Resection of craniopharyngioma via transcorpus callosum or frontal cortex-lateral ventricle approach

Treatment of diseases: craniopharyngioma Indication Transcranial or frontal cortex-lateral ventricle approach for craniopharyngioma resection is applicable to: 1. Simple intracranial craniopharyngioma, whose tumor originated in the third ventricle is extremely rare, and the tumor should be removed by transventricular approach. Generally, the lateral ventricle is not enlarged, and the transsacral approach is adopted; if the tumor blocks the interventricular space, the lateral ventricle is enlarged, and the frontal cortex-lateral ventricle approach can also be used. 2. A very small number of craniopharyngioma originating from the saddle upper pool breaks through the bottom of the third ventricle or the endplate, enters the third ventricle, and sometimes enters the lateral ventricle, forming a large intraventricular tumor mass. More common in older children or adults, and more substantial tumor mass than cystic, although this tumor can be operated through the subfrontal approach, but for the large intraventricular tumor mass, the transventricular approach is required. The third intracranial craniopharyngioma is similar to a colloidal cyst, but the colloidal cyst has a thin wall with a liquid content that can be removed by an aspirator or an ultrasound suction device. The capsule wall has no blood vessels and no wall of the third ventricle. Adhesive, only connected at the bottom of the cerebral plexus adjacent to the third ventricle, can be electrocautery cut, so the gelatinous cyst can be operated through the enlarged interventricular hole without cutting off the sacral or choroidal fissure. The adhesion of the craniopharyngioma to the hypothalamic wall and the internal cerebral vein is one of the most difficult operations in this area. For example, the injury caused by this area can cause coma, urine collapse and salt-wasting syndrome. , gastrointestinal bleeding and so on. Because the tumor is mostly substantial in this area, it is extremely difficult to remove before CUSA and laser surgery, and with the advancement of surgical techniques, it has created better conditions for its treatment. 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 1. Scalp incision, bone flap formation, dural incision, access to the lateral ventricle and the third ventricle anterior tumor resection. 2. The tumor is exposed to the lateral ventricle through the corpus callosum or the frontal cortex, and the interventricular space is advanced along the choroid plexus and the mound vein. The third intraventricular purple-brown mass is seen. Sometimes the tumor protrudes into the lateral ventricle through the interventricular pore. It can be cystic or has a calcified solid tumor mass. 3. Tumor resection After the tumor is revealed through the interventricular space, it is noted that the hypothalamic vein below it is penetrated into the interventricular space and connected to the internal cerebral vein, which is covered with the choroid plexus of the lateral ventricle. If the tumor is small, the interventricular pores are not enlarged, and one side of the Qianlong column can be cut in front of it; if the tumor is large, the transchoroidal fissure approach can also be used. If the tumor is soft, it can be pushed by the aspirator. After the cyst is removed, the capsule wall collapses and the block is removed. CUSA is the ideal tumor resection tool. It does not require a large exposure space. The CO2 laser can also be used to remove the solid tumor mass until the thin wall of the tumor is separated from the wall of the ventricle. The wall of the tumor moves inward, separating the interface with the third ventricle, and padding between the tumor and the ventricle wall with a small cotton pad, so that the tumor moves toward the center and the ventricular wall is not injured by the surgical instrument. Thus, for small cystic craniopharyngioma and not much adhesion to the ventricular wall, complete resection can be achieved. Giant third intracranial craniopharyngioma often invades and extracranial structures, such as optic nerve, optic chiasm, internal carotid artery, etc., and the tumor base often adheres to the surrounding structure. When the tumor is removed from the ventricle, it is necessary to combine the preoperative CT and MRI imaging data with the intraoperative findings. Pay special attention to the tumor supply vessels in the front of the Willis arterial ring, and sometimes the branches of the basilar artery system. The tumor itself has no blood vessels, and there is not much bleeding during resection, but it is difficult to separate from the above blood vessels. If the tumor is large and substantial, the surrounding adhesion is tight, it is difficult to completely remove it. It is feasible to partially remove the cyst and the wall of the capsule, open the interventricular space, so that the hydrocephalus can be improved, or the Ommaya reservoir can be built into the tumor cavity. In the future, when the tumor recurs, the cystic fluid is aspirated through the puncture, and the drug or the radionuclide can also be injected through the tumor. After the tumor is resected, attention should be paid to the circulation of cerebrospinal fluid. If the opening of the interventricular hole is not satisfactory, the transparent septum can be opened, or the ventricle-cerebellar medullary cistern or ventricle-peritoneal shunt can be performed to relieve the obstructive hydrocephalus. For the expansion of the craniopharyngioma in the middle and posterior part of the third ventricle, resection can be performed through the choroidal fissure approach of the lateral ventricle. complication 1. Visual impairment. 2. Diabetes insipidus. 3. Pituitary dysfunction. 4. Symptoms of hypothalamic damage.