Zenker first identified a squamous epithelium-like lesion in the distal pituitary and nodes in 1857, but this lesion was neglected for many years. In 1932, Cushing’s book “Craniocerebral Tumors” described craniopharyngioma and concluded that partial resection of this cystic lesion and aspiration of the cystic fluid would lead to rapid recurrence. In spite of this, the overall treatment of craniopharyngioma is still not very successful, and the surgical mortality rate is still about 5%. In the face of this disorder, we need to have rich clinical experience, theoretical training and insight to make the right treatment decision for each craniopharyngioma case.
1.Pathology of craniopharyngioma
Craniopharyngioma is an epithelial cell tumor. One is the Embryo-genetic theory, which suggests that the tumor originates from the aneurysmal transformation of residual squamous cells in the craniopharyngeal duct, and the other is the Metaplastic theory, which suggests that the tumor originates from the metaplastic transformation of adenopituitary cells in the pituitary stalk or anterior pituitary gland [1,3,4,6].
According to WHO classification, craniopharyngioma is a grade I tumor, but cases of malignant transformation of the tumor have been reported [2]. Craniopharyngioma is mostly cystic and calcified, and the cyst may be one or multiple compartments, or a substantial lesion without a capsule, with an intact envelope. The cyst wall is mostly accompanied by calcified spots, and in most cases the calcifications are scattered and brittle, sometimes the calcified masses are large and hard. The cystic fluid is yellow or yellow-brown, sometimes dark green, transparent or cloudy, and the viscous cystic fluid can be celiac-like, with scintillating cholesterol crystals floating in the cystic fluid as an important feature of craniopharyngioma. Statistics from the literature show that simple cystic tumors account for 48% of the all-age group and 38% of the children’s group; simple parenchymal tumors are mostly seen in adults and only 10% in children; and mixed craniopharyngiomas account for 36% of the all-age group and 52% of the children’s group [5,7].
Histologically, craniopharyngiomas are usually divided into two types, enamel and squamous epithelial types. The enamel type is the most common and can be seen at any age, and almost all craniopharyngiomas in children are enamel type, while more than half of adult craniopharyngiomas are of this type. The tumor may be cystic and/or solid with necrotic debris, fibrous tissue, and calcified masses. The cystic cavity is multifocal and the color of the fluid depends on the amount of blood metabolites, proteins and cholesterol crystals present. Squamous epithelial craniopharyngioma is almost always found in adult patients. The proliferating epithelium is simple squamous epithelium with a well-differentiated cellular structure resembling the oropharyngeal mucosa, and the gross specimens are mostly cystic solid with a yellowish, viscous fluid.
Craniopharyngioma often causes reactive gliosis in the surrounding brain tissue. Some scholars refer to the reactive gliosis zone, epithelial cell layer and connective tissue layer around the tumor as the craniopharyngioma envelope structure, and they believe that the gliosis zone is a special tumor envelope structure, which is different from the envelope structure of other common tumors. Sometimes the epithelial cell layer of some tumors may protrude into the glial proliferation zone in a finger-like manner, but not into the normal brain tissue. The presence of the glial layer between the tumor and the brain tissue provides an operative interface for the operator to safely dissect the tumor without damaging the brain tissue, and this glial proliferation layer should be carefully identified and utilized during surgery [6,8,12].
The blood supply to the craniopharyngioma comes mainly from small branch vessels of the anterior circulation at the base of the skull. Sometimes the internal carotid artery and the posterior communicating artery may also supply blood directly, but craniopharyngiomas generally do not receive blood from the posterior cerebral artery or the basilar artery, and intra-saddle lesions may receive blood from the perforating arteries of the cavernous sinus.
2.The growth pattern of craniopharyngioma
Craniopharyngioma grows along the midline and can originate anywhere along the pituitary canal, but most of them are located in the pterygoid and paracranial regions. The majority of craniopharyngiomas (94-95%) develop suprasellarly, of which about 20-41% are purely suprasellar, 53-75% have both suprasellar and intra-sellar parts, and only 5% are purely intra-sellar. The suprasellar portion of craniopharyngioma can grow in the anterior (9%), middle (8%) and posterior (12%) cranial fossa. The rare sites of craniopharyngioma are the pure tricranial ventricles, nasopharynx, pterygoid, septal sinus, optic cross, temporal lobe, pineal gland and posterior cranial fossa [7,9].
