J Neurosurg 84:951–956, 1996

Bifrontal basal interhemispheric approach to

craniopharyngioma resection with or without division of
the anterior communicating artery
MASATO SHIBUYA, M.D., MASAKAZU TAKAYASU, M.D., YOSHIO SUZUKI, M.D.,
KIYOSHI SAITO, M.D., AND KENICHIRO SUGITA, M.D.
Department of Neurosurgery, Nagoya University School of Medicine, Nagoya, Japan

U The authors describe the use of a bifrontal basal interhemispheric approach with or without division of the anteri-
or communicating artery (ACoA) for removal of large craniopharyngiomas. This approach is a more basal modifica-
tion of the anterior interhemispheric approach, allowing preservation of most bridging veins. Since 1988, 22 patients
underwent operations using this approach to achieve total or near-total excision of large craniopharyngiomas. Division
of the ACoA was performed in 11 of 17 patients with retrochiasmatic tumors with no early or late complications relat-
ed to division of the artery. There were no operative mortalities. Visual improvement (59%) and preservation of the
pituitary stalk (64%) were achieved in a high percentage of patients. Preservation of the pituitary stalk correlated well
with postoperative pituitary function. The bifrontal basal interhemispheric approach allowed a bilateral, wider opera-
tive field with better orientation and views of important neural structures and perforating arteries without requiring
combination with other approaches. When the ACoA limited operative exposure, the artery could be divided safely.
The authors discuss indications for, and advantages of, the bifrontal basal interhemispheric approach with or without
division of the ACoA in the removal of large craniopharyngiomas.

KEY WORDS • anterior communicating artery • craniopharyngioma • pituitary stalk •

interhemispheric approach • surgical approach

LTHOUGH controversy still exists regarding the opti- vides additional space. In the present report we discuss

A mum treatment of craniopharyngiomas, all neuro-

surgeons agree that total removal of the tumor is
desirable if it can be done safely.1,4,7,15,16 However, suc-
cessful radical excision of craniopharyngioma remains
one of the most difficult procedures in the era of micro-
surgery. Surgeons use several different approaches, de-
pending on the location and size of the tumor as well as on
the surgeon’s preference. These include transsphenoidal,
pterional, transcortical–transventricular, subfrontal, sub-
temporal, transtemporal, anterior interhemispheric, and
anterior transcallosal approaches, which are used alone or
in combination.1,3,6,8,9,11,14–16 In our institution, a bifrontal
basal interhemispheric approach has been used since 1988
primarily for operations involving large craniopharyn-
giomas. This approach is a more basal modification of
the anterior interhemispheric approach17 that has proved
advantageous in the removal of large craniopharyn-
giomas. It allows a bilateral, wider operative field with
better orientation and views of important neural structures
and perforating arteries without requiring combination
with other approaches. Most of the bridging veins can
be preserved using this method. However, occasionally
the anterior communicating artery (ACoA) may limit the
exposure. In such instances, division of the ACoA pro-
indications for, and advantages of, using the bifrontal
basal interhemispheric approach with or without division
of the ACoA in the removal of large craniopharyngiomas.
Clinical Material and Methods
Since 1988, 22 patients underwent operations using the
bifrontal basal interhemispheric approach to achieve total
or near-total excision of large craniopharyngiomas. These
patients ranged in age from 2 to 64 years; there were 12
females and 10 males. The presenting symptoms were
visual disturbance in 18 patients, signs of hydrocephalus
in two, amenorrhea in one, and mental disturbance in two
patients. The maximum diameter of the tumors evaluated
by magnetic resonance (MR) imaging or computerized to-
mography (CT) scanning was 27 to 69 mm (average 41 6
12 mm, mean 6 standard deviation (SD)). Fourteen
tumors (64%) were larger than 40 mm. Five patients
(23%) had prechiasmatic tumors and 17 patients (77%)
had retrochiasmatic tumors (Table 1). Bilateral carotid
angiography was performed preoperatively and the devel-
opment of the ACoA and the A1 and A2 segments was
carefully evaluated to ascertain whether the ACoA could

