This document presents a case report of a 25-year-old female patient presenting with gradual vision loss and occasional headaches over the past 3 years. On examination, she was found to have complete blindness. Imaging showed a solid and cystic suprasellar mass. The clinical and radiological diagnosis was craniopharyngioma. The planned treatment was an endoscopic endonasal transsphenoidal resection of the tumor. The surgery involved an expanded endonasal approach through the nasal cavity, sphenoid sinus, planum sphenoidale, and sella to access and resect the tumor while avoiding vital structures. Postoperative management focused on monitoring for diabetes insipidus, CSF leaks, and

2. Preoperative case presentation
Dr.Md Abu Hena Mostafa
Resident ,Phase-B
Department Of Neurosurgery
BSMMU
On behalf of Orange Unit

3. Particulars of the patient
• Name: Eti
• Age :25 years
• Sex: Female
• Occupation: House wife
• Address: Khulna
• DOA: 27-07-2022

4. Chief Compliants
• Occasional headache for last 3 years
• Gradual dimness of vision for same duration

5. History of Present Illness
• According to the statement of the patient, she was
reasonably well 3 year back. Then, she developed
occasional headache which was global, insidious in
onset, intermittent, dull aching nature, moderate in
intensity. Headache was not associated with vomiting,
no aggravating factor or diurnal variation and relieved
after taking analgesic.

6. History of Present Illness(contd.)
• She also noticed gradual dimness of vision in both eyes (initially in left
eye) for last 3 years which was gradually progressive, more marked on
lateral aspect and does not give h/o blurring of vision, double vision,
ocular pain and now she is completely blind with both eyes.

7. History of Present Illness(contd.)
• She has no history of enlargement of acral parts, change of voice,
central obesity, heat intolerance, tremor, excessive sweating, lethargy,
hair loss, growth retardation but has weight gain.
• No history of convulsion, loss of consciousness or impairment in
cognition, hearing loss, change in voice, difficulty in eating and
swallowing of food, chronic cough, hemoptysis and vomiting with
blood.
• Patient denies any history of trauma.
• She is non asthmatic, non diabetic and normotensive.
• Her bowel and bladder function was normal

8. History of Present Illness(contd.)
• With these above complaints, she got admitted into Department of
Neurosurgery, BSMMU for further management

9. Past Medical History
• Drug History: Nothing significant
• Immunization History: BCG mark is present on left
upper arm.
• Blood Transfusion History: Nothing significant.
• Travelling History: Nothing significant.
• History of Allergy : Not allergic to any food or drugs.

10. • Family History:
None of her family members suffering from
such type of illness.
• Personal History:
Non alcoholic, non smoker and doesn’t take any
tobacco and betel nuts.
• Socioeconomic Condition:
She belongs to a middle class family.
Menstrual history:
menarche:11yrs

11. General Examination
• Appearance: Anxious
• Body built: Below average
• Co-operation:co-operative
• Decubitus: on choice
• Anaemia: Absent
• Jaundice: Absent
• Cyanosis: Absent
• Clubbing: Absent
• Koilonychia: Absent
• Leukonychia: Absent
• Thyroid gland: normal
• Edema: Absent
• Dehydration: Absent
• Lymph Node: Not palpable
• Neck vein: not engorged
• Temp: 98 F
• Pulse Rate: 80 /min
• RR: 16/ min
• Blood pressure:100/70mm hg

12. Systemic Examination
• Respiratory System Examination:
Trachea is midline position. Breath sound is vesicular and no
added sound.
• Cardiovascular System Examination:
Apex beat present in left 5th intercostal space.S1-S2 normal and
no murmur.
• Gastrointestinal System Examination:
Abdomen is scaphoid, soft, non tender. No organomegaly or
lump on palpation.

13. Cranial Nerve Examination
Olfactory nerve examination:
Intact
Optic nerve examination:
Visual Acuity: NO PL, PR
Color Vision: Could not be assessed
Fundoscopy: sharp margin, reduced vessel count

16. Occulomotor, Trochlear, Abducent nerve examination:
Pupil:
EOM: Normal
Nystagmus : Absent
Right Left
Size 3mm 3mm
Shape round round
Light Reflex Direct Absent Absent
Indirect Absent Absent
Accomodation Absent Absent

17. Trigeminal Nerve Examination:
Sensory: Intact
Corneal Reflex: Present
Motor: Intact bilaterally
Jaw jerk: Absent
Facial Nerve Examination:
Intact.

