Microsurgical resection of a pure third ventricular craniopharyngioma through an interhemispheric transcallosal transforaminal approach

Abstract

Background:

Craniopharyngiomas account for approximately 2–4% of all intracranial tumors and demonstrate a bimodal age distribution, typically affecting children aged 5–9 years and adults aged 55–69 years. Third ventricular craniopharyngiomas are rare, benign epithelial tumors that may arise primarily within the third ventricle or secondarily extend from the suprasellar region; the purely intraventricular subtype is particularly rare, with a reported incidence ranging from 0.5% to 14% of all cases. Despite benign histology, infiltration of adjacent neural tissue imparts clinically aggressive behavior and complicates complete resection. Their deep location near the hypothalamus, optic apparatus, and fornices poses major surgical challenges, and transcallosal approaches risk cognitive or memory deficit. A purely third ventricular craniopharyngioma, classified as Type D by Yaşargil and Type IV by Kassam, is confined to the third ventricle and is not accessible through an endonasal approach, making transcranial routes more suitable given the tumor’s deep location and proximity to critical neurovascular structures, although select cases of successful endonasal resection have been reported.

Case Description:

We present a 34-year-old woman with galactorrhea and progressive weight gain over 6 months, together with intermittent diplopia and headaches. Magnetic resonance imaging demonstrated a homogeneously contrast-enhancing mass occupying the third ventricle, measuring 3.0 × 2.9 × 2.3 cm, with preservation of the pituitary stalk and third ventricular floor, causing moderate obstructive hydrocephalus. An interhemispheric transcallosal transforaminal approach was performed, with the dural opening adjusted according to the drainage pattern of the bridging veins, a 1.5 cm callosotomy, and septal fenestration. Gross total resection was achieved with preservation of the pituitary stalk, and a third ventriculostomy was performed to allow cerebrospinal fluid flow. Postoperative magnetic resonance imaging confirmed complete resection, and histopathological examination confirmed a World Health Organization Grade I papillary craniopharyngioma. Surveillance imaging at 27 months confirmed tumor recurrence, and the patient was referred for radiation therapy, after which no further recurrence was observed. Follow-up imaging at 48 months demonstrated continued absence of disease.

Conclusion:

Although there are reports of purely intraventricular craniopharyngiomas resected through the endonasal route, traditional transcranial approaches remain the standard for tumors located entirely within the third ventricle. Although this case was treated before routine molecular testing and targeted therapy became standard, modern management now requires a multidisciplinary strategy integrating microsurgery, radiotherapy, and targeted therapy with BRAF (B-Raf proto-oncogene, serine/threonine kinase) and MEK (mitogen-activated protein kinase kinase) inhibitors when appropriate.

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Video Annotations[1-10]

00:08 – 00:30: Background information

00:31 – 01:14: Clinical history and preoperative magnetic resonance imaging

01:15 – 02:52: Management

02:53 – 03:41: Patient positioning and skin incision

03:42 – 05:11: Interhemispheric dissection and callosotomy

05:12 – 08:12: Transforaminal access and tumor resection

08:13 – 08:17: Hemostasis

08:18 – 08:38: Postoperative imaging

08:39 – 09:31: Postoperative course

09:32 – 09:52: Conclusion

Ethical approval:

The Institutional Review Board approval is not required.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understands that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Video available on:

https://doi.org/10.25259/SNI_896_2026

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