J. Neurosurg. / Volume 84 / June, 1996 951

 M. Shibuya, et al.

TABLE 1 The olfactory nerves are dissected from the basal sur-
Characteristics and outcomes of 22 patients who underwent a face of the frontal lobes bilaterally all the way to the ol-
bifrontal basal interhemispheric approach with or factory trigone. This maneuver minimizes the risk of in-
without division of the ACoA* advertent damage to the nerves during retraction of the
frontal lobes. Both frontal lobes are retracted together
Characteristics Preserved ACoA Divided ACoA Total
& Outcomes (11 patients) (11 patients) (22 patients) with the superior sagittal sinus, and dissection of the inter-
hemispheric fissure is performed only from the basal side,
characteristics not from the convexity surface (Fig. 1 right). Therefore,
age (yrs) the extent of dissection in the area of the fissure is less
,18 4 5 9 (41%)
$18 7 6 13 (59%) than that caused by the conventional anterior approach
follow-up period (mos)† 35 6 23 31 6 15 33 6 19 and most of the bridging veins that drain into the superior
tumor size (mm)† 42 6 14 40 6 11 41 6 12 sagittal sinus are preserved. The arachnoid dissection is
tumor location directed toward the pre- and suprachiasmal region, expos-
prechiasmatic 5 0 5 (23%) ing the A2 segment bilaterally, the genu of the corpus cal-
retrochiasmatic 6 11 17 (77%)
losum, the ACoA, and the chiasm. Usually, the brain be-
outcomes comes sufficiently slack after removal of cerebrospinal
tumor recurrence 2 1 3 (14%)
visual acuity
fluid from the basal cisterns. In cases of prechiasmatic
improved 7 6 13 (59%) tumors, the ACoA is compressed and displaced supero-
unchanged 4 3 7 (32%) posteriorly and the artery usually does not affect the oper-
deteriorated 0 2 2 (9%) ative approach. On the other hand, in cases of retrochias-
mental problems matic tumors, the ACoA is located anterior to the tumor
preop 1 2 3 (14%)
postop 2 3 5 (23%)
and often limits operative exposure. Division of the
pituitary stalk ACoAs may be necessary for the removal of the latter type
preserved 8 6 14 (64%) of tumor.
severed 1 3 4 (18%) The lamina terminalis is opened in the midline. Internal
undetected 2 2 4 (18%) decompression is the next step toward removal of the tu-
* ACoA = anterior communicating artery. mor. The cyst is punctured and intracapsular removal of
† Values expressed are the mean 6 standard deviation. the tumor is done using a smooth or serrated suction tube
to extract the solid part of the tumor.13 The two-suction
method is useful for this purpose. Chemical meningitis is
prevented by avoiding spillage of cyst fluid into the sub-
be divided safely. The indication for division of the ACoA arachnoid space; this is accomplished using cottonoid
was determined in patients with retrochiasmatic tumors by coverage of the surrounding operative field as well as con-
weighing the importance of a wider exposure for total tinuous suction drainage through a small silastic tube
removal of the tumor with the disadvantage of sacrificing placed in the bottom of the operative field. Sufficient
the ACoA. internal decompression facilitates the following step of
Endocrine studies included preoperative and postopera- capsular dissection from adjacent vital structures such as
tive measurement of basal serum levels of adrenocorti- the hypothalamus.
cotropic hormone (ACTH), growth hormone (GH), and At this stage the surgeon must decide whether the
thyroid-stimulating hormone (TSH). Provocation testing ACoA should be divided. The artery is one of the main
was only performed in limited cases. Insulin (0.1 U/kg) structures limiting operative exposure of retrochiasmatic
and thyroid-releasing hormone (TRH; 500 U) were craniopharyngiomas in the anterior interhemispherical
administered intravenously for provocation testing of approach (Fig. 2 left). Although we always try to preserve
ACTH, GH, and TSH. The provocation test results were the artery, dividing it often provides a much wider operat-
judged as normal when the ACTH level increased to more ing space, which subsequently makes the operation easier
than twice the basal value, the GH level increased to and safer (Fig. 2 right). When the artery is left intact, it
more than 10 ng/ml, and the TSH level increased to more may inadvertently be damaged during retraction of the
than 10 mU/ml. hemispheres, especially in pediatric cases in which one
encounters thin-walled arteries. The ACoA is occluded
Operative Technique with small vascular clips and incised between the clips.
The patient is placed supine with the neck slightly The hypothalamic arteries must always be preserved, even
extended. A bicoronal skin incision is made behind the if they look small. The cut edges of the artery and the vas-
hairline and subperiosteal dissection of the skin flap is cular clips are covered with Biobond (glue)-soaked oxycel
extended to the glabella and the orbital ridges. The supra- to prevent slippage of the clips. Clipping and dividing of
orbital nerves are preserved. A bifrontal craniotomy is the ACoA may be difficult when it is too short and many
performed, which includes removal of the nasal part of the perforating arteries branch off from the artery. When one
frontal bone in a single continuous bone flap or separate side of the A1 segment is hypoplastic, it may be divided
flaps (Fig. 1 left). The frontal sinus is almost always instead of the short ACoA, although we have not had such
opened, the mucosa is pushed downward, and the inner a case.
table of the sinus and the crista galli are removed with The tumor usually adheres most tightly to the chiasm,
rongeurs or air drills. The falx and the superior sagittal pituitary stalk, or hypothalamus, whereas it usually sepa-
sinus are divided after double ligation. rates easily from the upper wall of the third ventricle. The

