Endonasal endoscopic resection of suprasellar craniopharyngioma: A retrospective single-center case series

IntroductionEndoscopic endonasal approach (EEA) has recently been proposed as an option for resection of primary and recurrent suprasellar craniopharyngioma. However, surgical outcome has not yet been fully evaluated, especially in regards to recurrent cases.MethodsWe analysed our institution (Sir Charles Gairdner University Hospital, Perth, Australia) case-series retrospectively. There were 16 patients operated through an endonasal endoscopic approach from February 2014 to February 2019 for suprasellar craniopharyngiomas. There were 14 primary, and two recurrent lesions. Extent of resection, complications, visual and endocrinological outcomes are presented.ResultsMean age of the patients was 42.9 ± 19.3 years old, with 56% female. The most common clinical symptoms were headaches (9 patients, 56%) and bi-temporal hemianopsia (9 patients, 56%), followed by unilateral optic neuropathy (5 cases, 31%), memory loss (1 case, 6%), hydrocephalus (1 case, 6%), delayed growth and puberty (1 case, 6%), and secondary amenorrhoea (1 case, 6%). Only two cases (12%) initially presented with normal visual function. Gross total resection (GTR) was achieved in 10/16 patients (62.5%), with subtotal resection (STR) in the remainder. Visual symptoms improved in 13/16 patients (81%) and remained unchanged in 3/16 patients (19%). Most common complications included new endocrinological deficit in nine patients (56%), mostly diabetes insipidus, and cerebrospinal fluid leak requiring a new intervention in three patients (19%). There was one mortality case (complicated meningitis, stroke and vasospasm). Mean follow-up time was 22.05 ± 14 months and three patients (19%) had a recurrence of the disease during this period and were referred for radiation therapy.ConclusionEndonasal endoscopic approach is a safe and effective surgical option for both primary and recurrent suprasellar craniopharyngiomas.     

经基底纵裂间入路治疗鞍区肿瘤

目的 探讨经基底纵裂间入路治疗鞍区肿瘤的效果.方法 对15例鞍区肿瘤患者,采用经基底纵裂间入路,对手术效果进行分析总结.结果 15例患者肿瘤全切,1例颅咽管瘤患者因高渗性缺水,出院后死亡,2例颅咽管瘤患者纠正高渗性缺水后正常出院.1例颅咽管瘤患者术后半年有复发迹象,行γ-刀治疗,其余患者无复发,术后无颅内感染及脑脊液鼻漏发生,术后不影响美观.结论 经基底纵裂间入路,手术视野广泛,向上可以进入第三脑室,向后可显露中脑导水管,向下可进入鞍内,应用范围广,手术效果好.     

Craniopharyngiomas in children: Turkey experience

Objectives Craniopharyngiomas are the most frequently encountered suprasellar tumors in children. Although they have a benign histology, total resection without morbidity is very difficult.Methods We aimed to review the results of pediatric craniopharyngioma patients treated in eight institutions in Turkey. There were 51 boys and 36 girls, ranging in age from 20 months to 18 years (mean 10.2 years). The most frequent symptom was headache, followed by visual disturbances. Hydrocephalus was seen most frequently in tumors greater than 4 cm in size (P=0.002). Hydrocephalus was associated with the decreased gross total resection (P=0.043). The recurrence (28%) was significantly higher in patients with subtotal and partial tumor removal (P=0.010). Bad outcome was significantly associated with tumor dimension (P=0.039); the greater the tumor dimension, the worse the outcome. Outcome was significantly better in patients older than 10 years (P=0.032). Gender, tumor type and location, presence of hydrocephalus and calcification, histological type of craniopharyngioma, and surgical approach did not have a significant effect on the outcome.Conclusions The treatment should be individualized and a multidisciplinary approach should be used. The goal of surgery should be gross total removal without mortality and with acceptable morbidity.     

Surgical treatment and outcome of skull base meningiomas with extracranial extensions

Objective

Recurrent cranial base meningiomas occasionally extend into craniofacial structures, and are one of the most difficult tumors to surgically manage. We reviewed our experience of surgical treatment in a series of patients with meningiomas showing extensive extracranial extensions.

Methods

We surgically treated a total of 10 patients with recurrent cranial base meningiomas with large extension to multiple craniofacial structures. All patients underwent orbitozygomatic or zygomatic frontotemporal craniotomy for surgical resection of the tumor. An endoscopic endonasal technique was also employed, if necessary, as an adjunct to the transcranial approach.

