachnoidal, and pars tuberalis. As previously reported by our group, we can identify 2 anatomical scenarios 10 : (1) the stalk-infundibulum (SI) complex is enlarged by the CP, and (2) the intact pituitary stalk is displaced anteriorly, medially, or laterally by a CP expanding within the third ventricle. In the first scenario, CP grows inside the infundibular recess enlarging the pituitary stalk, which together with the outer part of the infundibulum becomes a gate to enter the ventricular cavity. In the second scenario, the pituitary stalk remains a key reference landmark for defining CP's topography, and both the circumferential expansion of the infundibulum and the bulging of the third ventricle floor beneath the stalk are signs of primary tumor growth at hypothalamic level. Along with the growing experience, the EEA through 2 different corridors, ie, the suprachiasmatic through lamina terminalis or most commonly the subchiasmatic through the infundibulum, gained entering the third ventricle chamber. 10 , 22 - 24 This study describes our experience with extended EEA for the removal of CPs involving the third ventricle, focusing on the impact of different topographies of intraventricular CPs, distinguishing between lesions involving the pituitary stalk and infundibulum (positioned lower along the hypothalamus-pituitary axis) and those occupying the infundibulum-third ventricle region (at a higher position). METHODS Among one hundred fifty CPs undergone surgical resection by EEA at the Division of Neurosurgery between January 2001 and March 2023, we identified 61 cases (40.7%) arising or secondary extending into the ventricular chamber. The endoscopic endonasal transtuberculum/transplanum approach was performed in all cases. 10 , 15 All the surgeries required dedicated team, being each procedure run according to the so-called 3 to 4 hands technique. 25 In this scenario, 2 experienced surgeons, as best-tuned duo, have been working together. This study was conducted according to 1964 Declaration of Helsinki and its later amendments. Owing to its retrospective nature, Institutional Review Board gave its approval and waived the need for informed consent. Demographic data, preoperative assessment, tumor features, surgical results, complications, follow-up, recurrence, and hypothalamic disturbance were reported. In the study, we included both pediatric and adult patients with CP involving the third ventricle. The age of pediatric population ranged from 12 to 18 years. We selected cases with a well-pneumatized sphenoid sinus, an adequate wide chiasm-pituitary corridor, and lateral extension not beyond the optic nerve/internal carotid artery. According to our classification, we defined 4 main growth patterns of CP: SI, infundibulum-ventricular chamber, SI-ventricular chamber, and ventricular chamber (Figure 1 ). 10 Extent of resection (EOR) was stated according to MRI at 3 months and classified as gross total resection (GTR) when no tumor remnant was visible, near-total resection (NTR) if ≥95% of tumor volume was resected, subtotal resection (STR) if ranging from 70% to 95%, and partial if <70%. All patients received computed tomography scan after surgery to exclude perioperative complications and thereafter underwent post-Gad MRI before being discharged to assess EOR. MRI scan at 3 months was then considered to rule out tumor remnants or regrowth that require adjuvant treatment; scans were then repeated regularly at follow-up. FIGURE 1. Open in a new tab Schematic drawing showing the ventricular involvement at different level along the SI axis. A , SI lesion, enlarging the stalk and abutting in the infundibular region of the third ventricle. B , IV involvement: in this case the lesions has pushed downward the posterior wall of the infundibulum and the third ventricle floor, so that can be accessed through such path; C , SI-ventricular lesion in which tumor has both widening the stalk and pushed down the posterior wall of the infundibulum and the third ventricle floor; D , Ventricular lesion in which tumor growing within the chamber, above the level of an anatomically intact third ventricle floor. IV, infundibulum-ventricular chamber; SI, stalk-infundibulum. Statistical Analysis Student t test or Mann-Whitney U test were used. For categorical variables, the difference was analyzed using the Fisher exact test. The effects of preoperative variables were analyzed using multivariate logistic regression models; in each case, P value < .05 was considered statistically significant. All statistical analyses were performed using R studio (Integrated Development for R. RStudio, Public-benefit Corporation). RESULTS Demographic and Clinical Data at Surgery Among 61 patients enrolled in the study, 27 were female (44.3%) and 34 male (55.7%), and mean age was 51.87 years (range 10-79 years ± 13.66 SD). The most common presenting symptom was visual defect (73.8%), with bitemporal hemianopia in 42.3% of cases (Table 1 ). Rarely hydrocephalus (8.2%) and headache (6.5%) led to diagnosis of CP. Endocrinological disturbances were detected in 31 patients (50.8%): panhypopituitarism in 21.3% of cases; 9 (14.8%) presented with anterior hypopituitarism 1 axis, 2 (8.2%) presented with anterior hypopituitarism 2 axes, 2 (3.3%) with isolated diabetes insipidus (DI), and 5 (25%) with panhypopituitarism and DI. Four patients (6.5%) were admitted with manifestations consciousness impairment suggestive for intracranial hypertension. Symptoms of hypothalamic disorders were present in 30 of 61 (49.2%): obesity in most cases (39.3%). Seven patients (11.5%) experienced a previous surgical treatment; in 3 cases (3.3%), previous radiotherapy was performed. The median surgery time was 7 hours during the first 10 years; in the latter period, the median time has decreased to 5 hours. The median length of stay was 9.2 days, ranging from 7 to 30 days, depending on the clinical condition and any complications that occurred during the stay. The mean follow-up was 79.13 ± 30.74 SD months. Data are reported in Tables 1 - 3 . TABLE 1. Demographic and Clinical Data of 61 Craniopharyngiomas With Intraventricular Extension Covariates Overall series (61) Demographic and clinical data Sex Female 27 (44.3%) Male 34 (55.7%) Age (y) Mean 51.87 (range 10-79 ± SD 13.66) BMI Mean 29.2 ± 5.86 SD (range 19-49.78) <30 37 (60.6%) ≥30 24 (39.4%) Presenting symptoms and signs Preoperative visual impairment 52/61 (85.2%) Hydrocephalus 5/61 (8.2%) Headache 4/61 (6.5%) Pituitary disfunction 31/61 (50.8%) Obesity 24/61 (39.3%) Consciousness impairment 4/61 (6.5%) Memory disturbance 2/61 (3.2%) Panhypopituitarism 13/61 (21.3%) Hypopituitarism 1 axis 9/61 (14.8%) Hypopituitarism 2 axis 2/61 (3.3%) Panhypopituitarism + Diabetes insipidus 5/61 (8.2%) Diabetes insipidus 2/61 (3.3%) Bitemporal hemianopsia 22/61 (36%) Visual acuity 20/61 (32.8%) Bilateral quadrantanopia 3/61 (4.9%) Unilateral quadrantanopia 2/61 (3.3%) Unilateral hemianopsia 1/61 (1.6%) Hemianopsia + Quadrantanopia 3/61 (4.9%) Amaurosis + Hemianopsia/Quadrantanopia 1/61 (1.6%) Prior surgical treatments 7/61 (11.5%) Craniotomy 3/61 (4.9%) Craniotomy + Ommaya 2/61 (3.3%) EEA 2/61 (3.3%) Radiotherapy 3/61 (3.3 %) Open in a new tab BMI, body mass index; EEA, endoscopic endonasal approach. TABLE 3. Surgical and Outcome Data of 60 Craniopharyngiomas With Intraventricular Extension Covariates Overall series (61) EOR GTR 40 (65.6%) NTR (70%-95%) 8 (13.1%) STR (>70%) 13 (21.3%) Visual outcome Improved 40/52 (76.9%) Unchanged 10/52 (19.2%) Worsened 2/52 (3.9%) Endocrinological outcome Unchanged 17/31 (54.8%) New-onset 26/30 (86.7%) Postoperative endocrinological symptoms Panhypopituitarism 21/61 (34.4%) Hypopituitarism 1 axis 17/61 (27.9%) Hypopituitarism 2 axis 12/61 (19.7%) Diabetes insipidus Unchanged 7/7 (100%) New onset 40/54 (74.1%) Hypothalamic disturbance Improved 6/30 (20%) Unchanged 9/30 (45%) New-onset 5/31 (16.1%) Post BMI Stable 37/61 (60.7%) <10 kg weight gain 15/61 (24.6%) 10-20 kg weight gain 6/61 (9.8%) >20 kg weight gain 3/61 (4.9%) Complications CSF leak 6/61 (9.8%) Subdural hematoma 2/61 (3.25%) Hemorrhage 2/61 (3.25%) Cranial nerves palsy 1/61 (1.6%) Meningitis 1/61 (1.6%) Hydrocephalus 2/61 (3.25%) Death related complication 1/61 (1.6%) Death related disease progression 2/61 (3.25%) Recurrence 4/61 (6.5%) Adjuvant treatments Radiation therapy 21/61 (34.4%) Immunotherapy 1/61 (1.6%) PFS 27 mo Follow-up 79.13 ± 30.74 SD Open in a new tab BMI, body mass index; CSF, cerebrospinal fluid; EOR, extent of resection; GTR, gross total resection; NTR, near total resection; PFS, progression-free survival; STR, subtotal resection. Tumor Features Two cases (3.3%) were purely intraventricular CPs. Most of the lesions (96.7%) presented with various degree of secondary involvement: 22 (36%) involved the SI, 28 (45.9%) the infundibulum-ventricular chamber, and 9 (14.8%) the SI-ventricular chamber. The pathological report disclosed 53 cases (86.9%) of adamantinomatous CPs, whereas 8 (13.1%) were papillary. Tumors were defined as mixed solid-cystic (72.1%), solid (21.3%), and cystic (6.6%), respectively (Table 2 ). TABLE 2. Pathologic Data of 61 Craniopharyngiomas With Intraventricular Extension Covariates Overall series (61) Tumor growth pattern SI 22/61 (36%) IV 28/61 (45.9%) SIV 9/61 (14.8%) V 2/61 (3.3%) Histology Adamantinomatous 53/61 (86.9%) Papillary 8/61 (13.1%) Consistency Mixed 44/61 (72.1%) Solid 13/61 (21.3%) Cystic 4/61 (6.6%) Open in a new tab IV, infundibulum-ventricular chamber; SI, stalk-infundibulum; SIV, stalk-infundibulum-ventricular chamber; V, purely ventricular. EOR and Surgical Outcomes Postoperative visual function improved in 40 cases (76.9%), remained stable in 10 (19.2%), and in 2 cases (3.9%) worsened. Regarding the postoperative endocrinological status, primary condition was found unchanged in 54.8%. New-onset of postoperative pituitary gland dysfunction was reported in 86.7% (new hypopituitarism: 19, new pan hypopituitarism: 6, new DI: 5). The DI remained unchanged after surgery in every case (Table 3 ). An improvement in intellectual ability was observed in 6 patients (20%), no change in 9 patients (45%), and deterioration in 5 cases (16.1%). Body mass index remained unchanged in 37 patients (60.7%), whereas in 15 cases (24.6%), we observed weight gain lesser than 10 kg, in 6 (9.8%) between 10 and 20 kg, and in 3 (4.9%) more than 20 kg. We did not find a statistically significant effect of third ventricle involvement with hypothalamic disturbance ( P > .5). GTR was achieved in 40 patients (65.6%), a NTR in 8 (13.1%), and STR in 13 (21.3%). The EOR resulted significantly influenced by the sex (95% CI, 0.080-0.60; P = .02), previous treatment (95% CI, 0.08-0.31; P = .04), and tumor location (95% CI, 0.44-0.10; P = .05). Female sex, previous treatment (ie, surgery or/and radiotherapy), and SI group were associated with low incidence of GTR (Table 4 ). The postoperative cerebrospinal fluid (CSF) leakage rate was 9.8% (5/61); it occurred in 4 of the 21 patients (19.04%), who received gasket seal/grandma cap reconstruction technique 26 , 27 ; in 1 of 17 (5.9%) in whom multilayer sandwich technique was adopted; and in 1 of 23 patients in whom 3F reconstruction technique was performed. 