952 J. Neurosurg. / Volume 84 / June, 1996

Bifrontal basal interhemispheric approach to craniopharyngiomas

FIG. 1. Drawings displaying the bifrontal basal interhemispheric approach. Left: Skin incision and craniotomy. A
bifrontal craniotomy is performed, which includes removal of the nasal part of the frontal bone in separate bone flaps.
Right: The extent of dissection of the interhemispheric fissure. The dissection area of the fissure in this approach (A) is
much less than that created in the conventional anterior interhemispheric approach (B). Most of the bridging veins drain-
ing into the superior sagittal sinus are preserved in the bifrontal basal interhemispheric approach.

bilateral, wider exposure obtained by this approach en-
ables the surgeon to view the lesion from many different
angles and to locate the dissection plane between the
tumor capsule and the important neural structures or per-
forating arteries on both sides. Consequently, there is a
good chance of preserving the hypothalamus, pituitary
stalk, and perforating arteries using this approach. More-
over, the wider operative field reduces blind operative
procedures and facilitates complete tumor resection.
Illustrative Case
Examination. This 51-year-old man was referred to
our hospital for visual disturbance. His visual acuity was
20/100 on both sides. Goldmann’s perimetry showed a
binasal lower quadrantanopsia with central scotoma in the
lower half of both eyes. Gadolinium-enhanced MR imag-
ing showed a well-enhanced multilobular suprasellar solid
mass, 40 mm in diameter, in the third ventricle (Fig. 3
left). The pituitary stalk was clearly shown in the midline
on the coronal image (Fig. 3 center).
Operation. The operation was performed using the bi-
frontal basal interhemispheric approach. When the inter-
hemispheric fissure was dissected, as described previous-
ly, the pituitary stalk could be clearly seen below the
chiasm. The lamina terminalis was bulging and was
opened in the midline, avoiding damage to the hypotha-
lamic arteries. A yellowish, granulomatous, solid tumor
appeared in the third ventricle. The tumor was tough and
could not be removed by suction using the usual smooth
tip. However, a serrated suction tip was effective in cut-
ting and removing the tumor. Fortunately, the tumor did
not adhere tightly to the wall of the third ventricle except
behind the optic chiasm and thus could be retracted infe-
riorly as it was removed little by little. Initially, the ACoA
was preserved; however, total removal of the tumor ap-
peared to be impossible without sacrificing the artery. The
ACoA was fenestrated with a median artery of the corpus
callosum arising from it. A wide operative field was
obtained when the ACoA was cut between two Weck
clips. Additional parts of the tumor were removed by
means of scissors, bipolar cutting, and suction. The por-
tion of tumor that tightly adhered behind the optic chiasm
was dissected using a silver dissector under direct vision,
which was obtained by changing the angle of the micro-
scope. Fortunately, there was a membrane separating the
tumor from the perforating arteries, and the tumor could
be totally removed without disturbing these vessels (Fig.
3 right). The pituitary stalk was left intact.
Postoperative Course. Postoperatively, the patient ex-
hibited diabetes insipidus and required hormone replace-
ment for a few months. By 6 months after the operation
he was able to do well without hormone replacement.
His vision improved markedly postoperatively (right eye,
20/40, left eye, 20/20) and his visual fields widened. He
still has central scotoma in the lower halves of both eyes.
Although his olfaction decreased slightly postoperatively,
he experiences no difficulties in daily life.
FIG. 2. Drawings depicting the operative view in a patient with
a retrochiasmatic craniopharyngioma before (left) and after (right)
division of the anterior communicating artery. The broken line
shows the extent of the tumor. Division of the artery provides a
much wider operating space, subsequently making the operation
easier and safer.

