Orbitozygomatic Transsylvian Resection of a Craniopharyngioma: A Step-by-Step Guide

Adamantinomatous craniopharyngioma (ACP) is a rare sellar region tumor seen in 0.5-2 cases per million persons each year,¹ presenting a bimodal distribution that peaks at 5-15 years in children and 45-60 years in adults.² Arising from embryonic remnants of the Rathke pouch epithelium, ACPs are associated with calcifications in 90% of cases and grow cranially toward the floor of the diencephalon.¹ Craniopharyngiomas are benign but locally aggressive tumors, with microsurgery being the best chance of cure.³ The natural history is to compress the optic apparatus and hypothalamic-pituitary axis as they expand, with a propensity to encase the carotids. Endoscopic transbasal approaches have gained wide acceptance in the management of these tumors.^4-6 However, open microsurgical approaches via pterional and orbitozygomatic craniotomies afford wider visualization of different corridors that help mitigate the surgical risks.^7-9 The orbitozygomatic craniotomy allows lesions that extend above the optic chiasm to be safely approached from an inferior-to-superior corridor.⁹ The wide exposure of the basal arachnoid cisterns allows protection of the lenticulostriate perforators during resection.^8-11 We demonstrate a step-by-step orbitozygomatic approach with dissection of the sylvian, carotid, carotid-oculomotor, chiasmatic, and lamina terminalis cisterns that allowed safe resection of a third ventricular ACP. The patient was a male in his 70s, who presented with progressive headaches and visual impairment. Magnetic resonance imaging showed a multicystic suprasellar lesion extending through the third ventricle. The surgery was performed with no complication (Video 1). Postoperative vision stabilized, and magnetic resonance imaging showed complete resection.