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The patient came to the clinic 30-November-2006 complaining
of headache for 1 year with progressing course. weight gain,
dyspnea, thirst, polyurea for 6 months and visual disturbances for
the last 3 months. Amenorrhea for 4 months. MRI performed
15-November-2006 in Libya, showing suprasellar mass.
On examination; The patient had signs of panhypopituitarism with
hypothyroidism. Visual fields were full of scatomas and decreased
vision both eyes more in the left. She had slight weak right
upper and lower limbs with Hoffmann positive in the right side and
Babinski positive both sides. She had pretibial edema both lower
limbs.
The patient was started in minirin nasal spray and L-thyroxin 50
microgram a day, predinoisolone 5 mg 2 tab three times a day. Cardio
consultation was negative.
The patient was sent for more detailed investigations and MRI of
the sella showed the above diagnosed craniopharyngioma.
Combined bifrontal with left pterional approach was created and
the left olfactory tract was tiny at the retrobulbar part and it was
impossible to mobilize it. The right one was preserved. Most of the
tumor was resected lateral to the left optic nerve and tract. The
cavity was cleaned properly and the solid part was removed from the
basilar artery, left ICA, chiasm and tract. It was possible to see
the pushed behind the left oculomotor nerve. The chiasm remained
pushed by the underlying mass, for what, starting from under the
right optic nerve the solid partially soft, partially calcified
tumor mass was remove. Working under the chiasm. every attempt was
directed to preserve the pituitary stalk, which was pushed to the
left and posteriorly under the left optic nerve. Inspection for
remnants behind the chiasm confirmed absence of remnants. All the
neural structures were hanging free after the tumor removal
completion and meticulous heamostasis was achieved. Ommaya reservoir
was inserted lateral to the left optic tract and directed laterally
parallel to the sylvian cistern and after closure the
reservoir was put under the skin.
Uneventful postoperative recovery and the patient kept in minirin
and decadron.
Comments:
1. Craniopharyngiomas are different in origin and in this case
it was from the pituitary stalk. In contrast, the
previously operated case was
originating from the tuber cenirium.
2. Almost radical removal of the tumor is the best choice. For more
details
click here! Radiotherapy is preferred to prevent tumor
recurrence and insertion of Ommaya reservoir during the first
surgery, can help to avoid future surgeries in case of recurrence
with cystic formation.
3. During the 27 years of performing more than 800 operations with
subfrontal approach, an hypoplastic olfactory tract was noted and it
was impossible to mobilize it, but the contralateral right one was
anatomically preserved.
4. There is a relationship between the prominence of the frontal
sinuses and the thickness and deepness of the crista Gallii. When
the frontal sinus is hypoplastic, the crista Gallii also do so. This
important, because during performance of subfrontal approach,
surgeon must know how to create the bone flap with minimal burr
holes. In this case, it was necessary to perform midline burr hole
using high-speed drill above the nasion and violate the frontal
sinuses to achieve an approach flush with anterior fossa to minimize
traction injury. For more details about this topic,
click here! |