Usually, the parenchymal part of the tumor is located below the lesion, while the cystic part protrudes into the third ventricle in a “pear shape”, and the cystic part may also protrude in a “finger shape” into the lateral fissure pool, paracranial fossa, base of the middle cranial fossa, slope and pontocerebellar horn. About 20% of craniopharyngiomas develop anteriorly to the optic chiasm, and most of these tumors are cystic and large, and are often embedded in frontal brain tissue [4,10]. Asymptomatic self-rupture of the cystic cavity of craniopharyngiomas has been reported [18].
Many neurosurgeons classify craniopharyngiomas according to their possible location of origin and mode of growth, with the aim of guiding surgical treatment.Rougerie, who first classified craniopharyngiomas in 1962, classified craniopharyngiomas into five types: intraparietal, suprasellar, retrooptic, giant, and atypical.Hoffman (1989) classified craniopharyngiomas into Yasargil [5] (1990) classified craniopharyngioma into six types and Choux [1] classified craniopharyngioma into four types based on the possible origin of the tumor. Both purely solid and purely cystic craniopharyngiomas are rare in clinical practice, and seemingly solid tumors often have varying degrees of cystic changes, while equally cystic lesions may also have a substantial solid component, and the growth pattern of tumors is even more variable.
3.Clinical thinking of craniopharyngioma treatment methods
Currently, there are many treatment options available for craniopharyngioma. One is the aggressive approach, that is, to adopt an aggressive attitude to completely remove the tumor and maximize the patient’s life; the other is the conservative approach, that is, not to completely remove the tumor or only to perform cyst puncture and aspiration, and then to carry out general radiotherapy, nuclear irradiation therapy or stereotactic radiosurgery. The advocates of an aggressive approach to the treatment of craniopharyngioma include Yasargil , Samii , Laws , Hoffman and Choux , who recommend that total resection of the tumor should be sought at the first treatment [1, 3, 5,11]. Advocates of a conservative approach include Backlund, Lunsford, and Steiner, who recommend internal nuclear irradiation for cystic craniopharyngiomas and gamma-knife treatment for solid tumors. A few authors believe that the diagnosis of craniopharyngioma should not be followed by any urgent treatment, but by long-term follow-up and observation. Overall, an aggressive approach to the treatment of craniopharyngioma is the mainstay.
Neurosurgeons should have a proper concept and clinical thinking in making decisions about treatment options for craniopharyngioma. The surgical treatment of craniopharyngioma is a challenge for neurosurgeons and requires extensive clinical experience and skilled surgical technique to perform it competently. The neurosurgeon cannot decide to treat all craniopharyngiomas with a particular treatment plan based on personal preference alone. The preferred treatment option for craniopharyngioma is total surgical resection of the tumor, with a combination of surgery and radiation therapy as a second option. Neurosurgeons need to minimize or mitigate postoperative complications, improve the quality of survival and prolong the life of patients through accurate preoperative evaluation, selection of appropriate surgical approach, application of skillful surgical techniques and proper hormone replacement therapy. We should neither start with the conservative idea of only subtotal or partial resection of the tumor with postoperative supplemental radiation therapy, nor blindly seek radical tumor surgery in spite of the unfavorable intraoperative conditions, resulting in serious postoperative complications and disastrous results for the patient. Neurosurgeons should make specific analysis for each craniopharyngioma case and choose the correct treatment plan and modality according to their age, health status, tumor growth characteristics and doctors’ clinical experience to minimize or mitigate the complications of treatment [4, 10, 17].
4. Clinical thinking of surgical treatment of craniopharyngioma
4.1 Preoperative assessment
Craniopharyngioma has high surgical risks and many persistent postoperative complications, and patients often require lifelong treatment after surgery. In order to achieve good treatment results, accurate preoperative evaluation is necessary, which includes assessment of the patient’s general health status, assessment of endocrine function, assessment of imaging data and neuropsychological assessment.
