Craniopharyngiomas are more common in children and adolescents, and less common in older patients. Because of the deep site of craniopharyngioma, it is difficult to perform total resection, and the risk of craniotomy is greater in elderly patients, or they cannot tolerate craniotomy. We used neuroendoscopic transnasal butterfly surgery to treat 8 cases of craniopharyngioma in the elderly and achieved satisfactory results. Subjects and methods 1. General data From December 2007 to September 2010, our center treated 8 cases of elderly craniopharyngioma patients, including 5 males and 3 females; age ranged from 60 to 78 years old, average 66.8 years old, including 6 cases under 70 years old and 2 cases over 70 years old. The duration of the disease ranged from 1 month to 3 years, with an average of 13 months. 2. Clinical manifestations All 8 cases had decreased visual acuity, with 6 cases of preoptic index and 2 cases of light perception; 8 cases had visual field defects; 5 cases had headache and dizziness; 3 cases had excessive drinking and urination; 2 cases had mental depression; and 1 case had physical activity disorder. The main body of the lesion was located in the supra-saddle of the saddle in 3 cases, the supra-saddle in 2 cases, and the intra-saddle in 3 cases. The cystic part of the lesion was mainly cystic (complete cystic and small solid large cystic type) in 5 cases, and the solid tumor was mainly solid (large solid small cystic type) in 3 cases. Among the 8 cases, 2 cases had undergone craniotomy and 4 cases had undergone stereotactic radiosurgery. Past medical history: hypertension in 4 cases, coronary heart disease in 2 cases, diabetes mellitus in 3 cases, cerebral infarction in 1 case, and chronic emphysema in 1 case. 3.Treatment method All the patients in this group were operated by KARL STORZ neuroendoscopic transnasal-paranasal approach: the patient was placed in supine position with the head dropping backward by 15°. Endotracheal intubation, general anesthesia, nasal surface anesthesia with 2% dicaine plus 1:1000 epinephrine 3.0 ml. 0° endoscopic identification of the posterior nostril, the posterior end of the middle turbinate, fracture the middle turbinate and push it to the lateral side or remove the middle turbinate, arc the mucosa at the junction of the middle turbinate corresponding to the nasal septum, turn the mucosa backward and outward with a stripper, reveal the opening of the pterygoid sinus and the anterior wall of the pterygoid sinus, enlarge the opening of the pterygoid sinus and the anterior wall of the pterygoid sinus with a small grinding drill and biting forceps. The opening of the pterygoid sinus and the anterior wall of the pterygoid sinus were enlarged by 1.5-2.0 cm with a small grinding drill and biting forceps. The walls of the pterygoid sinus were carefully observed, and the bony elevations of the optic canal, internal carotid artery, trigeminal nerve, etc. in the cavity of the pterygoid sinus and the internal carotid artery-optic nerve fossa, saddle base and slope were carefully identified. For craniopharyngioma that has already invaded the pterygoid sinus, the tumor can be revealed at this point. For intra-saddle tumor, after confirming the saddle base, grind away the saddle base and enlarge it with biting forceps or grind away the saddle base with grinding drill to remove the saddle base bone as widely as possible, reveal the dura of the saddle base, observe the color and texture of the dura, disinfect the dura and electrocoagulate, try to penetrate without blood, then use a small hook and loop knife to cut the dura in “ten” shape, those with normal pituitary tissue should be carefully set aside to avoid damage. After the operation, the cavity was filled with gelatin sponge and the artificial dura (Gore, 2.0×3.0×0.3cm) was used to repair the tumor according to the “sandwich method”. “A layer of artificial dura was placed in the dura of the saddle base, another layer of artificial dura was placed between the bone of the saddle base and the dura, and the gelatin sponge was placed between the two layers of artificial dura and glued with a little medical otocerebral glue. The pterygoid sinus was filled with gelatin sponge, and then the nasal cavity was filled with iodoform gauze, which was removed after 3-5 days. For simple cystic craniopharyngioma, a cystic wall window was used, and the diameter of the fistula was about 1.0 cm, and the operation was completed by aspiration of the cystic fluid. Results Eight patients showed varying degrees of visual acuity and visual field improvement on the same day after surgery. There were no serious complications or surgical deaths in this group, and one case had a postoperative nasal leak of cerebrospinal fluid, which healed on its own after 1 week of semi-recumbency or absolute bed rest. Among the 8 patients, the clinical symptoms disappeared in 4 cases, improved significantly in 3 cases, and did not change in 1 case; the imaging results showed that the tumor disappeared completely in 5 cases, shrunk in 1 case, and increased