Surgical approach to craniopharyngiomas: Transcranial routes

The optimal treatment of patients with craniopharyngioma remains controversial because an effective balanced protocol between aggressive therapy and reducing adverse sequelae is still lacking. Radical resection is considered the therapy of choice for primary treatment, being associated with the best outcome in terms of survival and recurrence-free survival. Transcranial surgery is performed in case of purely suprasellar or large intrasuprasellar dumbbell-shaped tumors, with extension toward the third ventricle and hypothalamus, subfrontal, retrochiasmatic, and retro-sellar regions. Transcranial approaches comprise the frontopterional, the fronto-orbitozygomatic (FOZ), and the combined interhemispheric subcommissural translaminaterminalis approach (CISTA). The most relevant anatomic elements infl uencing the extent of resection and potential effectiveness of surgery, as well as the risk of surgical morbidity in craniopharyngioma surgery are tumor relationships with the third ventricle and hypothalamus, arachnoid plane and pia mater layer, optic pathways, pituitary stalk and vascular structures. We discuss and comparatively analyze the role of FOZ, and CISTA in terms of indication, peculiar features and technique in the surgical treatment of craniopharyngiomas.