28 , 29 Of these patients, 5 presented with frank postoperative CSF leakage that required second surgery: in 4 cases, a watertight reconstruction was achieved using de novo gasket seal technique, whereas in 1 case, the multilayer sandwich technique was adopted. In a single case, small weeping was observed, so awake sealant technique was used to seal the CSF leakage. 30 Lumbar drain was not used preoperatively or postoperatively in any cases, as well as no patient required lumbar-peritoneal shunts. One patient with retrosellar lesion suffered on postoperative day 1 of transient third cranial nerve palsy in the right eye (1.6%); we also observed 2 cases of subdural hematoma (3.25%, 2/61), 2 cases of hemorrhage (3.25%, 2/61), 2 cases of hydrocephalus (3.25%, 2/61), and 1 case of meningitis (1.6%, 1/61). Three patients (4.9%) died during follow-up: 2 for progression disease (3.25%, 2/61) and 1 for meningitis complication (1.6%, 1/61) (Table 5 ). 31 On discharge, we recommend nasal rinsing with a topical nasal spray, usually 10 to 15 days after surgery. For up to 4 to 6 weeks, patients are advised to avoid straining and any activities that may promote Valsalva maneuvers and/or leaning the head forward. 32 Postoperative nasal discomfort was not reported in any case. TABLE 4. Tumor Features, Outcome, and Extent of Resection Tumor features GTR (65.6%) N = 40 NTR (13.1%) N = 8 STR (21.3%) N = 13 P -value Gender female 13 (32.5%) 5 (62.5%) 9 (69.2%) .02 Previous treatment 3 (7.5%) 2 (25%) 2 (15.4%) .04 Age (y) 51.3 50.77 49.64 .83 Location SI 12 (30%) 5 (62.5%) 6 (46.1%) .05 SIV 6 (15%) 0 2 (15.4%) .4 IV 22 (55%) 3 (37.5%) 3 (23.1%) .2 V 0 0 2 (15.4%) .76 Consistency Cystic 3 (7.5%) 1 (12.5%) 0 .88 Solid 10 (25%) 1 (12.5%) 2 (15.4%) .36 Mixed 27 (67.5%) 6 (75%) 11 (84.6%) .3 Size (max diameter, cm) <3 19 (47.5%) N = 3 (37.5%) 5 (38.4%) .68 >3 21 (52.5%) N = 5 (62.5%) 8 (61.5%) Pathology Adamatinomatosus 38 (95%) N = 8 (100%) 7 (53.8%) .05 Papillary 2 (5%) 0 6 (46.2%) CSF leak 4 (10%) 1 (12.5%) 1 (7.7%) .3 Recurrence rate 2 (5 %) 1 (12.5%) 1 (7.7%) .99 Open in a new tab CSF, cerebrospinal fluid; GTR, gross total resection; IV, infundibulum-ventricular chamber; NTR, near total resection; SI, stalk-infundibulum; SIV, stalk-infundibulum-ventricular chamber; STR, subtotal resection; V, purely ventricular. Bold represents statistically significant data ( P < .05). TABLE 5. Tumor Complication and Intraventricular Craniopharyngioma Topography According to Our Previous Classification Tumor features SI (36%) (N = 22) SIV (14.8%) (N = 9) IV (45.9%) (N = 28) V (3.3%) (N = 2) P -value CSF leak 0 N = 1 (12.5%) N = 5 (17.85%) 0 .32 Hemorrhage N = 2 (8.7%) 0 N = 2 (7.1%) 0 .98 Cranial nerves palsy 0 0 0 N = 1 (50%) .15 Meningitis 0 14.3% (N = 1) 0 0 .17 Hydrocephalus 0 N = 1 (11.1%) 0 N = 1 (50%) .04 Diabetes insipidus N = 15 (65.2%) N = 6 (75%) N = 21 (75%) N = 2 (100%) .4 Open in a new tab CSF, cerebrospinal fluid; IV, infundibulum-ventricular chamber; SI, stalk-infundibulum; SIV, stalk-infundibulum-ventricular chamber; V, purely ventricular. Bold represents statistically significant data ( P < .05). Follow-Up During the follow-up (mean 79.13 ± 30.74 SD months), tumor recurrence was registered in 4 cases (6.5%) with a mean progression-free survival of 27 months: 2 of them undergone GTR (1 was previously treated through EEA + Ommaya reservoir positioning and by pure EEA), 1 after NTR, and the 1 after STR. Adjuvant stereotactic radiosurgery was administered in 21 patients (34.4%), of which 10 after NTR, 7 after STR, and 4 after GTR. One patient undergone STR of a papillary CP harboring BRAF (V600E) mutation, received adjuvant treatment with BRAF/methyl ethyl ketone inhibitor and the MRI at last follow-up disclosed no tumor. 33 In univariate analysis, risk of recurrence was not significantly increased with tumor removal ( P = .99). No significant difference was found in the Kaplan-Meier analysis regarding progression-free survival rate according to tumor resection ( P = .5). DISCUSSION CP is a histologically benign but locally aggressive tumor, which can arise along hypothalamus-pituitary axis. 3 , 34 , 35 The involvement of the third ventricular chamber is quite common, either due to the extension of lesions from their origin in the sellar-suprasellar area or, less frequently, from growth of the ventricular floor lining cells. There is not a univocal consensus in the literature regarding the optimal treatment strategy for CPs. 1 , 5 , 34 , 36 , 37 Multiple classifications have been proposed to support the choice of the best management strategy on anatomical tumor features and functional considerations. 38 , 39 To strengthen the results of the present series, we compared our data with those retrieved from the literature. We summarized the outcomes observed in surgical series of CPs extending into the ventricular chamber and purely third ventricle CPs. Specifically, we focused on third ventricle CPs treated by EEA or transcranial approach from January 2000 to December 2024 (Table 6 ). 