4.1.1 Endocrine function assessment: Due to the compression of the pituitary gland, pituitary stalk and hypothalamus by the craniopharyngioma, patients often show low endocrine function. Endocrine tests and some excitatory stimulation tests are needed to assess the patient’s endocrine function, which mainly focuses on urothelial, thyroid axis function, adrenal axis function and gonadal axis function. Patients with craniopharyngioma who have preoperative uremia have a significantly increased incidence of postoperative uremia. Hyperprolactinemia suggests that the patient has hypothalamic dysfunction or injury, and a functioning hypothalamus is capable of inhibiting the secretion and release of prolactin. Low preoperative serum thyroxine levels suggest that the patient has hypothyroidism and should be supplemented with oral levothyroxine before surgery, and such patients should be supplemented with thyroxine early after surgery; patients with normal preoperative thyroid function generally do not require thyroxine supplementation within one week after surgery. The elderly should be cautious with thyroxine supplementation because thyroxine can induce cardiac arrhythmia and myocardial ischemia. Adrenocorticotropic hormone replacement therapy should be given preoperatively and intraoperatively to all patients except those with microscopic craniopharyngioma with normal preoperative ACTH secretion. The first physiologic aspect of adrenal crisis is the induction period of anesthesia and therefore a stress dose of hydrocortisone should be given on the morning of surgery [7, 9].
4.1.2 Evaluation of imaging data: in order to make the correct treatment choice for each case of craniopharyngioma, a detailed preoperative evaluation of the patient’s imaging data is essential, which should be evaluated in terms of the following points [1, 10, 13, 14].
(1) Tumor growth pattern: infer the possible starting location of the tumor, whether the tumor is growing from the saddle to the suprasaddle or from the pituitary stalk or nodes to the periphery, and clarify the growth of the lesion to the anterior interval of the optic cross, paracentral and posterior saddle.
(2) Relationship between tumor and optic nerve and optic cross: It is important to understand the relationship between tumor and optic nerve and optic cross, which is related to the surgical exposure of tumor and the protection of optic structure.
(3) Relationship between the tumor and the third ventricle: ?teo [13] classified the relationship between the craniopharyngioma and the three ventricles into three types: extra-ventricular, intra- and extra-ventricular and intraventricular. Some experienced neurosurgeons consider it extremely important to fully understand the relationship between the tumor and the third ventricle preoperatively, which is related to the success or failure of the surgery [10, 14]. True pure intraventricular craniopharyngioma is rare; in most cases, the tumor protrudes upward from the pterygoid saddle to elevate the base of the third ventricle or breaks through the base of the third ventricle to enter the third ventricle, which may lead to hydrocephalus if the interventricular foramen is blocked by pressure. It is sometimes difficult to distinguish whether the tumor is purely intraventricular or protruding into the three ventricles, and the position of the papillary body can give us a hint.
(4) Relationship of the tumor with the pterygoid saddle and pituitary gland: This can help in the differential diagnosis of craniopharyngioma and pituitary tumor, which is often seen with clear pituitary signal. In patients with severe central uveitis, the nodular short T1 high signal shadow typical of the normal posterior pituitary lobe disappears because of the lack of antidiuretic hormone secretory granules in the posterior pituitary gland due to craniopharyngioma. It is worth noting that sometimes the dorsal saddle bone marrow shows short T1 high signal image, which resembles the posterior pituitary lobe, and should be carefully identified and not mistaken for the posterior pituitary lobe. In general, the pituitary stalk cannot be identified by preoperative MRI.
(5) Relationship between tumor and blood vessels: As the tumor grows, the surrounding large blood vessels often shift, which requires careful identification of the relationship between the lesion and these vessels, the most important of which are the anterior arterial complex, the internal carotid artery and the basilar artery. The anterior arterial complex has important reference value for the design of surgical access, and the anterior communicating artery can indicate the location of the optic cross. A high anterior communicating artery indicates that the anterior gap of the optic cross may be wider, while the opposite indicates that the optic cross may be anterior or the tumor is located within the trigone.
(6) Relationship between tumor and brainstem: tumor can squeeze brainstem posteriorly, but no invasion into brainstem has been seen, which may be because there are soft meningeal structures between the two.
4.1.3 Neuropsychological assessment: Neuropsychological tests, especially in pediatric patients, are performed to assess the neuropsychological status of the patient using Wechsler intelligence and memory scores. Most craniopharyngiomas in children are huge, and the tumor often affects the fornix causing memory impairment in children, and surgical trauma often exacerbates the damage, resulting in temporary postoperative memory deficits. Preoperatively, the surgeon should communicate with the child’s family to let them understand the relevant treatment, long-term results and possible neuropsychological changes in the child in order to assist in follow-up observations.
