Supraorbital Approach

Abstract

The goal of craniopharyngioma surgery is maximal safe tumor removal with reversal of neurological deficits and complication avoidance. The two most commonly used minimally invasive approaches are the extended endonasal endoscopic transsphenoidal route and the supraorbital (SO) eyebrow craniotomy. While most craniopharyngiomas are optimally removed via the endonasal endoscopic approach, certain factors may preclude this approach or favor an alternative transcranial route. These factors include (1) extensive anterior and lateral tumor extension, (2) recurrent tumors and previously irradiated tumors, and (3) young pediatric cases in which the sphenoid sinus is poorly pneumatized. In such cases, the SO approach may offer an excellent alternative. Through an eyebrow incision and a strategically placed craniotomy that is flush with the orbital roof, the SO approach offers an anterolateral subfrontal trajectory to the posterior planum, suprasellar cistern, opticocarotid cistern, perimesencephalic region, suprachiasmatic region, and Sylvian fissure. The surgical exposure afforded by the SO route is similar to that of a standard frontotemporal craniotomy but because of the relatively small bony opening, can be somewhat restrictive in terms of exposure and maneuverability. Appropriate low-profile instrumentation and endoscopy are thus essential to maximize tumor access for the SO approach. Despite these limitations, the reduced extent of scalp, muscle, and bone dissection compared to conventional craniotomies and minimal to no need for brain retraction offer the potential for excellent outcomes with rapid recovery, short hospital stay, and a satisfactory cosmetic result. We discuss the rationale, key selection factors, and limitations of this approach and detail the technical nuances of the SO approach for craniopharyngiomas.