Results

Eight patients were treated solely with a frontotemporal approach associated with an extended resection of the floor of the middle fossa. In 2 patients, an endoscopic endonasal approach was additionally required for resection of tumors located in the nasal cavity and ethmoid sinus. A gross total resection was achieved without serious surgical complications in 9 out of the 10 patients. In all patients, the tumors were found to invade the surrounding tissue such as the bone and skeletal muscle to varying degrees.

Conclusion

Our data indicate that recurrent craniofacial meningiomas can usually be managed by using a lateral cranial base approach. Whereas it would be expected that a radical resection may prevent further recurrence with an acceptable quality of life, a long-term follow-up would be required for confirming the benefit of this treatment strategy.     

颅咽管瘤的显微手术治疗及随访

目的探讨翼点入路为基础的颅咽管瘤全切除方法，并通过长期随访了解患者生存状态。方法根据肿瘤影像学表现的生长部位及扩展方向将翼点入路进行改良，对121例颅咽管瘤患者进行手术治疗，并对其中83例进行12-84个月的随访。结果本组全切除、近全切率分别为79．3％、19．0％，术后最常见的肿瘤残留部位位于肿瘤与第三脑室底部前端连续处。术后最常见的下丘脑反应为尿崩症（86、8％）及低钠、高钠血症（68、6％），其中高钠血症预示严重的下丘脑反应，但经过处理术后反应多可良好控制。围手术期死亡3例（2．5％）。11例随访期内复发，复发率13％。随访期患者复发最常见于术后2年内。结论根据肿瘤生长方向及大小，选择各种改良翼点入路进行积极的全切除，多数颅咽管瘤可以得到良好的长期控制和生存质量。     

前纵裂人路显微手术切除颅咽管瘤

目的探讨前纵裂人路显微手术切除颅咽管瘤的方法和治疗效果。方法回顾性分析43例经前纵裂人路手术的颅咽管瘤病人的临床资料,其中复发颅咽管瘤2例。分析其术前评估、手术技巧和术后处理。结果肿瘤全切除30例,次全切除13例。垂体柄保留37例,切除6例。术后视力恢复或好转32例,无明显变化2例。术后并发症：多饮多尿9例,其中一过性尿崩症5例;电解质紊乱6例;颅内感染1例。本组无脑脊液漏及死亡病例。32例随访6。24个月,无肿瘤复发。结论经前纵裂人路能很好暴露手术视野,对脑组织损伤小,是手术切除中线生长的颅咽管瘤安全、有效的手术人路。但术前全面评估选择合适的手术入路也至关重要。     

颅咽管瘤按发生位置分型和命名——附手术入路与切除方法

目的介绍按颅咽管瘤发生位置来分型方法,并探讨其临床价值。方法回顾性分析215例颅咽管瘤患者的临床资料,根据术前影像学资料、术中发现将颅咽管瘤划分为4种类型,即：Ⅰ型,鞍内颅咽管瘤;Ⅱ型,鞍上颅咽管瘤;Ⅲ型,室下颅咽管瘤;Ⅳ型,室前颅咽管瘤。结果59例Ⅰ型颅咽管瘤全部采用翼点入路切除肿瘤,全切除率为83.1%（49/59）;75例Ⅱ型颅咽管瘤中,74例采用翼点入路,1例采用翼点联合胼胝体入路,全切率为82.7%（62/75）;49例Ⅲ型颅咽管瘤,全部采用翼点入路,全切除率为93.9%（46/49）;32例Ⅳ型颅咽管瘤,全部采用胼胝体入路,全切除率为93.8%（30/32）。结论按发生位置来分型颅咽管瘤是可行的,并使其各自成为相对独立的疾病,更有利于在制定诊疗方案和疗效评价上达成共识。     

颅咽管瘤的显微手术治疗及疗效评估

目的探讨显微手术治疗颅咽管瘤的手术入路及手术疗效。方法回顾性分析43例颅咽管瘤病人的临床资料,采用经鼻蝶入路7例,翼点入路32例,额底经纵裂终板入路2例,经胼胝体前部入路2例。评估病人手术前后神经功能、垂体功能、视功能评分。结果肿瘤全切除32例(74%),次全切除9例(21%),部分切除2例(5%)。术后发生电解质紊乱31例,双侧硬脑膜下积液1例,继发颅内硬脑膜外血肿1例,死亡2例。随访4~90个月,平均28个月。肿瘤复发3例,其中再次手术治疗2例,γ-刀治疗1例。手术前后神经功能、视功能变化不明显,垂体功能障碍发生率明显增加(P<0.05)。结论颅咽管瘤应根据肿瘤部位、生长方式及术者经验选择合适的手术入路,术后垂体功能易受影响。     