4.2 Surgical strategy
4.2.1. Management of hydrocephalus
Hydrocephalus is the primary problem to be dealt with in craniopharyngioma surgery. Hydrocephalus is present in almost half of the cases when craniopharyngioma is diagnosed and sometimes manifests as acute intracranial pressure increase, especially in children, with the incidence of obstructive hydrocephalus exceeding 60% in pediatric patients with craniopharyngioma. Hydrocephalus is caused by tumor growth obstructing the interventricular foramen, therefore, early on, ventriculo-abdominal shunts were performed before craniotomy. Nowadays, most neurosurgeons do not advocate shunt surgery first, and believe that the problem of obstructive hydrocephalus can be solved after removing the tumor with a reasonable surgical approach. In addition, the enlarged ventricle facilitates intraoperative puncture and decompression, which is more conducive to surgical exposure and operation. Some authors have even pointed out that performing a shunt before resection of the tumor may worsen the condition of patients with giant suprasellar tumors.
For patients with severe intracranial hypertension caused by hydrocephalus before surgery, temporary extraventricular drainage is feasible to buy time to improve preoperative preparation and correct endocrine dysfunction, and then perform tumor resection after the condition is in remission. After surgery, the external ventricular drainage tube is left at the physiological height level (about 10 cm above the level of external auditory canal) for 3~4 days, and then the height is gradually raised. If the patient has no manifestation of increased cranial pressure and there is no ventricular enlargement on CT scan, the external drainage tube can be removed. If the hydrocephalus is not relieved after surgery, ventriculo-abdominal shunt surgery will be considered again [1,5,10].
4.2.2 Tumor cystic puncture
Some patients with giant cystic craniopharyngioma are in a critical state at the time of consultation, with poor weight, apathy, or even coma, and severely depressed endocrine function, which is common in pediatric patients. The immediate surgical treatment of such patients is extremely risky, often with catastrophic postoperative consequences and high mortality. In such patients with craniopharyngioma, we recommend to first implant the Ommaya capsule under stereotactic guidance and puncture the capsule cavity to aspirate fluid to alleviate the tumor-occupying effect; the amount of capsule fluid aspirated by each puncture should not be too much and the speed should not be too fast, otherwise it may cause hypothalamic damage. After the patient’s condition improved, the tumor was removed using the appropriate surgical access according to the specific situation [4, 13].
4.2.3. Recurrent craniopharyngioma
There are several treatment modalities to consider for recurrent craniopharyngioma, which include secondary surgical total resection of the tumor, subtotal resection of the tumor supplemented with radiation therapy, and radiation therapy alone. The choice of these treatment options depends on factors such as the patient’s clinical presentation, lesion size and tumor growth pattern. Despite the risk of high mortality and low cure rate, most neurosurgeons still advocate aggressive surgical treatment. Considering clinical practice, reoperation to remove craniopharyngioma that received full-dose radiation therapy after subtotal resection is more difficult and risky, but it is not difficult to perform secondary surgical operation for craniopharyngioma that did not receive radiation therapy after surgery. Recurrent tumors that received radiation therapy have significant adhesions to surrounding nerves and blood vessels, while tumors that did not receive radiation therapy do not have significant adhesions to surrounding structures. In patients with recurrent craniopharyngioma in good health, especially in children, reoperation to remove the tumor is mostly advocated. If the tumor is not completely removed by the second surgery, it should be supplemented with radiation therapy [3, 5].
4.2.4. Surgical access options
(1) Inferior frontal approach
The inferior frontal approach is a familiar route for neurosurgeons and is suitable for craniopharyngiomas with strictly midline growth, especially for tumors growing from the base of the anterior cranial fossa and the suprasellar pool. Advantages include simplicity of operation, ease of control of the bilateral optic nerve and internal carotid artery, and the ability to reveal the anterior inferior tricranial tumor via the endplate. The disadvantages are: (1) the frontal sinus needs to be opened, and there is a possibility of cerebrospinal fluid nasal leakage; (2) the supraorbital nerve and olfactory nerve are easily damaged; (3) the lateral aspect of the pterygoid saddle and the posterior aspect of the optic cross are poorly exposed, which cannot meet the needs of multi-angle operation and poorly expose larger and complex tumors; (4) patients with anterior optic cross are not suitable [1, 7].
(2) Anterior longitudinal approach
The anterior longitudinal fissure approach is mainly suitable for suprasellar and anterior third ventricle tumors, and tumors entering the third ventricle can be resected via the end plate. The position of the optic cross has a great influence on the anterior longitudinal approach. If the optic cross is posterior and the first interval is open, the tumor can be resected through the inferior optic cross first; if the optic cross is anterior and the first interval cannot reveal the tumor, then the tumor behind the optic cross or the lower part of the anterior third ventricle can be resected through the end plate. If the tumor cannot be revealed in the first interval, then a transendoscopic approach can be chosen to remove the tumor behind the optic cross or in the anterior and inferior part of the tricompartment. The blood supply vessels on the tumor envelope can be cut off by pre-electrocoagulation, and the transcranial approach below the optic cross can facilitate the identification and protection of the pituitary stalk. The unilateral frontal flap approach is sufficient to meet the needs, and bilateral craniotomy is usually not required.