18. Auditory Nerve Examination:
Glossopharyngeal, Vagus Nerve Examination:
Voice: Normal
Gag reflex: Intact
Swallowing: Normal
Position of Uvula: Midline
Palatal movement: Both palate elevates equally
Right Left
Weber’s test Normal Normal
Rinne’s test AC ˃ BC BC ˃ AC

19. • Accessory Nerve Examination:
• Hypoglossal Nerve Examination:
Deviation of tongue: Absent
Atrophy of tongue muscle: Absent
Fasciculation: Absent
Right Left
Sternocleidomastoid Intact Intact
Trapezius Intact Intact

20. Upper Limb Examination
Right Left
Inspection Normal Normal
Bulk Normal Normal
Tone Normal Normal
Fasciculation Absent Absent
Power Elbow Flexors 5 5
Wrist Extensors 5 5
Elbow Extensors 5 5
Finger Flexors 5 5
Finger Adductors 5 5
Jerks Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Hoffman Negative Negative

21. Lower Limb Examination
Right Left
Inspection Normal Normal
Bulk Normal Normal
Tone Normal Normal
Fasciculation Absent Absent
Power Hip Flexors 5 5
Knee Extensors 5 5
Ankle Dorsiflexors 5 5
Great Toe Extensors 5 5
Ankle Plantar Flexors 5 5
Jerks Knee ++ ++
Ankle ++ ++
Plantar Flexor Flexor

22. SENSORY SYSTEM EXAMINATION
All modalities of sensations are intact in all dermatomal distribution.

23. Cerebellar sign
Right Left
Nystagmus Absent Absent
Dysmetria Absent Absent
Scanning speech Absent
Rebound phenomena Absent
Hypotonia Absent Absent
Dysdiadokokinesia Absent Absent
Heel -shin test Can perform Can perform
Pendular Knee jerk Absent Absent
Ataxia Absent

24. Clinical diagnosis
A case of sellar-suprasellar SOL

25. Investigations

28. t2w

36. Hormone profile:
prolactin 10.24ng/ml 1.9-25
GH .43 ng/ml .06-5
cortisol 1073mmol/l 138
TSH 1.14microIU/ml
FT4 .9 ng/dl

37. Clinico-radiological diagnosis:
• Craniopharyngioma with suprasellar extension.
• D/D
• Pituitary macroadenoma

38. Points in favour Points against
Craniopharyngioma Solid and cystic component
Irregular shape
Age
No calcification
Brilliantly enhancing
Hypointense cyst in t1w
Pituitary macroadenoma Most common suprasellar mass
Strong enhancement
Irregular shape
germinoma Age
Highly vascular
Brilliantly enhancing
Hypointense in T1
No huge edema

39. Plan:
• Expanded endoscopic endonasal transsphenoidal transplanum
removal of tumor.

40. Types:

42. Supine position with torso elevated 15 -20˚. Forehead and chin
lies horizontally. Level of head higher than chest (to improve
venous return).Head flex 15 ̊ and rotated 10-15 ̊ towards the
surgeon neck is tilted towards left.

43. Scrubbing & Draping

44. • The perinasal skin & nasal mucosa will be prepared with antiseptic
solution
• The nasal cavity will be packed adrenaline soaked gauze
• Antero lateral aspect of left thigh will also be prepared for harvesting a
fat graft
• Then draping will be done

45. Stages of surgery
• Nasal
• Planum
• Sphenoidal
• Sellar
• Reconstruction

46. For midline tumors, the nostril with a contralaterally deviated septum and larger size is selected. The operation begins with gentle hydro
dissection of the septal mucosa using local anesthesia (xylocaine containing epinephrine) near the anterior quadrangular cartilage or the tip
of the vomer bone.
1. Nasal stage:

47. • Endoscope is introduced at the
12 o’clock position of the right
nostril and is used to retract
the nasal vestibule superiorly
increasing the available space
for other instruments.
• A suction tip is introduced at
the 6 o’clock position on the
ipsilateral side

48. • The middle turbinate (MT) is usually the
first anatomical landmark seen when the
endoscope is advanced into the nostril.
• The choana is below and medial to the
middle turbinate, and it can be followed
superiorly along the sphenoethmoid
recess.