Radical resection of craniopharyngioma

Introduction The best management of craniopharyngioma in children remains a controversial topic among neurosurgeons. The two treatments for craniopharyngioma most commonly discussed in the literature are primary total resection and limited resection followed by radiotherapy. Without ignoring the challenging behavior of these tumors, we strongly believe that the first approach in a child with a craniopharyngioma is to attempt total removal. Trying to remove a craniopharyngioma that has been treated previously with other methods is, in our experience, much more dangerous because of adherences of the tumor to vascular and neural structures.Material and methods Between 1988 and 2004, we operated on 153 patients with craniapharyngioma (40% female and 60% male), whose ages at the time of surgery ranged from 15 days to 21 years (mean 10.5 years). Eighty-seven percent of the patients were found to have some visual disturbance and 42% endocrinological alterations. Fifty-four percent of the patients presented hydrocephalus, but only 18% had shunting. Gross total removal was attempted in all patients. Among the 153 patients, the tumor was prechiasmatic in 35 and retrochiasmatic in 112; in ten, these were considered giant forms, and eight had a posterior fossa extension. We performed 84 single and 69 combined approaches.Results We achieved total removal in 69% of our patients. None of our patients regarded as having undergone total tumor resection disclosed recurrence after a follow-up of 1–16 years. Radiation therapy was administered in children with subtotal removal. All children underwent total removal, but only 62% of those who underwent subtotal removal had good outcomes. After surgery, endocrinological status worsened in almost all patients, but visual status improved markedly.Conclusions The treatment of choice in craniopharyngioma in childhood is total resection in order to avoid radiation therapy and recurrence. When total resection is not possible, subtotal resection plus radiation therapy is the alternative.     

成人颅咽管瘤的手术治疗

目的探讨成人颅咽管瘤手术入路的选择、手术方法和预后。方法回顾性分析84例成人颅咽管瘤的临床表现、影像学特点、手术入路、肿瘤切除程度以及随访资料。结果手术采用传统翼点入路41例,额颞微骨孔入路23例,额下纵裂入路12例,经胼胝体-侧脑室入路4例,经眉弓入路3例,经蝶入路1例。肿瘤全切除57例(67.7%),次全切除27例(32.3%);全切率较高的为传统翼点入路(78%)和额下纵裂入路(75%),而额颞微骨孔入路(56.5%)和眉弓入路(50%)全切率较低。结论手术仍然是成人颅咽管瘤的主要治疗手段,根据肿瘤的位置、大小和患者一般情况等,选择个体化手术入路特别是锁孔手术入路对于尽可能彻底切除肿瘤、减少脑组织损伤非常重要。     

Multi-feature localization of epileptic foci from interictal,intracranial EEG

ObjectiveWhen considering all patients with focal drug-resistant epilepsy, as high as 40–50% of patients suffer seizure recurrence after surgery. To achieve seizure freedom without side effects, accurate localization of the epileptogenic tissue is crucial before its resection. We investigate an automated, fast, objective mapping process that uses only interictal data.MethodsWe propose a novel approach based on multiple iEEG features, which are used to train a support vector machine (SVM) model for classification of iEEG electrodes as normal or pathologic using 30 min of inter-ictal recording.ResultsThe tissue under the iEEG electrodes, classified as epileptogenic, was removed in 17/18 excellent outcome patients and was not entirely resected in 8/10 poor outcome patients. The overall best result was achieved in a subset of 9 excellent outcome patients with the area under the receiver operating curve = 0.95.ConclusionSVM models combining multiple iEEG features show better performance than algorithms using a single iEEG marker. Multiple iEEG and connectivity features in presurgical evaluation could improve epileptogenic tissue localization, which may improve surgical outcome and minimize risk of side effects.SignificanceIn this study, promising results were achieved in localization of epileptogenic regions by SVM models that combine multiple features from 30 min of inter-ictal iEEG recordings.     