10 , 39 - 60 TABLE 6. Previous Studies Reporting Series of Transcranial Approach and EEA of Intraventricular Craniopharyngiomas in the Literature After 2000 Authors No. of pts Third ventricular involvement Preoperative endocrinological status Postoperative endocrinological disorder Postoperative visual disorder Approach EOR Other complications Recurrence Mean Follow-up (mo) Chen 40 1 ITVC NA New onset DI 1 (100%) NA TCA GTR 100% NA 0 24 Behari et al 41 6 ITVC NA API 2 (33%), New onset DI 1 (17%) NA TCA GTR 50% Hydrocephalus 1 (17%) 0 20 Maira et al 42 8 ITVC NA API 2 (25%) NA TCA GTR 88% Neurological deterioration 2 (25%) NA 117 Steno et al 43 29 3CVP NA NA NA TCA GTR 75.9% NA 7 (24.1%) 54.5 Pasqual et al 44 1 ITVC NA NA NA TCA NTR 100% NA NA NA Madhavan et al 45 1 ITVC NA NA NA TCA — Death for myocardial infarction NA NA Agrawal et al 46 1 ITVC NA NA 0 TCA GTR 100% — NA NA Tayari et al 47 1 ITVC NA NA NA TCA GTR 100% — 0 NA Pan Jun et al 48 17 ITVC DI 8 (61.5%) HT 6 (46.2%) API 3 (23.1%) API 4 (30.8%) HT 5 (38.5%) DI 5 (38.5%) NA TCA GTR 76.5% Epidural hematoma with death (1/7.7%) 3 (30.8%) NA Jung et al 49 4 ITVC DI 1 (50%) API 2 (50%) 0 TCA GTR 100% NA 2 (50%) 59 Yu et al 50 24 ITVC DI 5 (20.8%) Partial API 8 (33.3%) Corticotroph insufficiency 13 (54.2%) New onset DI 15 (62.5%) NA TCA GTR 79% Memory loss 1 (4.1%) 6 (25%) 42 Cavallo et al 10 12 3CVP API + DI 2 (16.7%) API 6 (50%) Partial API 1 (8.3%) New onset DI 6 (50%) 1 (8.3%) EEA NA CSF leak 2 (16.7%) CSDH 2 (16.7%) 0 31.4 Gu et al 51 3 3CVP HT + HPRL 3 (100%) 0 0 EEA GTR 100% CSF leak 1 (33.3%) 0 35.6 Nishioka et al 52 3 ITVC NA API + New onset DI 3 (100%) 0 EEA GTR 100% NA 0 18.3 Forbes et al 53 10 ITVC HG 3 (30%) HG + HT 3 (30%) DI 2 (20%) New onset DI 5 (50%) API 9 (90%) 1 (10%) EEA GTR 90% CSF leak 1 (10%) FUO 1 (10%) 2 (20%) 46.8 Cai et al 54 27 TVC Partial HP 16 (59.3%) PanHy 2 (7.4%) DI 5 (18.5%) API 11 (40.1%) DI 10 (45.5%) 1 (3.7%) TCA 63% TCA endoscope assistant 37% GTR 85.2% Memory loss 1 (3.7%) Pseudomeningocele 2 (7.4%) Sellar hematoma 1 (3.7%) 1 (3.7%) 49.6 Hung et al 55 5 ITVC NA NA NA TCA NA NA NA NA Deopujari et al 39 25 ITVC 11 (44%) NA DI 7 (25%) TCA 18 (72%) EEA 7 (28%) GTR 40% Meningitis 2 (8%) Hydrocephalus 4 (16%) Death 3 (12%) 5 (20%) Fan et al 56 26 3CVP Partial API 7 (26.9%) DI 1 (3.8%) NA NA EEA GTR 92.3% NA 1 (3.8%) 24.2 Cao et al 57 11 TVC API 0 DI 3 (27.3%) API 7 (63.7%) New onset DI 5 (45.5%) 2 (18.2%) EEA GTR 72.3% Meningitis 1 (9%) Electrolyte imbalance 7 (63.7%) 1 (9.1%) 12.16 ± 3.40 Zoli et al 58 36 3CVP API 15 (41.6%) DI 2 (5.6%) API + DI 9 (25%) Partial API 35 (97.2%) 2 (5.5%) EEA GTR 91.7% CSF 5 (13.9%) Meningitis 3 (8.3%) third ventricle hematoma 1 (2.8%) Epistaxis 1 (2.8%) transitory palsy of the third cranial nerve 1 (2.8%) Transitory memory disturbance 1 (2.8%) 6 (16.7%) 43 ± 38 Cao et al 59 22 ITVC DI 5 (22.7%) HG 4 (18.2%) Partial API 2 (9.1%) API 15 (68.2%) 2 (9.1%) EEA GTR 95.5% CSF leak 1 (4.6%) 2 (9.1%) 22.16 ± 7.41 Zhou et al 60 14 ITVC Partial API 5 (35.7%) DI 1 (7.1%) API 5 (35.7%) New onset DI 1 (7.1%) 1 (7.1%) EEA GTR 92.8% NA O 26.2 Current study 61 3CVP API 13 (21.3%) Hypopituitarism 1 axis 9 (14.8%) Hypopituitarism 2 axis 2 (3.3%) API + DI 5 (8.2%) DI 2 (3.3%) API 21 (34.4%) Hypopituitarism 1 axis 17 (27.9%) Hypopituitarism 2 axis 12 (19.7%) New onset DI 40 (74.1%) 2/52 (3.9%) EEA GTR 65.6% CSF leak 6/61 (9.8%) Subdural Hematoma 2 (3.25%) Hemorrhage 2 (3.25%) Cranial nerves palsy 1 (1.6%) Meningitis 1 (1.6%) Hydrocephalus 2 (3.25%) Death related complication 1 (1.6%) Death related disease progression 2 (3.25%) 4/61 (6.5%) 79.13 ± 30.74 SD Open in a new tab 3CPV, third ventricle craniopharyngioma; API, anterior pituitary insufficiency; CSDH, cerebral subdural hematoma; CSF, cerebrospinal fluid; DI, diabetes insipidus; EEA, endoscopic endonasal approach; EOR, extent of resection; FUO, unknown fever; GTR, gross total resection; HG, hypogonadism; HPRL, Hyperprolactinemia; HT, hypothyroidism; ITVC, intrinsic third ventricle craniopharyngioma; NA, not applicable; NTR, near total resection; TCA, transcranial approach. Surgical Consideration CP, growing within the infundibular recess, typically expands the pituitary stalk, which, along with the infundibulum, serves as a gateway into the ventricular cavity. Tumor can move anteriorly the optic chiasm in a position of “prefixed chiasm”; in these cases, patients tend to have a narrow chiasm-pituitary corridor, whereas postfixed chiasms have a large chiasm-pituitary corridor. 61 , 62 Our data reveal that neither the location of the chiasm nor the size of the corridor between the top of the pituitary gland and the bottom of the chiasm should be considered an absolute contraindication for CP resection, thanks to gateway of the infundibulum. To avoid damage to the floor of the third ventricle, tumor removal begins with the superior intraventricular component, followed by the inferior portion along the floor of the third ventricle. This approach allows for better visualization of the hypothalamus and the arterial perforator vessels of the pituitary stalk and optic chiasm. Preoperative MRI key factors: Chiasm position: Prefixed position of the chiasm requires extreme care during tuberculum sellae bone opening, but, on the other hand, it allows an easier way to get into the subchiasmatic space; Chiasm-pituitary gland distance: A narrow chiasm-pituitary corridor can be considerate a relative contraindication of EEA; Position of the third ventricle floor: The floor of the 3D ventricle can be infiltrated at the level of tuber cinereum or at the infundibular recess, and the tumor can extend outside the ventricle in the interpeduncular cistern; Mammillary bodies–dorsum sellae distance: This distance is crucial for tumor dissection from the floor of the third ventricle, as the mammillary bodies mark the anterior limit of the brainstem; 19 Sphenoid sinus: A well-pneumatized sphenoid sinus allows a better visualization of sellar anatomic landmarks. Nevertheless, none of the anatomic variations of sphenoid sinus can be considered an absolute contraindication. The intraventricular component, compressing the lateral wall of the third ventricle from within, leads to widening of its floor. This, in turn, facilitates the infrachiasmatic corridor and simplifies tumor dissection maneuvers. 