Endoscopic Endonasal Approach for Resection of a Recurrent Craniopharyngioma: Techniques to Maximize Surgical Exposure and Extent of Resection

Craniopharyngiomas are challenging tumors of the central nervous system that originate from epithelial remnants of Rathke's Pouch. Despite maximum safe resection, these tumors present a high tendency to recur (∼20-40%), even after apparent gross-total resection. The management of recurrent craniopharyngiomas is more challenging, associated with a higher risk of permanent morbidity and complications. The endoscopic endonasal approach (EEA) is an option for recurrent tumors, especially in the presence of a previous transcranial approach. In this video, we present a case of a 63-year-old man with a recurrent craniopharyngioma with a 2-month history of visual decline, confusion, impaired memory, and episodes of urinary incontinence. On physical exam, he presented slow speech, word-finding difficulties and left homonymous hemianopsia. Magnetic resonance imaging evidenced a large suprasellar, retrochiasmatic mass with solid (calcified) and cystic components with interval progression compared to previous scans. Treatment options were discussed, and the patient consented to undergo maximum safe resection through an extended endoscopic endonasal approach. Surgical techniques are presented side-by-side with anatomical dissections to illustrate key-steps of the procedure. The patient tolerated the procedure well, with gross-total resection of the tumor and without complications or postoperative CSF leaks. He was subsequently discharged home on postoperative day 5 with continued hormonal replacement therapy. On follow-up, the patient presented marked improvement in his cognitive function. The patient gave informed consent for the use of their images.