Craniopharyngiomas in children: surgical experience at Children’s Memorial Hospital

Objectives Craniopharyngioma during childhood poses difficulty in management because of the high incidence of surgical complications and treatment failure. In order to identify less detrimental and more effective treatment, a personal series of craniopharyngioma was reviewed in regard to various clinical factors, patient factors (age and sex), tumor factors (location and extension, relationship with chiasm, and hydrocephalus), and therapeutic modes [extent of resection and radiation therapy (RT)].Materials and methods Fifty-four childhood craniopharyngiomas treated from 1984 to 2003 were reviewed. Preoperative neuroimaging studies were classified depending upon tumor location and extension. In this series of 54 patients, 43 had total tumor resection and 11 had subtotal resection. Of the total resection group, ten showed evidence of residual tumor on postoperative neuroimaging studies. Following the initial resection, 46 did not have RT whereas 8 with subtotal resection received RT.Results There were no surgical deaths. Postoperative complications included pseudoaneurysm in 1, hemiparesis in 3, severe obesity in 5, panhypopituitarism in 50, and worsening of visual function in 7. During follow-up ranging from 12 months to 21 years, 24 patients had recurrence. Of the 33 patients with radiographic total resection, 9 (27.3%) had recurrence. Among the patients with total resection but radiographic residual and those with subtotal resection, the craniopharyngioma recurred in 90% and 100%, respectively. Three (37.5%) of eight patients with subtotal resection with RT had recurrence. Overall recurrence-free survival was 62% at 5 years and 49% at 10 years. The sex and age, location and extension of the tumor, nature of the optic chiasm, and hydrocephalus did not influence survival with statistical significance. However, the extent of surgical resection and use of RT showed significant differences for survival. Patients with total resection had a recurrence-free survival rate of 83% and 70% at 5 and 10 years, respectively. Patients with subtotal resection with RT had 71% at 5 years and 36% at 10 years. Patients who had subtotal resection or radiographically residual tumor without RT had a recurrence-free survival rate of only 9%. Among 22 patients whose recurrent tumor was treated with RT, a second recurrence-free survival rate was 90% at 5 years.Conclusion Total resection provided the best outcome. However, recurrence rates and surgical complications remained high following radical tumor resection. RT was effective for recurrent tumors and should be considered being the primary treatment for recurrences or difficult tumors, which are not amenable to total resections.     

眉弓上锁孔入路显微手术切除大型颅咽管瘤

目的总结经眉弓上锁孔入路显微手术切除大型颅咽管瘤的手术经验。方法回顾性分析31例颅咽管瘤病人的临床资料,均经手术和病理证实。术中采用显露肿瘤,保护重要血管和神经,分块切除肿瘤的策略;术后积极处理并发症。结果 肿瘤全切24例,大部切除7例。术后病理检查显示:成釉细胞型12例,鳞状上皮型15例,未分型4例。术后尿崩症加重7例,高钠综合征2例,嗜睡3例,高热4例,视力损害加重2例;死亡1例。残余肿瘤给予常规放疗或立体定向放射外科治疗。30例随访3个月~7.2年,平均3.9年。术前症状均不同程度好转,肿瘤复发4例。结论采用眉上锁孔入路显微手术切除大型颅咽管瘤是一种微创、安全的手术方法,能取得良好的临床疗效。     

Surgical treatment of jugular foramen schwannomas

ObjectiveWe present our experience with surgery of jugular foramen schwannomas with special consideration of clinical presentation, surgical technique, complications, and outcomes.MethodsThis retrospective study includes ten patients with jugular foramen schwannomas treated by the senior author between January 2007 and December 2012. Three patients had undergone partial tumour resection elsewhere. The initial symptom for which they sought medical help was hearing loss, dysphagia, hoarseness, and shoulder weakness. Preoperative glossopharyngeal and vagal nerve deficits were the most common signs. In our series, tumour extension was classified according to Kaye-Pellet grading system. In two cases the tumours were classified into type A and 8 patients presented with type D tumours. A retromastoid suboccipital craniotomy was performed for type A tumours and modifications of cranio-cervical approach were suitable for type D.ResultsNo death occurred in this series. Four patients deteriorated after surgery: in two patients preoperative cranial nerve deficits deteriorated after surgery while new cranial nerve palsy occurred in 2 other patients. In four patients, the cranial nerve dysfunction had improved at the last follow-up examination. In all other patients, the cranial nerve dysfunction remained the same. One patient experienced tumour recurrence over a follow-up period of 40 months. This patient underwent a successful second surgery without further evidence of tumour growth.ConclusionsJugular foramen schwannomas can be radically managed with the use of skull base surgery techniques. However, the surgical treatment of jugular foramen schwannomas carries a significant risk of the lower CN deficits.     