The advantages of the anterior longitudinal approach are: (1) it can fully expose the anterior gap of the optic cross, the end plate and the anterior arterial complex; (2) the transendocranial approach facilitates resection of the tumor in the anterior lower part of the three ventricles; (3) there is less interference with the internal carotid artery. The disadvantages are: (1) long working distance; (2) easy to damage the penetrating vessels in the supraoptic area; (3) insufficient exposure of tumors with lateral and slope invasion; (4) easy to damage the olfactory nerve; (5) easy to develop frontal lobe infarction and brain swelling after surgery; (6) need to open the frontal sinus, which also has the risk of cerebrospinal fluid nasal leakage [10, 11].
(3) Transcallosal-transventricular approach
The transcallosal-transventricular approach is divided into three forms depending on the access to the three ventricles, namely, the transventricular foramen, the transventricular plexus approach, and the translucid septal space-interdome approach. The transcallosal approach is suitable for tumors of intraventricular type and protrusion into the ventricles. The advantages of the transcallosal-transventricular approach are: (1) under direct vision, the field of view is fully exposed, which facilitates the resection of suprasellar and intra-three ventricles tumors; (2) it can avoid the damage to the vessels penetrating the Willis ring. The disadvantages include: ①long working distance; ②easy to damage hypothalamic structures and difficult to identify the pituitary stalk; ③poor exposure of the anterior and inferior part of the three ventricles, the pterygoid saddle and lateral lesions; ④unskilled operation and easy to lose direction; ⑤postoperative patient reaction, risk of ventriculitis and obstructive hydrocephalus, and delayed discharge [3, 14].
(4) Pterygopoint approach
The pterygopoint approach is the most commonly used surgical approach for craniopharyngioma. Its greatest advantage is that it can reveal the lesion in multiple angles, followed by the shortest working distance, which facilitates the identification and protection of important neurovascular and pituitary stalk. The main disadvantage of the pterygopoint approach is that it is technically complex, and the surgeon must be skilled in microscopic manipulation; secondly, the pterygopoint approach does not reveal the endplate as well as the anterior approach, and the lesions in the posterior part of the three ventricles are poorly revealed, and the intraoperative interference with the internal carotid artery is great [5, 10, 11].
(5) Transsphenoidal approach
The transsphenoidal sinus approach is the earliest approach used for craniopharyngioma surgery and is suitable for patients with intra- and subsaddle septal tumors, especially those with an enlarged saddle. Since there is no need to open the cranium and pull the brain tissue, the surgery is safe and less damaging. The surgery can relieve the compression of the tumor on the optic nerve and anterior pituitary gland, and improve the symptoms of visual impairment and endocrine disorders. However, since craniopharyngioma mostly grows up the saddle and has a tough texture, and is prone to cystic degeneration, calcification and adhesions, it is difficult to remove the tumor completely with the transsphenoidal approach. However, with the increasing maturity of neuroendoscopic techniques, reports of transsphenoidal approach to remove craniopharyngioma have started to increase [15, 16].
4.2.5. Tumor resection strategy
Craniopharyngiomas are usually classified into four types according to the size of the tumor; those smaller than 2 cm are small, those between 2 and 4 cm are medium-sized, those between 4 and 6 cm are large, and those over 6 cm are huge. For small craniopharyngioma, regardless of whether the tumor is cystic or solid, and regardless of whether it is located in the saddle, suprasellar or intracerebroventricular, it is relatively easy to be completely resected. In clinical practice, most neurosurgeons believe that solid craniopharyngioma is easy to be completely resected, while cystic craniopharyngioma has more obvious adhesions with surrounding neurovascular structures and is not easy to be completely resected. Complete resection of large and giant craniopharyngiomas is very difficult, and postoperative complications are numerous and serious. He believes that there is no significant relationship between tumor size and the extent of tumor resection, and that the distal part of the tumor is mostly cystic, which can be resected without obvious adhesions. The key to successful and complete resection of tumor is surgical exposure. The biggest obstacle to surgical exposure of craniopharyngioma is the important nerve and vascular structures in the saddle area itself. It is relatively easy to surgically remove lesions that grow downward and laterally, but difficult to expose lesions that grow backward and upward. For cystic craniopharyngioma, first of all, the cystic fluid should be removed by puncture, and the process should be slow. After the cystic fluid is removed, the tumor will collapse toward the center, at this time, do not rush to remove the cystic wall, and the tumor can be fully removed by pulling the collapsed cystic wall and separating it. In such cases, the cyst wall is thin and brittle, and the fractured cyst wall fragments are often closely adhered to the deep neurovascular structures [1, 4, 5, 11].