J. Neurosurg. / Volume 84 / June, 1996 953


FIG. 3. Gadolinium-enhanced magnetic resonance images showing a retrochiasmatic craniopharyngioma in our illus-
trative case (left). The pituitary stalk is clearly shown in the midline on the coronal image (center). Postoperatively, total
removal of the tumor is shown (right).
Results
Patient follow-up periods in this study ranged from 4 to
78 months (33 6 19 months, mean 6 SD) (Table 1). Total
or near-total removal of the tumors was confirmed in
all cases by postoperative CT or MR imaging studies.
Division of the ACoAs was performed in 11 (65%) of 17
patients with retrochiasmatic tumors and in none of the
five patients with prechiasmatic tumors. In a 2-year-old
boy, the ACoA was initially left intact but was lacerat-
ed during retraction of the frontal lobes and eventually
divided.
No operative mortality occurred. However, three late
deaths occurred during the follow-up period. One patient
died of acute subdural hematoma caused by a fall 5 years
after the operation. Another man, who had preoperative
mental disturbance and postoperative deterioration, ran
away from the hospital 8 months after operation and was
found dead 1 month later in an abandoned house where he
had lived before hospitalization. The third patient, an 18-
year-old woman who had the entire tumor removed with a
section of the pituitary stalk, appeared to be well until 3
years postsurgery, when she suddenly became ill and died
within a day, probably due to acute pituitary insufficiency.
Three patients experienced recurrence of their tumors 16
months, 20 months, and 5 years after the initial operation.
In two of these patients the ACoA was not divided, which
might have prevented complete removal of the tumor. The
pituitary stalks were severed in two of these patients and
preserved in the remaining one.
Postoperative visual function tests, including visual
acuity and visual fields, showed improvement in 13 pa-
tients, no change in seven, and deterioration in two pa-
tients (Table 1). Mental disturbance was noted in five
patients, three of whom had experienced such disturbance
preoperatively (Table 1). Postoperative visual and mental
functions were similar between patients with and without
division of the ACoA.
The pituitary stalk was anatomically preserved in 14
patients (64%), severed in four (18%), and unidentified in
the remaining four patients (18%) (Table 1). All patients
had diabetes insipidus postoperatively except one, but
their illness was well controlled with a course of 1-
desamine-8-D-arginine vasopressin (DDAVP). Correla-
954
M. Shibuya, et al.
tion between preservation of the pituitary stalk and basal
serum levels of pituitary hormones was investigated (Ta-
ble 2). Basal serum levels of ACTH and TSH were with-
in a normal range postoperatively in approximately one-
half of the patients whose pituitary stalks were preserved.
On the other hand, only one of the patients whose pituitary
stalk was undetected or severed showed normal serum
levels of ACTH and TSH postoperatively. Only six
patients in this series underwent both preoperative and
postoperative provocation tests of ACTH, GH, and TSH.
In this group the pituitary stalks were preserved in five
patients and severed in one. Provocation tests of GH se-
cretion were negative both preoperatively and postopera-
tively in all six patients, suggesting friability of the pi-
tuitary–GH axis. On the other hand, ACTH and TSH
showed a normal or subnormal response to the provoca-
tion tests preoperatively. Postoperative ACTH and TSH
provocation tests did not elicit any response in the patient
whose pituitary stalk was severed, although they showed
normal and subnormal responses in two and three patients,
respectively, of the five patients whose pituitary stalks
were preserved. Correlation between preservation of the
pituitary stalk and postoperative hormone replacement is
shown in Table 3. The degree of hormone replacement
was classified into three types: none, needing no hormone
replacement; mild, requiring no daily hormone replace-
ment except DDAVP; and strict, requiring strict daily
replacement of corticosteroid and thyroid hormone. When
the pituitary stalk was anatomically preserved during the
operation, postoperative hormone replacement was none
or mild in more than half of cases. On the other hand, in
cases in which the pituitary stalk was severed or undetect-
ed, hormone replacement had to be strict in all but one
case. Results in postoperative pituitary function were sim-
ilar in patients with and without division of the ACoA.
No other major morbidity, such as hemiparesis or cra-
nial nerve palsy, was noted in these patients.
Discussion
We have shown the usefulness of the bifrontal basal
interhemispheric approach with or without division of the
ACoA for large craniopharyngiomas in a series of 22
J. Neurosurg. / Volume 84 / June, 1996
Bifrontal basal interhemispheric approach to craniopharyngiomas
TABLE 2
Correlation between preservation of the pituitary stalk and
normal levels of basal serum ACTH and TSH*
Pituitary Stalk (no. of patients)
Normal Levels Preserved Undetected
of Basal Serum (12 patients) (3 patients) (2 patients)
ACTH (>10 pg/ml)
preop 12 1 2
postop 6 1
TSH (>0.5 mU/ml)
preop 8 3
postop 5 0
* Based on total number of cases with measurement of basal serum
ACTH and TSH. ACTH = adrenocorticotropic hormone; TSH = thyroid-
stimulating hormone.
patients. Total or near-total removal of the tumors was
performed in all patients with reasonably low morbidity