Impact of maximal safe resection on the clinical outcome of adults with craniopharyngiomas

Recent studies suggest that subtotal resection (STR) followed by adjuvant radiation therapy is an appealing alternative to gross total resection (GTR) for craniopharyngioma, as STR provides similar tumor control without the associated endocrinological and behavioral morbidity. We have examined the impact of maximal safe resection on the clinical outcome of patients with craniopharyngioma. A total of 90 patients underwent surgical resection of craniopharyngioma at a single institution between January 1995 and April 2009. Sixty-one patients underwent GTR alone, four underwent GTR followed by adjuvant radiotherapy, 15 underwent STR alone, and 10 underwent partial removal followed by adjuvant radiotherapy. We analyzed and compared the clinical and endocrinological outcomes and radiological follow-up data of these patients. During the follow-up period, tumor recurrence following the initial resection occurred in 36 of 90 patients (40%). The repeat resection rate was higher in the STR group than the GTR group. Recurrence occurred in 20 of 61 patients (32.8%) from the GTR alone group, in 11 of 15 patients (73.3%) from the STR alone group, and in five of 10 (50%) patients from the STR with adjuvant radiation, such as radiotherapy or stereotactic radiosurgery, group (p=0.030). Maximal safe resection of craniopharyngioma leads to excellent local control. STR with adjuvant radiation therapy does not assure preservation of endocrine function, although it provides better local control than STR alone.     

Modern treatment of 84 newly diagnosed craniopharyngiomas

There is debate regarding the appropriate treatment for craniopharyngiomas, which often present symptomatically given their proximity to critical brain structures, and pose significant surgical challenges. The goal of this study is to identify which patient and tumor characteristics are associated with specific preoperative symptoms, surgical complications, patient outcomes, and tumor recurrence in order to guide craniopharyngioma treatment. We retrospectively identified 84 patients with newly diagnosed craniopharyngiomas treated at our institution from 1986–2010. We used binary logistic regression and survival analysis to determine the effect of several variables (including sex, age, tumor size, location, surgical approach, and extent of resection) on preoperative symptoms and postoperative outcomes, including complication rates and tumor recurrence. Age and tumor location were associated with increased rates of preoperative symptoms, with children being more likely than adults to present with endocrine dysfunction, and intraventricular tumors being more likely than extraventricular tumors to present with headaches and hydrocephalus. A transcranial surgical approach was associated with 1.5 times higher rate of surgical complications than transsphenoidal surgery, while only intraventricular tumor location was associated with a poorer patient outcome. The main factor significantly associated with tumor recurrence was extent of resection. We conclude that intraventricular tumor location is most highly correlated with preoperative symptoms. If feasible, transsphenoidal approaches are preferred, as they result in fewer surgical complications, and gross total resections are optimal because they lead to lower rates of recurrence. When gross total resection is not possible, we favor multimodal treatment approaches.     

Surgical treatment of dumbbell-shaped jugular foramen schwannomas via two-piece lateral suboccipital approach: Report of 26 patients

BackgroundDumbbell-shaped jugular foramen schwannomas (JFS) are rare but challenging for the treatment. Surgical resection is believed to be the optimal therapy; however, postoperative dysfunction of the lower cranial nerves (CNs), tumor residual, cerebrospinal fluid (CSF) leakage, and subcutaneous hydrops are common. The current study's objectives were to describe the optimal surgical strategies for the total removal of dumbbell-shaped JFS, the functional preservation of lower CNs, and the prevention of postoperative CSF leakage.Methods26 consecutive patients with dumbbell-shaped JFS were surgically treated between January 2014 and June 2019. All patients were operated on via two-piece lateral suboccipital approach, vascularized muscle flap was used for the repair of the dural defect after an operation. The clinical information and radiological data of these patients were retrospectively reviewed, and the optimal surgical strategies were further evaluated and discussed.ResultsThe tumor was completely removed in all 26 patients, one patient developed new CN Ⅶ paralysis, and 2 developed new CN IX and Ⅹ paralysis after an operation, all patients were significantly relieved during follow up. None of them developed subcutaneous hydrops and postoperative CSF leakage. No tumor recurrence was observed during a mean follow up of 38.8 (16–69) months.ConclusionsDumbbell-shaped JFS could be safely and completely removed via the two-piece lateral suboccipital approach. Postoperative CSF leakage could be effectively prevented by careful repair of the dural defect in the jugular foramen (JF) and filling the mastoid cavity with a vascularized muscular flap.     

