subfrontal craniopharyngioma resection

Treatment of diseases: craniopharyngioma Indication Transurethral resection of craniopharyngioma is applicable to: 1. Located in front of the optic chiasm (post-type optic chiasm) on the saddle septum - anterior chiasm - extracranial craniopharyngioma. 2. The saddle-saddle-segmented craniopharyngioma located in front of the optic chiasm is not suitable for transsphenoidal approach (eg, the tumor does not reach the saddle floor, the pituitary is below the tumor or the tumor is substantial, calcified component More people). Contraindications 1. This approach has been widely used in the past for the removal of craniopharyngioma, so there is no absolute contraindication. However, because the unilateral inferior approach can only expose the anterior and posterior optic nerve-carotid artery gaps, it is difficult to perform total resection for those with large craniopharyngioma and large tumors that expand to the outside. . 2. For the posterior aspect of the optic chiasm (frontal optic chiasm), the saddle-intra-brain type, and the craniopharyngioma located in the third ventricle, the tumor can not be found through this approach, and it needs to be separated further to the rear. The end-of-line approach can be found after the intersection. Preoperative preparation 1. There must be a correct positioning diagnosis before surgery. The relationship between the location of the lesion and the surrounding structure should be analyzed before surgery in order to select the appropriate surgical approach, to obtain the best exposure, avoid the important structure of the skull as much as possible, increase the safety of the operation and strive for good Effect. 2. Skin preparation, wash the head with soap and water 1 day before the operation, shave the hair on the morning of the operation. You can also shave your head on the eve of surgery. 3. Fasting the morning of surgery. It can be enema in the evening before surgery, but when the intracranial pressure is increased, the enema should be removed to avoid sudden deterioration of the condition. 4. Give phenobarbital 0.1g orally before surgery to ensure a quiet rest. One hour before the operation, 0.1 g of phenobarbital, 0.4 mg of atropine or 0.3 mg of scopolamine were intramuscularly injected. Surgical procedure Craniotomy Do a right forehead craniotomy (if the surgeon is used to the left hand, you can also do the left side). Some neurosurgeons tend to choose to perform surgery on the heavier side or on the side of the tumor that is more pronounced to the side of the saddle. Scalp incision: The scalp incision varies according to individual habits, but the Frazier incision is used more. In recent years, due to the purpose of beauty, more authors advocate the use of a coronal incision in the hairline to avoid leaving scars on the face. Open the bone flap and cut the dura mater: the bone flap of the forehead should be as low as possible, straight to the leading edge of the anterior cranial fossa, but the bone flap should be designed according to the frontal sinus size shown by the X-ray, try to avoid the sawing amount. Sinus, if the frontal sinus is accidentally sawn, it should be properly handled as usual. The dural incision is parallel to the upper edge of the iliac crest, and the inner and outer ends are cut forward and rearward to form two auxiliary incisions to form an "H" shape. The dura mater in front of the incision is sutured on the periosteum. 2. Reveal the tumor The surgical exposure of craniopharyngioma should be more extensive than that of pituitary tumors. After the frontal lobe is lifted into the saddle area with an automatic brain retractor, the optic chiasm and the internal carotid artery pool are opened under the operating microscope, showing ipsilateral or bilateral The upper part of the saddle of the optic nerve, the optic chiasm, and the anterior craniopharyngioma. Sometimes in order to fully reveal, it is best to open the root of the lateral fissure to reveal the proximal carotid bifurcation, the middle cerebral artery and the proximal anterior cerebral artery. If it is a craniopharyngioma that develops to the outside, the optic nerve-carotid artery space should be opened. However, due to the limitations of the approach itself, it is difficult to expose it to the outside more widely. 3. Tumor resection Before starting to remove the tumor, the arachnoid membrane of the optic chiasm, optic nerve pool and internal carotid artery pool should be separated first, and the space of the subarachnoid space should be preserved to facilitate the visualization of the tumor boundary. Then, the cystic part of the tumor is punctured, the cystic fluid is aspirated, and the solid tumor mass in the capsule is removed by an ultrasonic aspirator or a tumor-clamping force to reduce the tumor volume, thereby achieving sufficient intra-tumor decompression and optic nerve decompression. The wall of the capsule is often closely adhered to the surrounding nerves and blood vessels. Bluntly separating the wall of the capsule or excessively pulling it often causes peripheral nerve damage or arterial rupture, causing bleeding. Therefore, it is best to use microscopically after carefully identifying the surrounding boundary of the tumor. Scissors or sickle knives are sharply separated. Calcified tumors often adhere to the internal carotid artery, anterior cerebral artery and other blood vessels, and should be taken care of when removing. Do not remove too many tumors at a time, and pay attention to protecting the small blood vessels that supply the optic nerve, optic chiasm and optic tract. The wall of a large craniopharyngioma should be removed in blocks. After the tumor is separated from the optic nerve, optic chiasm, and optic tract, the superior and hypothalamus of the tumor are separated back and forth. There is often a thin layer of glial reaction layer between the two, with clear boundaries and easier separation. The pituitary stalk is mostly located on the posterolateral side of the tumor and should be carefully identified to maintain its integrity. For tumors that develop to the saddle, the tumor in front of the optic chiasm should be removed and fully decompressed. The direction of the surgical microscope should be adjusted. The enlarged optic nerve-carotid artery space is separated and excised outside the optic nerve. A tumor mass below the internal carotid artery. However, because the approach does not reveal the gap outside the internal carotid artery, the posterior communicating artery, choroidal artery and oculomotor nerve are not well exposed, so the total resection of the tumor outside the gap is limited. complication 1. Visual impairment. 2. Diabetes insipidus. 3. Pituitary dysfunction. 4. Symptoms of hypothalamic damage.