Early postoperative complication profile and acute hypothalamic dysfunction grading after surgery for adult...

Intraventricular craniopharyngiomas in adults are rare lesions, and their surgical treatment is associated with a risk of hypothalamic, cognitive, and seizure-related morbidity. Early postoperative complications in this subgroup remain insufficiently characterized.

To characterize the frequency and pattern of early postoperative complications in adults with intraventricular craniopharyngiomas, with particular focus on early postoperative MMSE change, new-onset seizures, and the severity of acute diencephalic syndrome (DS) according to an original four-stage grading scale.

We retrospectively analyzed 62 adult patients older than 45 years who underwent microsurgical treatment via either a transcallosal approach (n = 30) or a transcortical transventricular approach (n = 32) between 2015 and 2025. Early postoperative outcomes included MMSE change, new-onset seizures within 30 days, and DS severity. DS was graded using a four-stage scale incorporating level of consciousness, thermoregulation, water-electrolyte and endocrine disturbances, autonomic-hemodynamic instability, and respiratory dysfunction. Comparisons between surgical approaches were considered exploratory because approach selection was non-randomized.

In the overall cohort, the mean MMSE score decreased from 27.4 ± 2.1 preoperatively to 24.8 ± 3.5 in the early postoperative period (p < 0.05). Early postoperative MMSE decline ≥ 3 points was observed in 17 patients (27%). This decline was numerically more frequent after the transcallosal approach than after the transcortical approach (33% vs. 22%), but the difference was not statistically significant (p = 0.29). New-onset postoperative seizures occurred in 9 patients (15%) and were numerically more frequent after the transcortical approach (22% vs. 7%, p = 0.09), particularly in patients with large tumors. Acute DS of varying severity developed in 47 patients (76%). Severe-to-critical DS, defined as stages III-IV, occurred in 5 patients (8%) and was associated with destruction of the third ventricular floor (p = 0.02). No severe-to-critical DS was observed when the third ventricular floor was preserved, whereas after gross-total resection with floor destruction, severe-to-critical DS occurred in 4 of 13 patients (31%), including two fatal stage IV cases.

Early postoperative morbidity after surgery for adult intraventricular craniopharyngiomas includes screening-based MMSE decline, new-onset seizures, and acute diencephalic dysfunction. Approach-related differences in MMSE decline and seizure incidence were numerical and should be interpreted cautiously because of baseline differences between groups. Severe-to-critical DS was closely related to destruction of the third ventricular floor and was most frequent after gross-total resection in this anatomical subgroup. The proposed four-stage DS grading scale may provide a practical framework for early monitoring and risk stratification, but it should be regarded as an exploratory clinical tool requiring prospective validation.