Surgical Strategy for Skull Base Chordomas : Transnasal Midline Approach or Transcranial Lateral Approach

ObjectiveThe clinical management paradigm of skull base chordomas is still challenging. Surgical resection plays an important role of affecting the prognosis. Endonasal endoscopic approach (EEA) has gradually become the preferred surgical approach in most cases, but traditional transcranial surgery cannot be completely replaced. This study presents a comparison of the results of the two surgical strategies and a summary of the treatment algorithms for skull base chordomas. MethodsWe retrospectively analyzed the surgical outcomes and follow-up data of 48 patients with skull base chordomas diagnosed pathologically who received transnasal midline approaches (TMA) and transcranial lateral approaches (TLA) from 2010 to 2020. ResultsAmong the 48 patients, 36 cases were adopted TMA and 12 cases were performed with TLA. In terms of gross total resection (GTR) rate, 27.8% in TMA and 16.7% in TLA and with EEA alone it was increased to 38.9%, while 29.7% in primary surgery. In TMA, the cerebrospinal fluid (CSF) leak remains the most common complication (13 cases, 36.1%), other main complications included death, cranial nerve palsy, hypopituitarism, all the comparisons were no statistical significance. The Karnofsky Performance Scale scores in TMA were all better than those in TLA at different time, and the overall survival (OS) and recurrence free survival/progression free survival was just the reverse. ConclusionThe EEA for skull base chordomas resection has improved the GTR rate, but transcranial approach is still an alternative approach. It is necessary to select an appropriate surgical approach based on the location and the pattern of tumor growth in order to obtain the best surgical outcomes.     

Craniopharyngiomas in children: recurrence,reoperation and outcome

Introduction Craniopharyngioma bears a high rate of recurrence and morbidity in childhood. Although the outcome after recurrence and reoperation is an important parameter for the long-term evaluation of craniopharyngioma, it is poorly documented in literature. Materials and methods We studied children reoperated for recurrent craniopharyngioma in our institution since the advent of computed tomography (CT) scanner. Reoperation for tumor resection was decided whenever the recurrence was solid, with the aim total resection if possible and reasonable. Stereotactic techniques were used in case of cystic recurrence, and external irradiation was used only in case of recurrent tumor not amenable to surgery. Results From September 1981 to January 2007, we performed one or more reoperations in 20 children presenting with recurrent craniopharyngiomas. The total number of reoperations was 29: resection was total in 12 cases, near-total in 8 cases, partial in 8 cases, and undocumented in 1. In addition, stereotactic procedures were performed in 11 cases, and 5 patients underwent external irradiation. Discussion No patient died after surgery or because of tumor progression; one patient died abruptly of an undiagnosed cause during external irradiation. The event-free survival after reoperation was 49.9% at 5years and 40.0% at 10years. At last control, after a mean follow-up of 70.4months after the last surgery, nine patients were tumor-free and ten had stable disease. Conclusion Reoperation for recurrent craniopharyngioma is an efficient method for tumor control and should be proposed whenever the recurrent tumor is solid. Morbidity results above all from tumor aggressiveness, rather than from surgical damage.     

Craniopharyngioma and hypothalamic obesity in children

Background and purpose  Obesity is a major concern in children treated for craniopharyngioma and is caused by hypothalamic damage. The role of aggressive surgical removal has been questioned, leading some authors to recommend a minimalist approach. In order to test this hypothesis, we decided to study obesity in craniopharyngioma and the factors related to it. Materials and methods  We reviewed retrospectively our series of pediatric craniopharyngiomas operated since 1981. The body-mass index (BMI) was calculated for each patient pre- and at several intervals postoperatively and expressed as standard deviations (SD) adjusted for age and gender. Results  We operated on 45 cases, which were followed up for a mean duration of 11.0 years. Initial resection was total in 25 cases (55.6%). No patient died because of surgery or tumor progression; two died with delay presumably because of endocrine failure. At last control, 28 patients (62%) had obesity (BMI over +2SD). Hypothalamic involvement was significantly correlated with preoperative and postoperative BMI. Subtotal tumor resection was significantly associated with obesity at last control. Reoperation for tumor recurrence was associated with a significantly higher BMI. Conclusions  Our results suggest that obesity results from hypothalamic lesions caused by the tumor rather than by surgery. The postoperative weight gain appears to result from the continued impact of preoperative hypothalamic damage. The high rate of tumor recurrence in children, with the risk of additional damage to the hypothalamus, incites us to recommend total resection whenever it appears safe during initial surgery.