and no operative mortality.
A bifrontal anterior interhemispheric approach has been
advocated for use in removing third ventricular tumors by
Suzuki, et al.14 This bilateral approach provides a wider
operative view of the anterior circle of Willis, the optic
chiasm, and the third ventricular tumor itself, minimizing
damage to the brain and vessels. One disadvantage of this
approach, however, is that it often requires sacrifice of the
bridging veins that connect the medial superior aspects of
the frontal lobe and the superior sagittal sinus. Division of
the bridging veins, when combined with prolonged retrac-
tion of the frontal lobes, increases the risk of postoperative
cerebral ischemia and contusional hemorrhage.10
A basal interhemispheric approach has been described
by Yasui and colleagues17 as a modification of the anteri-
or interhemispheric approach for surgery of anterior com-
municating aneurysms, although these surgeons have used
unilateral dissection. Advantages of this approach are: 1)
most bridging veins are preserved because few veins of
significant size are found near the frontal base; 2) the
extent of dissection in the area of the interhemispheric fis-
sure is much less (limited to only the basal part of the fis-
sure) and, consequently, the operative time is shorter and
brain damage may be less; and 3) the upper part of the
third ventricular tumor can be visualized better from the
lower angle. Samii and Samii11 recommended a subfrontal
approach with a similar craniotomy to ours for removing
craniopharyngiomas. However, their approach was made
via a subfrontal space without dissecting the interhemi-
spheric fissure, which might require more retraction of the
frontal lobe.
We believe that bilateral median approaches are superi-
or to unilateral ones, such as the pterional approach, in the
removal of large midline tumors because of the parasagit-
tal alignment of important neural structures and perfora-
tors. In the unilateral approaches, important structures on
the contralateral side are located in a blind spot behind the
tumor, and the ipsilateral perforators located on the side of
the approach interfere with tumor dissection. On the other
hand, bilateral median approaches allow direct visualiza-
tion of both sides of these structures. Perforating arteries
do not disturb the operative view in the more median route
J. Neurosurg. / Volume 84 / June, 1996
TABLE 3
Correlation between preservation of the pituitary stalk and
postoperative hormonal replacement
Pituitary Stalk (no. of patients)
Severed Preserved Undetected Severed
Hormone Replacement* (14 patients) (4 patients) (4 patients)
none 1 0 0
mild 7 1 0
0 strict 6 3 4
1 * None = no hormone replacement needed; mild = no daily hormone
replacement other than pitressin needed; strict = strict daily replacement
0
was indispensable.
used in the basal interhemispheric approach. The hypo-
thalamus is one of the most important structures requiring
careful handling during surgery. When the hypothalamus
is involved in the tumor, one side of the gland is usually
more severely infiltrated than the other. The preoperative
coronal MR image helps to identify the extent of tumor
invasion into the hypothalamus. Because unilateral hypo-
thalamic damage does not seem to cause severe problems
postoperatively,16 one can identify the less infiltrated side
of the hypothalamus and preserve that side more easily.
The ACoA often limits lateral exposure of retrochias-
matic tumors in the anterior interhemispheric approach.
We have divided this artery without significant early or
late complications in 11 of 17 cases of retrochiasmatic
tumors. This procedure, also described by others,3,8,14 pro-
vided a much wider operating space, which made the op-
eration easier and safer in these cases. Although preserva-
tion of the artery should be attempted, an undivided
ACoA may be damaged inadvertently during retraction of
the hemispheres. A proper and early decision regarding
whether to divide the ACoA increases the ease and safety
of the operation. Since we started to use this approach,
the ACoA has been subjected to more careful scrutiny.
Interestingly, approximately 60% of patients had some
type of anomaly around the artery, such as a duplication of
or window formation in the ACoAs, the median artery of
the corpus callosum, the accessory middle cerebral artery,
and the azygos anterior cerebral artery, as indicated by
Serizawa and coworkers.12 These variations in arteries
should be carefully examined when the ACoA is divided.
Recurrence rates of craniopharyngiomas after what was
believed to be a total excision are surprisingly high in
spite of the benign histological nature of this tumor. The
recurrence rate has been reported as 5.5% by Symon and
Sprich,15 7% by Yasargil, et al.,16 and 29% by Hoffman, et
al.9 In our relatively small series, three patients experi-
enced recurrence during the follow-up period. To reduce
recurrence of the tumor, it may be important to minimize
blind spots during the operation, using an approach that
allows a wider exposure. The bifrontal basal interhemi-
spheric approach is useful for this purpose.
Another important issue relevant to recurrence is the
use of GH in children. Growth hormone was used in both
of our cases of recurrent tumor in children. In one of these
patients, the tumor was believed to have been totally re-
moved together with the pituitary stalk. In the other
patient, a minimum portion of tumor capsule was left on
955