10 , 23 The GTR was obtained in most of the cases (65.6%) and resulted significantly influenced by the sex ( P = .02), previous treatment ( P = .04), and tumor location ( P = .05). SI involvement was associated with low incidence of GTR. This variability depends on the growth pattern itself and the maneuvers adapted to preserve neurovascular structures, especially at the infundibulum where the tumor does not enlarge enough it. Adhesions and scar tissue in the surgical field from previous treatments affect the EOR. Regardless of the surgical approach used, the main problem of recurrent CP surgery is the loss of gliotic reaction between the tumor and the surrounding neural tissue, further complicated by the presence of arachnoid scars. As previously reported by our group, the use of the expanded endoscopic approach for recurrent and residual CPs improves the identification of boundaries between tumor and normal tissue, allowing a more secure and radical excision. 63 Concerning the hypothalamic-pituitary dysfunction, several factors should be considered, ie, age of onset, histological subtype, tumor location, and recurrence. Guo et al 64 found that hypothalamic syndrome was related to older age of onset, tumor recurrence, adamantinomatous type, and high preoperative neuroendocrine dysfunction. Previous studies have shown that weight gain may be related to suprasellar and invasive tumor behavior, which led damage of the paraventricular and the suprachiasmatic nucleus. 65 In a multidimensional analysis of brain structure/function by Lee et al. 66 , psychological and behavioral phenotypes showed that patients with hypothalamic disorders have lower neural activation in the left caudate nucleus in response to food imagery. Hypothalamic involvement has been reported to have a statistically significant negative effect on overall 20-year survival in children with CP, so understanding the pathological mechanisms could open new avenues for targeted psychobehavioral therapeutics. 67 It is worth noting that after extensive manipulation of the nasal mucosa, postoperative nasal discomfort including nasal crusting, discharge, and obstruction, with transient hyposmia, might occur. Although we did not conduct any quality-of-life assessment, through questionnaire or otolaryngology direct observation, we can say that major nasal discomfort was avoided, thanks to our strategy. Indeed, along years, with increasing confidence, we adopted a “nasal-sparing” technique; hence, we prioritized meticulous postoperative care, including the use of topical nasal sprays, which resulted in complete restoration of nasal function. The major drawback of this route is the higher risk of CSF leak. 38 , 53 No statistical difference was found regarding CSF leak and CPs with intraventricular extension topography ( P = .3); contrariwise difference was found for postoperative hydrocephalus (Table 5 ). Nevertheless, the introduction of nasoseptal flap to bolster the reconstruction that our school adopted in the so-called 3F technique reduced the risk of CSF leak. 29 - 68 In the 3F technique, fat pad is used as a cork through the osteodural break, then the flap is raised and reflected over the skull base defect, and the patient is mobilized as fast as possible. 29 The postoperative CSF leak in our series dropped significantly from 13.2% (5/38) using multilayer reconstruction technique—ie, autologous, heterologous, and/or synthetic, materials used in different methods—to 0 cases on 23 after the introduction of 3F technique. Limitations The mechanisms underlying hypothalamic disturbance are multifactorial; in our study, we evaluated only some aspects inherent in the eating behavior, sleep-wake quality, and memory disturbance through patient communication. Future studies and the use of specific psychobehavioral scales will help us better understand the biological mechanisms and neural target involved in patients with intraventricular CP. CONCLUSIONS Our study evaluates the possible impact of different topographies of intraventricular CPs on clinical outcomes distinguishing between lesions involving the pituitary stalk and infundibulum and tumor occupying the infundibulum-third ventricle region. Our results demonstrate that SI involvement was associated with lower incidence of GTR; this variability depends on maneuvers adapted to preserve neurovascular structures, especially at the infundibulum where the tumor does not enlarge it. Our data enforce the role of EEA as a safe and effective surgery for radical resection and low incidence of hypothalamic-pituitary complications for intraventricular CPs. Nonetheless, it is essential to refine surgical strategy that takes into account the anatomy and key features of the region. Acknowledgments Author Contribution: Conception and design: Cavallo. Acquisition of data: Bove, Palmiero, Somma. Analysis and interpretation of data: Cavallo, Solari, Bove, Esposito. Drafting the article: Solari, Bove, Cavallo. Critically revising the article: Solari, Esposito, Cappabianca, Cavallo. Reviewed submitted version of manuscript: Solari, Cavallo. Approved the final version of the manuscript on behalf of all authors: Solari, Cappabianca, Cavallo. Statistical analysis: Bove, Esposito, Somma. Study supervision: Cavallo. Contributor Information Ilaria Bove, Email: [email protected]. Teresa Somma, Email: [email protected]. Riccardo Nocini, Email: [email protected]. Carmela Palmiero, Email: [email protected]. Felice Esposito, Email: [email protected]. Paolo Cappabianca, Email: [email protected]. Luigi Maria Cavallo, Email: [email protected]. Funding This study did not receive any funding or financial support. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 1. Yang I, Sughrue ME, Rutkowski MJ, et al. Craniopharyngioma: a comparison of tumor control with various treatment strategies. Neurosurg Focus. 2010;28(4):e5. [ DOI ] [ PubMed ] [ Google Scholar ] 2. Mrowczynski OD, Langan ST, Rizk EB. Craniopharyngiomas: a systematic review and evaluation of the current intratumoral treatment landscape. Clin Neurol Neurosurg. 2018;166:124-130. [ DOI ] [ PubMed ] [ Google Scholar ] 3. Prieto R, Rosdolsky M, Hofecker V, Barrios L, Pascual JM. Craniopharyngioma treatment: an updated summary of important clinicopathological concepts. Expert Rev Endocrinol Metab. 2020;15(4):261-282. [ DOI ] [ PubMed ] [ Google Scholar ] 4. Prieto R, Pascual JM, Hofecker V, et al. Craniopharyngioma adherence: a reappraisal of the evidence. Neurosurg Rev. 2020;43(2):453-472. [ DOI ] [ PubMed ] [ Google Scholar ] 5. Godil SS, Tosi U, Gerges M, et al. Long-term tumor control after endoscopic endonasal resection of craniopharyngiomas: comparison of gross-total resection versus subtotal resection with radiation therapy. J Neurosurg. 2021;136(5):1347-1355. [ DOI ] [ PubMed ] [ Google Scholar ] 6. Shirane R, Hayashi T, Tominaga T. Fronto-basal interhemispheric approach for craniopharyngiomas extending outside the suprasellar cistern. Childs Nerv Syst. 2005;21(8-9):669-678. [ DOI ] [ PubMed ] [ Google Scholar ] 7. Yaşargil MG, Curcic M, Kis M, Siegenthaler G, Teddy PJ, Roth P. Total removal of craniopharyngiomas. Approaches and long-term results in 144 patients. J Neurosurg. 1990;73(1):3-11. [ DOI ] [ PubMed ] [ Google Scholar ] 8. Liu JK, Sevak IA, Carmel PW, Eloy JA. Microscopic versus endoscopic approaches for craniopharyngiomas: choosing the optimal surgical corridor for maximizing extent of resection and complication avoidance using a personalized, tailored approach. Neurosurg Focus. 2016;41(6):e5. [ DOI ] [ PubMed ] [ Google Scholar ] 9. Koutourousiou M, Gardner PA, Fernandez-Miranda JC, Paluzzi A, Wang EW, Snyderman CH. Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations. J Neurosurg. 2013;118(3):621-631. [ DOI ] [ PubMed ] [ Google Scholar ] 10. Cavallo LM, Solari D, Esposito F, Cappabianca P. The endoscopic endonasal approach for the management of craniopharyngiomas involving the third ventricle. Neurosurg Rev. 2013;36(1):27-38; discussion 38. [ DOI ] [ PubMed ] [ Google Scholar ] 11. Cavallo LM, Frank G, Cappabianca P, et al. The endoscopic endonasal approach for the management of craniopharyngiomas: a series of 103 patients. J Neurosurg. 2014;121(1):100-113. [ DOI ] [ PubMed ] [ Google Scholar ] 12. Fomichev D, Kalinin P, Kutin M, Sharipov O. Extended transsphenoidal endoscopic endonasal surgery of suprasellar craniopharyngiomas. World Neurosurg. 2016;94:181-187. [ DOI ] [ PubMed ] [ Google Scholar ] 13. Park HR, Kshettry VR, Farrell CJ, et al. Clinical outcome after extended endoscopic endonasal resection of craniopharyngiomas: two-institution experience. World Neurosurg. 2017;103:465-474. [ DOI ] [ PubMed ] [ Google Scholar ] 14. Laws ER, Kanter AS, Jane JA, Dumont AS. Extended transsphenoidal approach. J Neurosurg. 2005;102(5):825-827; discussion 827-8. [ DOI ] [ PubMed ] [ Google Scholar ] 15. Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica. Neurosurg Focus. 2005;19(1):e3. [ PubMed ] [ Google Scholar ] 16. Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL. Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum. Neurosurg Focus. 2005;19(1):e4. [ PubMed ] [ Google Scholar ] 17. Hardesty DA, Montaser AS, Beer-Furlan A, Carrau RL, Prevedello DM. Limits of endoscopic endonasal surgery for III ventricle craniopharyngiomas. J Neurosurg Sci. 2018;62(3):310-321. [ DOI ] [ PubMed ] [ Google Scholar ] 18. Kassam AB, Gardner PA, Snyderman CH, Carrau RL, Mintz AH, Prevedello DM. Expanded endonasal approach, a fully endoscopic transnasal approach for the resection of midline suprasellar craniopharyngiomas: a new classification based on the infundibulum. J Neurosurg. 2008;108(4):715-728. [ DOI ] [ PubMed ] [ Google Scholar ] 19. Pascual JM, Prieto R, Carrasco R, Barrios L. Displacement of mammillary bodies by craniopharyngiomas involving the third ventricle: surgical-MRI correlation and use in topographical diagnosis. J Neurosurg. 2013;119(2):381-405. [ DOI ] [ PubMed ] [ Google Scholar ] 20. Almeida JP, Workewych A, Takami H, et al. Surgical anatomy applied to the resection of craniopharyngiomas: anatomic compartments and surgical classifications. World Neurosurg. 2020;142:611-625. [ DOI ] [ PubMed ] [ Google Scholar ] 21. Fan J, Liu Y, Pan J, et al. Endoscopic endonasal versus transcranial surgery for primary resection of craniopharyngiomas based on a new QST classification system: a comparative series of 315 patients. J Neurosurg. 2021;135(5):1298-1309. [ DOI ] [ PubMed ] [ Google Scholar ] 22. Solari D, Morace R, Cavallo LM, et al. The endoscopic endonasal approach for the management of craniopharyngiomas. J Neurosurg Sci. 2016;60(4):454-462. [ PubMed ] [ Google Scholar ] 23. Cavallo LM, Di Somma A, de Notaris M, et al. Extended endoscopic endonasal approach to the third ventricle: multimodal anatomical study with surgical implications. World Neurosurg. 