in 1 case, with an effective control rate of 87.5%. The pituitary function test during the follow-up period: 4 cases with improvement, 4 cases with no change, and no hypopituitary function. A B: Pre- and postoperative MRI images of craniopharyngioma A: Pre-operative MRI image of craniopharyngioma (sagittal position); B: 1-year postoperative cranial MRI showed no recurrence of tumor. Craniopharyngioma is a congenital tumor, which is histologically benign and occurs mostly in children, but is rare in the elderly[1] . Because of the deep location of the tumor and its proximity to the lower part of the optic thalamus, the optic cross and important neurovascular vessels such as the internal carotid artery and Willis ring, it is very difficult to be completely removed by traditional craniotomy, and the incidence of serious complications and mortality are high. Craniopharyngioma is relatively rare in the elderly, and some of them may be combined with other important organ dysfunction, such as hypertension, heart disease, diabetes mellitus, chronic emphysema and other common diseases in the elderly. Traditional craniotomy is more risky or intolerant to craniotomy. The endoscopic transsphenoidal approach is a very safe procedure with a mortality rate of less than 2% [3,4].Cappabianca et al [5] summarized the postoperative complication rate of 146 cases of endoscopic transsphenoidal surgery, which was lower than that of conventional microscopic transsphenoidal surgery (same operator), and without complications such as septal perforation, mucosal crusting and adhesions. Compared with the disadvantages of traditional craniotomy, such as severe brain tissue retraction and limited exposure [6,7,8], endoscopic transsphenoidal treatment of craniopharyngioma has the following advantages: 1) direct access to the tumor; 2) less brain tissue retraction; 3) less visual cross harassment; 4) shorter hospital stay [9]; and 5) significantly lower disability and mortality [10]. When applying endoscopic transsphenoidal resection of the tumor, the tumor and its surrounding associated structures should be fully exposed, and the pterygoid plateau can be abraded if necessary, in addition to abrading the bone of the saddle base. The operator and the main surgeon should coordinate to achieve “four hands” operation. Craniopharyngioma is an extramedullary tumor, and there is a boundary between it and the surrounding nerve tissue in all primary cases. When separating the tumor, we should use sharp separation, avoid pulling and tugging, and try not to damage the surrounding small arteries except the blood vessels that supply blood to the tumor. After removing the highest point of the tumor wall, the gray matter structure at the base of the three ventricles and the tumor should be clearly demarcated, which should be carefully protected. Bipolar electrocoagulation should be used sparingly, but when it is necessary, the output power should be reduced and the front end of the electrocoagulation forceps should be rinsed with saline to lower the temperature. The penetrating artery near the ring of Willis should also be carefully protected. Postoperative recurrence of craniopharyngioma is one of the treatment challenges, with most recurrences occurring within 3 years [11,12,13]. The main reason is tumor residual. In our group, there was one case of recurrence, and the tumor was found to be gradually enlarged by regular cranial MRI, and then stereotactic gamma knife treatment was performed, and the tumor was well controlled. The recurrent craniopharyngioma has significantly increased adhesions with the surrounding normal structures, displaced adjacent neurovascular structures, and disturbed anatomical relationship, which makes the operation more difficult and should not be forcibly removed as much as possible. In our group, two cases of recurrent craniopharyngioma were treated with partial resection + 32P internal radiotherapy, and one case was treated with cystic fluid aspiration + windowing, and the clinical results were satisfactory. Cerebrospinal fluid nasal leakage is the most common complication of endoscopic transnasal butterfly surgery, and its incidence was reported by Kitano [14] et al. to be 9%. One case occurred in our group, which may be related to intraoperative opening of the base of the three ventricles. Skull base reconstruction is essential to prevent postoperative complications. We use the “sandwich method”: artificial dura mater – gelatin sponge – artificial dura mater for saddle base reconstruction, which is really effective. Muscle and broad fascia can also be used for repair. Once the cerebrospinal fluid leak occurs after surgery, the patient should be absolutely bedridden and remain in a semi-recumbent position, and if necessary, lumbar pool drainage or endoscopic repair is feasible. In conclusion, the treatment of craniopharyngioma in the elderly by transsphenoidal neuroendoscopic surgery is minimally invasive, safe, with satisfactory tumor control and few complications, and is an effective and feasible treatment method.