title: Shattering the Rock: Technique of Bilateral Optic Nerve Mobilization and Drilling Heavily Calcified Craniopharyngiomas for Its Excision.
abstract: BACKGROUND
  Resection of heavily calcified craniopharyngioma is quite challenging. The stretched optic nerves, perforators, and stalk are likely to be jeopardized further during attempts to break the calcified chunks, especially through narrow corridors. We describe a surgical technique to mobilize bilateral optic nerves and drill the calcified chunk to crumple it.
  
  
  METHODS
  This technique was used in 6 patients with heavily calcified craniopharyngiomas (2 recurrent) who had presented with progressive visual loss. Frontotemporal craniotomy was used in 5 patients, and fronto-temporo-orbito-zygomatic craniotomy was used in 1 patient with a large retrosellar component. The Sylvian fissure was widely split. The bilateral optic canal was deroofed, and the falciform ligament was cut to mobilize both optic nerves. The calcified tumor could be dissected and mobilized into the widened corridor where the tumor was drilled. Multiple holes were drilled in the calcified chunk to shatter it to small pieces. These pieces were then dissected from perforators and stalk, while protecting them.
  
  
  RESULTS
  Symptoms improved in all of the patients. Gross total excision could be achieved in 3 patients, near total excision in 2 patients (both recurrent), and subtotal excision in 1 patient (because of extensive skull base involvement). All of the patients had transient diabetes insipidus. Two patients who had preoperative hypopituitarism required long-term postoperative hormonal replacement. There were no approach-related complications.
  
  
  CONCLUSIONS
  Mobilizing bilateral optic nerves improves the exposure and allows dissection of arachnoid from calcified craniopharyngiomas. Its drilling through widened corridors helps to shatter it. Using the technique, the neurovascular structures can possibly be better preserved while achieving maximal resection.
authors.affiliation: Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India. Electronic address: drpravin_salunke@yahoo.co.uk.
authors.forename: Pravin
authors.initials: P
authors.lastname: Salunke
authors.affiliation: Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Apinderpreet
authors.initials: A
authors.lastname: Singh
authors.affiliation: Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Arsikere N
authors.initials: AN
authors.lastname: Deepak
mesh_terms: D000293:Adolescent; D000328:Adult; D002114:Calcinosis / Q000000981:diagnostic imaging / Q000601:surgery*; D002648:Child; D003397:Craniopharyngioma / Q000000981:diagnostic imaging / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D019635:Neurosurgical Procedures / Q000379:methods*; D009900:Optic Nerve / Q000000981:diagnostic imaging / Q000601:surgery*; D010911:Pituitary Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery*; D019291:Skull Base / Q000000981:diagnostic imaging / Q000601:surgery; D055815:Young Adult
keywords: Calcified craniopharyngioma; Drilling tumor; Optic nerve mobilization; Outcome