Transpterional approach for craniopharyngioma resection

In recent years, due to the improvement of microsurgical techniques, the application of pterional approach in intracranial tumors and aneurysm surgery has become increasingly widespread. For craniopharyngioma resection, a slight change in this approach can fully reveal the anterior and posterior chiasm, the optic nerve-carotid artery space and the internal carotid artery lateral space, and even the cerebellar margin and internal carotid artery bifurcation. The structure near the department, so its indications are wider. It has been used (Yasargil, 1990) as the primary surgical approach for the removal of various craniopharyngioma. Treatment of diseases: craniopharyngioma Indication Transsphenoidal approach for craniopharyngioma resection is applicable to: 1. A craniopharyngioma that extends to the saddle-saddle-type, saddle-upper-brain-type anterior and posterior chiasm. 2. A side of the ventricle and a craniopharyngioma that extends to the back of the saddle. Preoperative preparation Surgery is usually performed under general anesthesia. In the supine position, the upper body is slightly raised by 15° to 30°, and the specific head position is often slightly different with the transcranial approach. The pterional approach is 60° to 90° to the opposite side. The head is about 15° lower to facilitate lifting the frontal lobe and exposing the saddle. Surgical procedure Scalp incision and bone flap The scalp incision is mostly in the hairline. The bone flap is as close as possible to the base of the anterior and middle fossa so as to lift the frontal and temporal lobes. The lateral side of the sphenoid bone is removed as much as possible Sometimes the location of the incision and bone flap may vary slightly depending on the location and size of the tumor. If the tumor expands to the midline, before or after the optic chiasm, the tumor is larger, invading the bottom of the third ventricle, or extending to the lateral side of the optic nerve, a coronary scalp incision can be used, and the bone flap is moved inward and upward to the sagittal sinus margin. That is, the forehead-wing point joint approach. The tumor expands outward, reaching the ipsilateral saddle, or the ventricle-type craniopharyngioma and the posterior saddle extension. The incision can move outward and backward, and if necessary, expose the posterior margin of the temporal lobe and the cerebellum. 2. Tumor exposure After the dura mater is opened, the frontal lobes should be opened close to the frontal lobes, the cerebrospinal fluid should be released, and the frontal and/or temporal lobes should be pulled out to show the ipsilateral optic nerve and internal carotid artery. If the tumor is paraventricular or the tumor expands to the posterior saddle, the lateral fissure should be separated at a higher position, and the root of the lateral fissure should be opened to fully expose the internal carotid bifurcation, middle cerebral artery and anterior cerebral artery. Proximal, open anterior interstitial space, optic nerve-carotid artery space and lateral carotid artery space, revealing the anterior and middle cerebral arteries, posterior communicating artery, choroidal artery, oculomotor nerve and tumor extending to the saddle. If the tumor is located in the front of the midbrain in the saddle, the Lilie-quist membrane should be cut into the inter-foot pool. If necessary, the free edge of the cerebellum can be cut open, and the anterior and posterior pools of the cerebral ventricle can be opened to show the tumor extending to the saddle. Body and basilar artery bifurcation, posterior cerebral artery, superior cerebellar artery, cerebral peduncle, and pons. 3. Tumor resection It is basically the same as the anterior subfrontal anterior approach for craniopharyngioma resection, but because the approach can fully reveal the tumor and surrounding structures, the tumor can be removed more completely and the total resection can be achieved. However, it is necessary to pay attention to the protection of the surrounding structure, using sharp separation, the tumor block should not be too large each time, the wall of the giant craniopharyngioma should be removed by block. When the tumor of each gap is removed, the direction of the surgical microscope should be adjusted to make it clear, and it should not be bluntly separated or blindly pulled. For tumors extending to the side of the saddle, the direction of the surgical microscope should be reversed after removal of the tumor block in front of the optic chiasm, and the enlarged optic nerve-internal carotid artery space or the lateral carotid artery lateral space should be removed. At this time, attention should be paid to the protection of the posterior communicating artery, the thalamic penetrating artery, and the choroidal artery, so as not to cause damage. The ocular eye often traverses the surface of the tumor in the lateral space of the internal carotid artery, and the tumor should be removed separately in the space above or below it. The oculomotor nerve is very fragile and can be damaged by a little pulling, so the operation is particularly gentle. The tumor mass extending to the inter-foot pool and the anterior chamber of the pons is often adhered to the basilar artery, the posterior cerebral artery, the superior cerebellar artery, and the pons, and the cells are separated and the segments are removed. For cystic intraventricular and ventricular paracranous tumors with posterior chiasm (frontal optic chiasm), if the approach is used, the lateral fissure pool and carotid artery pool should be opened, showing anterior optic chiasm and anterior cerebral ventricle. Arterial segment 1, anterior communicating artery and dilated endplate. Because the tumor is pressed forward, the endplate is often thinned, bulging forward, and the color becomes black. A cystic tumor can be seen by cutting the endplate and a very thin third ventricular wall. The cystic cavity is punctured, the sac fluid is withdrawn, and the tumor wall is separated and completely removed. 4. Guan skull. complication 1. Visual impairment. 2. Diabetes insipidus. 3. Pituitary dysfunction. 4. Symptoms of hypothalamic damage.