TOPIC REVIEW Microsurgical removal of craniopharyngioma: endoscopic and transcranial techniques for complication avoidance Saira Alli 1,2 • Semra Isik 1,2 • James T. Rutka 1,2 Received: 1 February 2016 / Accepted: 4 May 2016 Ó Springer Science+Business Media New York 2016 Abstract Craniopharyngioma remains a challenging entity for neurosurgeons because of its midline, deep seated location and intimate relationship with critical neurovas- cular structures. Although gross total resection is ideal, the need to reduce surgical morbidity and preserve quality of life has led to a number of neurosurgical approaches which have attained this goal. Here we discuss the commonly used approaches for surgical resection and highlight tech- nical considerations to reduce the potential of complica- tions. We also discuss the mutually exclusive underlying genetic lesions in different histopathological subtypes that will likely lead to future treatment options for these tumors. Keywords Craniopharyngioma Á Surgery Á Approaches Á Transcranial Á Endoscopic Introduction Craniopharyngioma remains a challenging entity for neu- rosurgeons because of its midline, deep seated location and intimate relationship with critical neurovascular structures. The spectrum of clinical presentation and potential surgical morbidity indicate that the only benign aspect of this tumor is its histological grading. Surgical management aims to achieve either gross total resection (GTR) or subtotal resection (STR) coupled with adjuvant radiation therapy [1]. The latter strategy has gained some favour in recent years due to reduced mor- bidity and equivalent progression free and overall survival [2]. However, neurosurgical expertise and tumor relation- ships with the normal neuroanatomy are often the ultimate determinants of the degree of resection. As neurosurgeons, we must focus on preserving quality of life as well as long- term tumor control and survival. There are several transcranial routes that can be used for craniopharygioma and they can be broadly classified as midline anterior (transsphenoidal interhemispheric, and unilateral subfrontal/bifrontal transbasal) or frontolateral (pterional-frontotemporal and modified orbitozygomatic). Other approaches have been described such as the posterior transpetrosal approach but these will not be discussed in further detail here [3, 4]. In this review, we outline com- monly used approaches and highlight technical considera- tions to reduce the likelihood of surgical complications. Endonasal endoscopic approach (EEA) The introduction of the endoscope to the transsphenoidal approach has enhanced anatomical visualization whilst offering direct tumor access with minimal brain retraction [5]. The procedure is commonly conducted in conjunction with an otolaryngologist responsible for raising the nasoseptal flap and initial transnasal portion of the opera- tion. Thereafter, a bilateral approach is conducted with the otolaryngologist providing visualisation with the Saira Alli and Semra Isik contributed equally to this work. Electronic supplementary material The online version of this article (doi:10.1007/s11060-016-2147-4) contains supplementary material, which is available to authorized users. & James T. Rutka james.rutka@sickkids.ca 1 Division of Neurosurgery, The Hospital for Sick Children, Suite 1503, 555 University Avenue, Toronto, ON M5G 1X8, Canada 2 Department of Surgery, University of Toronto, Toronto, ON, Canada 123 J Neurooncol DOI 10.1007/s11060-016-2147-4