the stalk. Administration of GH had to be stopped in both
patients after recurrence of the tumors was confirmed.
Whether use of GH induces tumor recurrence is an unset-
tled question;2,5 however, it is not recommended for pa-
tients with residual tumors.
Postoperative improvement in visual function was ob-
tained in more than half of the patients in our series (13
cases) and deterioration was observed in only two pa-
tients. These results seem to be better than those reported
in recent series, in which unilateral approaches were pri-
marily used.9,16 The bifrontal basal interhemispheric ap-
proach enables the surgeon to identify both sides of the
optic nerves, chiasm, and the optic tracts, possibly allow-
ing more chance for postoperative visual improvement.
Anatomical preservation of the pituitary stalk was ob-
tained in 64% of our cases. This value is much higher than
that reported by Yasargil, et al.16 (36.5%). When the pitu-
itary stalk was anatomically preserved during the op-
eration, postoperative hormone replacement was none or
mild in more than half of the cases, whereas it had to
be strict in all but one case in which the pituitary stalk
was severed or undetected. Although anatomical preser-
vation does not necessarily mean preservation of function,
patients have a greater chance of remaining free from
strict postoperative hormone replacement therapy. More-
over, severe endocrine dysfunction might be related to one
late death in our series, in which the patient’s pituitary
stalk was severed during the operation. Preservation of the
stalk does not seem to increase the recurrence rate.
Conclusions
The present results suggest that the bifrontal basal in-
terhemispheric approach with or without division of the
ACoA is a useful and safe procedure for removal of large
craniopharyngiomas. When the ACoA limits operative
exposure, division of the artery can be accomplished safe-
ly without significant early or late complications.
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Manuscript received September 21, 1995.
Accepted in final form January 17, 1996.
Address reprint requests to: Masato Shibuya, M.D., Depart-
ment of Neurosurgery, Nagoya University School of Medicine, 65
Tsurumai-cho, Showa-ku, Nagoya 466, Japan.
J. Neurosurg. / Volume 84 / June, 1996