2015;84(2):267-278. [ DOI ] [ PubMed ] [ Google Scholar ] 24. Prieto R, Barrios L, Pascual JM. Strictly third ventricle craniopharyngiomas: pathological verification, anatomo-clinical characterization and surgical results from a comprehensive overview of 245 cases. Neurosurg Rev. 2022;45(1):375-394. [ DOI ] [ PubMed ] [ Google Scholar ] 25. Castelnuovo P, Pistochini A, Locatelli D. Different surgical approaches to the sellar region: focusing on the “two nostrils four hands technique”. Rhinology. 2006;44(1):2-7. [ PubMed ] [ Google Scholar ] 26. Leng LZ, Brown S, Anand VK, Schwartz TH. “Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery. 2008;62(5 Suppl 2):ONSE342-ONSE343; discussion ONSE343. [ DOI ] [ PubMed ] [ Google Scholar ] 27. Cavallo LM, Messina A, Esposito F, et al. Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions. J Neurosurg. 2007;107(4):713-720. [ DOI ] [ PubMed ] [ Google Scholar ] 28. Somma AD, Bronzoni C, Guadagno E, et al. The “extended” endoscopic endonasal approach for the removal of a mixed intrasuprasellar germinoma: technical case report. Surg Neurol Int. 2014;5:14. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 29. Cavallo LM, Solari D, Somma T, Cappabianca P. The 3F (fat, flap, and flash) technique for skull base reconstruction after endoscopic endonasal suprasellar approach. World Neurosurg. 2019;126:439-446. [ DOI ] [ PubMed ] [ Google Scholar ] 30. Cavallo LM, Solari D, Somma T, Savic D, Cappabianca P. The awake endoscope-guided sealant technique with fibrin glue in the treatment of postoperative cerebrospinal fluid leak after extended transsphenoidal surgery: technical note. World Neurosurg. 2014;82:e479-e485. [ DOI ] [ PubMed ] [ Google Scholar ] 31. Pagliano P, Caggiano C, Ascione T, et al. Characteristics of meningitis following transsphenoidal endoscopic surgery: a case series and a systematic literature review. Infection. 2017;45(6):841-848. [ DOI ] [ PubMed ] [ Google Scholar ] 32. Bove I, Solari D, Bruneau M, et al. Endoscopic endonasal pituitary surgery: how we do it. Consensus statement on behalf of the EANS skull base section. Brain Spine. 2023;3:102687. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 33. Fasano M, Della Corte CM, Caterino M, et al. Dramatic therapeutic response to dabrafenib plus trametinib in BRAF V600E mutated papillary craniopharyngiomas: a case report and literature review. Front Med (Lausanne). 2021;8:652005. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 34. Dandurand C, Sepehry AA, Lari M, Akagami R, Gooderham P. Adult craniopharyngioma: case series, systematic review, and meta-analysis. Neurosurgery. 2018;83(4):631-641. [ DOI ] [ PubMed ] [ Google Scholar ] 35. Henderson F, Schwartz TH. Update on management of craniopharyngiomas. J Neurooncol. 2022;156(1):97-108. [ DOI ] [ PubMed ] [ Google Scholar ] 36. Clark AJ, Cage TA, Aranda D, et al. A systematic review of the results of surgery and radiotherapy on tumor control for pediatric craniopharyngioma. Childs Nerv Syst. 2013;29(2):231-238. [ DOI ] [ PubMed ] [ Google Scholar ] 37. Lin LL, Naqa IE, Leonard JR, et al. Long-term outcome in children treated for craniopharyngioma with and without radiotherapy. J Neurosurg Pediatr. 2008;1(2):126-130. [ DOI ] [ PubMed ] [ Google Scholar ] 38. Algattas H, Setty P, Goldschmidt E, et al. Endoscopic endonasal approach for craniopharyngiomas with intraventricular extension: case series, long-term outcomes, and review. World Neurosurg. 2020;144:e447-e459. [ DOI ] [ PubMed ] [ Google Scholar ] 39. Deopujari C, Behari S, Shroff K, et al. Intraventricular craniopharyngiomas-overcoming their relative inaccessibility: institutional experience with a review of literature. Front Neurol. 2021;12:755784. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 40. Chen CJ. Suprasellar and infrasellar craniopharyngioma with a persistent craniopharyngeal canal: case report and review of the literature. Neuroradiology. 2001;43(9):760-762. [ DOI ] [ PubMed ] [ Google Scholar ] 41. Behari S, Banerji D, Mishra A, et al. Intrinsic third ventricular craniopharyngiomas: report on six cases and a review of the literature. Surg Neurol. 2003;60(3):245-252; discussion 252-3. [ DOI ] [ PubMed ] [ Google Scholar ] 42. Maira G, Anile C, Albanese A, Cabezas D, Pardi F, Vignati A. The role of transsphenoidal surgery in the treatment of craniopharyngiomas. J Neurosurg. 2004;100(3):445-451. [ DOI ] [ PubMed ] [ Google Scholar ] 43. Steno J, Malácek M, Bízik I. Tumor-third ventricular relationships in supradiaphragmatic craniopharyngiomas: correlation of morphological, magnetic resonance imaging, and operative findings. Neurosurgery. 2004;54(5):1051-1058; discussion 1058-60. [ DOI ] [ PubMed ] [ Google Scholar ] 44. Pascual JM, González-Llanos F, Barrios L, Roda JM. Intraventricular craniopharyngiomas: topographical classification and surgical approach selection based on an extensive overview. Acta Neurochir (Wien). 2004;146(8):785-802. [ DOI ] [ PubMed ] [ Google Scholar ] 45. Madhavan M, P JG, Abdullah Jafri J, Idris Z. Intraventricular squamous papillary craniopharyngioma: report of a case with intraoperative imprint cytology. Acta Cytol. 2005;49(4):431-434. [ DOI ] [ PubMed ] [ Google Scholar ] 46. Misra V, Singla M, Chauhan S, Singh P, Agrawal R. Intraventricular adamantinomatous craniopharyngioma in a child. Neurol India. 2008;56(2):207-209. [ DOI ] [ PubMed ] [ Google Scholar ] 47. Tayari N, Etemadifar M, Hekmatnia A, Mahzouni P, Maghzi AH, Rouzbahani R. Intrinsic third ventricular craniopharyngioma: a case report. Int J Prev Med. 2011;2(3):178-185. [ PMC free article ] [ PubMed ] [ Google Scholar ] 48. Pan J, Qi S, Lu Y, et al. Intraventricular craniopharyngioma: morphological analysis and outcome evaluation of 17 cases. Acta Neurochir (Wien). 