49. STEPS:
Lateralization of Inferior turbinate
Resection of middle turbinate
(Turbinectomy scissors)

50. Harvesting HADAD FLAP

51. • A unipolar electro cautery is used with an insulated needle tip.
• Two parallel incisions are performed following the superior and inferior
insertions of the septum.
• These parallel incisions are joined anteriorly by a vertical incision usually
placed just rostral to the anterior head of the inferior turbinate.
• Posteriorly, the superior incision is extended Iaterally inferior to the
natural sphenoid ostium.
• The inferior incision extends laterally on the superior margin of the
choana.
• The flap can be stored in the nasopharynx .

52. 2. Sphenoid stage:
1. Identification of sphenoid ostium which is
generally 1 cm post-inferior end superior
turbinate .Once the superior turbinate is
retracted, the ostium comes into better
view.
2. Bilateral sphenoidotomies
3. Removal of mucosa and intrasinus sphenoid
septum
Identification of osteum

53. • The posterior nasal septum is disarticulated from the rostrum of the
sphenoid bone
• Its posterior edge (1-2 cm) is resected with a backbiting forceps or a
microdebrider.

54. 4. lntraoperativre view of the sellar face
. The sellar prominence is viewed in the center, the superior
intercavernous sinus and tuberculum sella (Tuberc) above, the clival
recess below, the carotid prominences (ICA) lateral to the sella and more
superiorly the optic nerves (ONI), between them the medial optico
carotid recess and the lateral opticocarotid recess.

55. Tactile feedback of bony thickness of sellar floor.if the floor of the sella is thin due to erosion by the tumor, a blunt hook may be used to
penetrate and elevate the bone. Or if floor is thicked then drilled will used.
3. Sellar stage

56. Planum stage:
• Further rostal exposure will be made at anterior skull base removing
posterior ethmoid sinuses(upto posterior ethmoid artery).
• About 2cm of anterior cranial base will be opened.

57. A wide opening is made in the floor of the sella. The tumor bulge on the Dura can be seen.

58. A sickle knife/ 11 no knife is used to open the Dura and expose the pituitary tumor.

59. Further bone removal should extend to the level of the carotid arteries bilaterally. The dotted red line in this figure represents the cruciate
dural opening that gives access for resecting intrasellar and suprasellar lesions. Opening will be extend to anterior dura of tuberculumn. A
hand-held micro doppler probe should be used to guide the dural opening, and care should be taken during opening of anterior dura as
careless opening may injure superior hypophyseal artery which was pushed by the tumor against anterior dura.

60. A small pituitary rongeur is used to pull out a specimen carefully,internal debulking
will be done. Fine and meticulous dissection of tumor from surrounding
neurovascular structure will be done by capsule mobilization and extracapsular
sharp dissection.

61. Checking for CSF leakage
Use of Valsalva Maneuver

62. - Haemostasis will be achieved with
electro cautery and fibrillar.
- Gap will be packed by fat and fascia - graft
taken from thigh.
-Nasoseptal flap will be given
- Leak will be closed by fibrin glue
_ Merocel nasal packing

63. Injection of fibrin glue in the sella,
filling the dead space after the tumor removal.

64. Closure:
• The nasal cavity is packed with an expandable
foam sponge (Merocel) and antibiotic impregnated
ribbon gauze.

65. Complications:
Perioperative:
1. Vascular injury: Cavernous sinus, Int. carotid
artery
2. Nerve injury: Optic chiasm, cavernous cranial
nerves especially Cr. N.III, VI, VI
3. Hypothalamic injury
4. Brain stem injury
5. Diabetes insipidus
6. CSF leak
7. Pneumocephalus

66. Postoperative:
• DI & electrolyte imbalance,
• CSF rhinorrhea,
• Visual impairment,
• Infections: meningitis, sinusitis, pituitary abscess,
• Nasal : hematoma, anterior septal perforation, saddle
nose deformity,
• Secondary empty sella syndrome,
• Iatrogenic hypopituitarism.

67. POSTOPERATIVE CONSIDERATIONS
• Fluid and Electrolytes balance should be closely monitored
• The patient should also be kept on a stress dose of
corticosteroids.
• CT scan of brain should be done on 1 st POD
• Urine output should be monitored hourly

68. Thank you