Name:
10.3171/2026.7.FOCVID26115
Description:
10.3171/2026.7.FOCVID26115
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/15bbd70d-ecfa-4857-aeb8-17695727f652/videoscrubberimages/Scrubber_221.jpg
Duration:
T00H08M46S
Embed URL:
https://stream.cadmore.media/player/15bbd70d-ecfa-4857-aeb8-17695727f652
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/15bbd70d-ecfa-4857-aeb8-17695727f652/8. 26-115.mp4?sv=2019-02-02&sr=c&sig=HBHw3yaFYt6gKLEfYmJoZ9eZV8HMIs7iQGj7Xd%2BWpYE%3D&st=2026-11-05T07%3A54%3A32Z&se=2026-11-05T09%3A59%3A32Z&sp=r
Upload Date:
2026-11-05T08:41:10.3552772Z
Transcript:
Language: EN.
Segment:0 .
[AUDIO LOGO]
SPEAKER: This video will demonstrate the inside-out technique in the resection of craniopharyngiomas. The case refers to a 57-year-old man who presented with confusion, drowsiness, and imbalance, resulting in a fall. He had unrelenting headaches with the past several months, had not seen physicians. He did have an alcohol use disorder as well as he smoked heavily. He was drowsy but arousable. He was oriented, but had difficulty with higher-order executive functions and memory.
SPEAKER: He did have subjective blurred vision, but his visual fields were normal to confrontation. He was intact otherwise. Imaging disclosed a suprasellar contrast-enhancing lesion, causing obstructive hydrocephalus with significant extension up to the third ventricle. And he did have internal calcifications, which was suggestive of an adamantinomatous craniopharyngioma.
SPEAKER: An external ventricular drain was placed. Because of the obstructive hydrocephalus, surgical resection was recommended. Whenever considering resection for craniopharyngiomas, a heavily T2-weighted image is obtained to evaluate the suprasellar window. You see here the optic nerve in red and the suprasellar window in the yellow arrows. When considering approach selection, anterolateral and posterolateral approaches, we believe have a poor visualization of the ipsilateral interface with the hypothalamus.
SPEAKER: The interhemispheric transcallosal transventricular approach is a little limited, because it's tethered by the callosotomy, providing limited versatility, and similarly the interhemispheric translamina terminalis has a blind aspect right behind the chiasm. An endoscopic endonasal approach aligns perfectly with the long axis of the lesion and provides visualization of both interfaces with the hypothalamus.
SPEAKER: The patient was positioned supine and was placed in three-point fixation. We did use stereotactic navigation. We had a Doppler available and diamond burrs. The key surgical steps of the procedure consisted of a nasal step, where we raised the nasoseptal flap and contralateral reverse flap; the bony exposure exposing the tuberculum planum, followed by the inside-out technique, which we will analyze, and of course, a multilayer reconstruction.
SPEAKER: It is notable that craniopharyngiomas are intra-axial lesions that displace the pia in its microvasculature centrifugally. This is in contrast to suprasellar lesions that are extra-axial, such as meningiomas, which displace the microvasculature posteriorly. So the microvasculature of hypothalamus runs in the pia. Classic craniopharyngioma surgery with subarachnoid dissection.
SPEAKER: Subsequently, this cannot be extrapolated up towards the third ventricle, and rather a sharp dissection of the pia has to ensue at the level of the hypothalamus, which potentially disrupts the microvasculature. In contrast, we believe an epidural dissection plane or a subpial dissection plane facilitates extrapolation of this plane of dissection into a third ventricle preserves the microvasculature that you see here in red.
SPEAKER: We believe that the correct dissection plane for this craniopharyngiomas is epitumoral and subpial but not subarachnoid. So this inside-out technique consists of finding where the tumor comes closer to the surface and establishing an entry into the tumor, and start dissecting the tumor from the inside out, debulking the tumor internally, and starting dissecting the tumor in a subcapsular fashion just above the tumor, resulting at the end with the pia staying intact.
SPEAKER: So the tumor dissection is not subarachnoid, but epitumoral or subpial. This is a demonstration of the procedure. We start with wide sphenoidotomy, already raised, a right-sided nasoseptal flap and performed a reverse flap. This is performed in conjunction with ENT and neurosurgery with dynamic endoscopy. We perform a wide exposure, exposing widely the sella and removing the middle clinoids as well as the medial opticocarotid recesses.
SPEAKER: We proceed to expose the tuberculum and some of the planum. We also expose the floor of the sella, and this facilitates downward displacement of the diaphragma, which increases our suprasellar space and working window. The exposure of planum is not absolutely necessary, but for tall tumors it does facilitate superior displacement of the instruments, but certainly no dural openings necessary in the planum.
SPEAKER: We open above and below the superior intercavernous sinus, which was coagulated, divided, followed by exposure of the suprasellar space in the prechiasmatic recess. And you see here the microvasculature that's running in the pia. We do not perform very extensive subarachnoid dissection, but rather open into the tumor and start internally debulking it to create space.
SPEAKER: The next step is start to create this epidermal dissection plane. You see here we're not dissecting the tumor in the subarachnoid space, but rather create a space within the tumor after internal debulking and intracapsular dissection. So we're staying right above the tumor and start developing this dissection plane right above the tumor.
SPEAKER: We're not in the subarachnoid space. We're in the subpial space. This is a back-and-forth between internal debulking and intracapsular dissection. You see how nicely the pia stays with its microvasculature and is not disrupted. At no point here, we're cutting sharply at the interface with the hypothalamus, but rather we're starting to trying to stay right under the tumor.
SPEAKER: Again, back-and-forth internal debulking. And usually the attachment of the tumors, the craniopharyngiomas are the tuber cinereum or the stalk. So when this is dissected the tumor can be nicely delivered. You see here that we did not disrupt the microvasculature of the hypothalamus. And the surrounding pia with its microvasculature remains intact. Reconstruction, of course, is very important.
SPEAKER: We place a dural substitute followed by our nasal septal flap, which is nicely enhancing with ICG angiography. Place some Surgicel and packing. We already have CSF diversion with any external ventricular drain in this case. So the patient's EVD was weaned. Unfortunately he did have pulmonary embolism, require anticoagulation, but remain neurologically intact.
SPEAKER: His mental status improved and was discharged to rehabilitation. He required both DDAVP and hydrocortisone replacement. Of note, the preservation of the stalk with this inside-out technique does not necessarily always aim at preservation function, but rather it aims at preserving the correct dissection plane and extrapolating up towards the third ventricle, a more complete resection and preservation of the correct planes.
SPEAKER: Here's his immediate postoperative scan, showing no immediate complications and a complete resection. And here the view of the 9-month MRI, at which point the patient was completely neurologically intact with no residual recurrence. So in conclusion, craniopharyngiomas are intra-axial tumors. In our opinion, the correct plane of dissection is epitumoral, subpial, and not subarachnoid.
SPEAKER: Microvascular injury can lead to morbidity and hypothalamic injury and visual disturbances. And this inside-out technique can potentially decrease microvascular injury and facilitate the correct plane of dissection with the hypothalamus and third ventricle. Thank you very much.
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