The relationship between the tumor and the three ventricles, pituitary stalk and blood vessels should be correctly recognized and handled during surgery. Minimizing damage to the wall of the trichocephalon and hypothalamus should avoid the occurrence of severe postoperative hypothalamic dysfunction. The pituitary stalk is easily identified and protected during surgery for small craniopharyngiomas. Large craniopharyngiomas often displace the pituitary stalk laterally or posteriorly, which is not easily identified intraoperatively. The surface of the pituitary stalk has characteristic striated structures formed by portal vessels, and the central saddle septum is its relatively fixed location. Hoffman and Sweet believe that the pituitary stalk should be sacrificed to eliminate the source of craniopharyngioma recurrence, and Rougerie and Konovalov advocate preserving the pituitary stalk as much as possible, even if a small amount of tumor remains. The total removal of the tumor is more important than the preservation of the pituitary stalk, especially in children. The pituitary stalk should be sharply separated intraoperatively, and electrocoagulation should be used sparingly to protect the blood supply to the pituitary stalk and pituitary gland. Craniopharyngiomas often distort and displace vessels and adhere to the arachnoid membrane surrounding the great vessels, not usually to the great vessels themselves, but may adhere to the perforating vessels of the ring of Willis. Craniopharyngioma usually does not adhere to the brainstem and basilar artery, and the compressed brainstem can be reset after surgery.
5.Effectiveness assessment
The evaluation of the efficacy of craniopharyngioma is difficult, mainly because of poor direct comparability. The best evaluation method is to follow up and observe the survival rate of treated craniopharyngioma patients for 5, 10, 15 and 20 years after surgery. Determination of the extent of craniopharyngioma resection by the neurosurgeon is also difficult, and the operator needs a combination of surgical manipulation and postoperative CT and MRI examinations to assess. Postoperative MRI can clearly show the optic pathway, the base of the three ventricles and pituitary stalk and residual tumor tissue, and CT scan can show residual calcification. For those with significant residual tumor, secondary surgery is recommended and radiation therapy should not be given easily, especially in children [6, 12, 17].
The rate of total tumor resection reported in the literature varies widely. Overall, the total resection rate of craniopharyngioma in children and young adults is higher than that in adults. Yasargil [5] (1990) reported 144 cases of craniopharyngioma and 90% of the tumors were completely resected, of which the good surgical outcome rate was 93% for tumors less than 2 cm, 82.1% for 2-4 cm, 65% for 4-6 cm, and only 12.5% for tumors larger than 6 cm. The overall efficacy of the first surgery was significantly better than that of the second surgery for tumor recurrence. A valuable study was conducted to show that 81% of the patients treated with surgery alone had normal psychosocial adjustment ability, and 22% of the patients treated with surgery plus adjuvant radiotherapy or radiation alone had normal psychosocial adjustment ability, and the average IQ of the patients in the surgery alone group was 88%, and the average IQ of the radiation alone group was 75%.
Early life craniopharyngiomas are poorly treated and have high mortality and disability rates. Through the efforts of many neurosurgeons, the treatment of craniopharyngioma has made great progress, and now the overall operative mortality rate is 1-2%, and the serious postoperative disability rate is less than 10%. Tumor recurrence mostly occurs within 5 years after surgery, and most data show that the recurrence rate after total tumor resection is about 15-25%, with an average of 20%. The recurrence rate after subtotal tumor resection without radiation therapy is 75%, and the 10-year survival rate is only 25%; the 10-year survival rate can be increased to 75-80% if radiation therapy is received [1, 5, 12, 17,]. The surgical treatment of craniopharyngioma requires both proper decision-making and skilled surgical technique on the part of the operator. Postoperative complications of craniopharyngioma are numerous and difficult to manage, and the postoperative tumor recurrence rate, patient mortality and disability depend largely on the experience of the operator; therefore, surgical treatment of craniopharyngioma should be performed in a large neurosurgical center by a surgeon with extensive experience.