2011;153(4):773-784. [ DOI ] [ PubMed ] [ Google Scholar ] 49. Jung TY, Jung S, Jang WY, Moon KS, Kim IY, Kang SS. Operative outcomes and adjuvant treatment of purely third ventricle craniopharyngioma after a transcallosal approach. Br J Neurosurg. 2012;26(3):355-360. [ DOI ] [ PubMed ] [ Google Scholar ] 50. Yu T, Sun X, Ren X, Cui X, Wang J, Lin S. Intraventricular craniopharyngiomas: surgical management and outcome analyses in 24 cases. World Neurosurg. 2014;82(6):1209-1215. [ DOI ] [ PubMed ] [ Google Scholar ] 51. Gu Y, Zhang X, Hu F, et al. Suprachiasmatic translamina terminalis corridor used in endoscopic endonasal approach for resecting third ventricular craniopharyngioma. J Neurosurg. 2015;122(5):1166-1172. [ DOI ] [ PubMed ] [ Google Scholar ] 52. Nishioka H, Fukuhara N, Yamaguchi-Okada M, Yamada S. Endoscopic endonasal surgery for purely intrathird ventricle craniopharyngioma. World Neurosurg. 2016;91:266-271. [ DOI ] [ PubMed ] [ Google Scholar ] 53. Forbes JA, Ordóñez-Rubiano EG, Tomasiewicz HC, et al. Endonasal endoscopic transsphenoidal resection of intrinsic third ventricular craniopharyngioma: surgical results. J Neurosurg. 2019;131(4):1152-1162. [ DOI ] [ PubMed ] [ Google Scholar ] 54. Cai M, Ye Z, Ling C, Zhang B, Hou B. Trans-eyebrow supraorbital keyhole approach in suprasellar and third ventricular craniopharyngioma surgery: the experience of 27 cases and a literature review. J Neurooncol. 2019;141(2):363-371. [ DOI ] [ PubMed ] [ Google Scholar ] 55. Hung ND, Ngan VK, Duc NM. Intrinsic third ventricular papillary craniopharyngioma: a report of five cases and literature review. Int Med Case Rep J. 2021;14:83-87. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 56. Fan J, Liu Y, Wang C, et al. Reinvestigating tumor-ventricle relationship of craniopharyngiomas with predominantly ventricular involvement: an endoscopic endonasal series based on histopathological assessment. Front Oncol. 2021;11:740410. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 57. Cao L, Wu W, Kang J, et al. Expanded transsphenoidal trans-lamina terminalis approach to tumors extending into the third ventricle: technique notes and a single institute experience. Front Oncol. 2021;11:761281. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 58. Zoli M, Guaraldi F, Zenesini C, et al. Role of endoscopic endonasal approach for craniopharyngiomas extending into the third ventricle in adults. Brain Spine. 2022;2:100910. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 59. Cao L, Wu W, Kang J, et al. Feasibility of endoscopic endonasal resection of intrinsic third ventricular craniopharyngioma in adults. Neurosurg Rev. 2022;45(4):1-13. [ DOI ] [ PubMed ] [ Google Scholar ] 60. Zhou Y, Wei J, Jin T, et al. Extended endoscopic endonasal approach for resecting anterior intrinsic third ventricular craniopharyngioma. Front Oncol. 2022;12:998683. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 61. Koutourousiou M, Gardner PA, Fernandez-Miranda JC, Tyler-Kabara EC, Wang EW, Snyderman CH. Endoscopic endonasal surgery for craniopharyngiomas: surgical outcome in 64 patients. J Neurosurg. 2013;119(5):1194-1207. [ DOI ] [ PubMed ] [ Google Scholar ] 62. Omay SB, Almeida JP, Chen YN, et al. Is the chiasm-pituitary corridor size important for achieving gross-total resection during endonasal endoscopic resection of craniopharyngiomas? J Neurosurg. 2018;129(3):642-647. [ DOI ] [ PubMed ] [ Google Scholar ] 63. Cavallo LM, Prevedello DM, Solari D, et al. Extended endoscopic endonasal transsphenoidal approach for residual or recurrent craniopharyngiomas. J Neurosurg. 2009;111(3):578-589. [ DOI ] [ PubMed ] [ Google Scholar ] 64. Guo Y, Pei L, Li Y, et al. Characteristics and factors influencing hypothalamic pituitary dysfunction in patients with craniopharyngioma. Front Endocrinol (Lausanne). 2023;14:1180591. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 65. Jung UJ, Choi MS. Obesity and its metabolic complications: the role of adipokines and the relationship between obesity, inflammation, insulin resistance, dyslipidemia and nonalcoholic fatty liver disease. Int J Mol Sci. 2014;15(4):6184-6223. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 66. Lee M, Park MJ, Lee KH, Kim JH, Choi HJ, Kim YH. Obesity mechanism after hypothalamic damage: Cohort analysis of neuroimaging, psychological, cognitive, and clinical phenotyping data. Front Endocrinol (Lausanne). 2023;14:1114409. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 67. Müller HL, Merchant TE, Puget S, Martinez-Barbera JP. New outlook on the diagnosis, treatment and follow-up of childhood-onset craniopharyngioma. Nat Rev Endocrinol. 2017;13(5):299-312. [ DOI ] [ PubMed ] [ Google Scholar ] 68. Hadad G, Bassagasteguy L, Carrau RL, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope. 2006;116(10):1882-1886. [ DOI ] [ PubMed ] [ Google Scholar ] Articles from Operative Neurosurgery are provided here courtesy of Wolters Kluwer Health ACTIONS View on publisher site PDF (773.3 KB) Cite Collections Permalink PERMALINK Copy RESOURCES Similar articles Cited by other articles Links to NCBI Databases Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM Add to Collections Create a new collection Add to an existing collection Name your collection * Choose a collection Unable to load your collection due to an error Please try again Add Cancel Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top