Open Access Hori et al., J Neurol Neurophysiol 2014, 5:1 DOI: 10.4172/2155-9562.1000187 Open Access Volume 5 • Issue 1 • 1000187 J Neurol Neurophysiol ISSN: 2155-9562 JNN, an open access journal Neurosurgery Proposal of a New Grading System Based on Surgical Results of 100 Craniopharyngiomas Tomokatsu Hori 1 *, Takakazu Kawamata 1 , Kousaku Amano 1 , Yasuo AIhara 1 , Yosikazu Okada 1 , Masami Ono 2 and Nobuhiro Miki 2 1 Department of Neurosurgery, Tokyo Women’s Medical University, Japan 2 Division of Internal Medicine, Tokyo Women’s Medical University, Japan *Corresponding author: Tomokatsu Hori, Department of Neurosurgery, Tokyo Women’s Medical University, Japan, Tel: 81-3-3358-6220; E-mail: thoribeco@spn1.speednet.ne.jp Received November 13, 2013; Accepted January 24, 2014; Published February 04, 2014 Citation: Hori T, Kawamata T, Amano K, AIhara Y, Okada Y, et al. (2014) Proposal of a New Grading System Based on Surgical Results of 100 Craniopharyngiomas. J Neurol Neurophysiol 5: 187. doi:10.4172/2155-9562.1000187 Copyright: © 2014 Hori T, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Keywords: Craniopharyngioma; Lateral extension; Grading; Interhemispheric approach; Pterional; Transsphenoidal; Sagittal diameter; Coronal diameter; Foramen Monro; Mammillary body Introduction Craniopharyngiomas are one of the most difcult challenges for neurosurgeons, because of the difculty in total removal and the tendency to recur even operated by experienced hands [1-11]. Craniopharyngiomas have been classifed according to the relationship with the sella turcica, optic chiasm, and third ventricle [5,10,11]. Most classifcation systems reported until now take into account the relationship between the tumor and the third ventricle. However, lateral extension of the tumor should be also considered for selecting appropriate operative approach and comparing surgical results reported in the literature. To classify craniopharyngiomas appropriately, it is necessary to establish a new classifcation or grading system based on MRI fndings including not only the sagittal diameter but also the coronal diameter of the tumor, as in the widely used Knosp grading system for pituitary adenomas [12]. Te grading system should be simple, easy to use by all physicians and surgeons, and consider not only the size but also MRI features of the tumor as well as the relationship of the tumor with surrounding structures such as the mammillary body, foramen of Monro and posterior clinoid process. For example, invasion of the mammillary body by the tumor will cause memory dysfunction, while obstruction of the foramen of Monro will cause hydrocephalus. If the tumor extends below the clinoidal line, it is relatively difcult for most neurosurgeons to extirpate the tumor completely by a transsphenoidal or subfrontal interhemispheric approach. Te grading system should also take into consideration the MRI features of the tumor, whether it has an entirely cystic or multicystic component, mixed cystic and solid components, or solid component only [10]. Te grading system should be useful not only for selecting the best approach to remove the tumor satisfactorily, but also for predicting the out come. Such system should be developed by experienced neurosurgeons who have operated on many patients with good surgical results. Perioperative management should be discussed based on the same grading system, not only by neurosurgeons but also among physicians especially endocrinologists, and by radiotherapists. Here, the authors propose a new grading system of Abstract Objective: Craniopharyngiomas pose a baffing problem to neurosurgeons because of the diffculty in total removal and tendency to recur even operated by experienced hands. We propose a new classifcation or grading system of craniopharyngiomas based on MRI fndings including not only sagittal diameter but also coronal diameter of the tumor, the usefulness of which was evaluated in 100 consecutive patients mainly operated by one neurosurgeon (T.H.). Methods: Between 1981 and 2012, 100 patients comprising 55 males and 45 females aged from 1 year to 75 years (mean 33.1 ± 22.7) underwent surgeries for craniopharyngiomas, including endoscopic removal in two patients. Thirty-six pediatric (younger than 15 years) patients comprising 23 males and 13 females with a mean age of 8.1 ± 4.3 years were included. Surgeries were conducted by a transnasal transsphenoidal (TSR), pterional (PTR) or anterior interhemispheric (AIH) approach, orbyendoscopic removal (END).Based on MRI fndings with or without gadolinium enhancement, tumor size was classifed by the maximum sagittal diameter into <2 cm (score 1), 2-4 cm (score 2), and >4 cm (score 3). Tumor size was also classifed by the maximum coronal diameter perpendicular to midline into<2 cm (score 1), 2-4 cm (score 2), and >4 cm (score 3).A score of 1 was added when the lower limit of the tumor was below the clinoidal line, when the tumor extended to the mammillarybody, or when the tumor reached the foramen of Monro. From MRI fndings, tumor composition was classifed as cystic only (score 0), multi-cystic (score 1), mixture of cystic and solid (score 2), and solid only (score 3). In each patient, the total score was calculated and graded as follows: score 2 as grade I, scores 3-5 as grade II, scores 6-8 as grade III, scores 9-11 as grade IV, and score 12 as grade V. Results: Mean age was 35.6 ± 22.8 in grade II patients, 34.9 ± 22.8 years in grade III, 24.1 ± 20.6 in grade IV, and 1 year in grade V (1 patient).Although tumor grade was apparently higher in younger patients, there was no signifcant difference. Higher grades were associated with lower pre- and postoperative performance status. Preoperative grade was signifcantly lower in patients operated via the TSR compared to PTR or AIH approach. Conclusion: The new grading system is useful for analyzing pre- and post-operative performance status, and for selecting operative approach. It is also useful to compare treatment outcomes reported in the literature. Journal of Neurology & Neurophysiology J o u r n a l o f N e u r ol o g y & N e ur o p h y s i o l o g y ISSN: 2155-9562 Case Report