BACKGROUND: Suprasellar masses commonly include craniopharyngiomas and pituitary adenomas. Suprasellar glioblastoma is exceedingly rare with only a few prior case reports in the literature. Suprasellar glioblastoma can mimic craniopharyngioma or other more common suprasellar etiologies preoperatively.
METHODS: A 65-year-old male with no significant history presented to the emergency department with a subacute decline in mental status. Work-up revealed a large suprasellar mass with extension to the right inferior medial frontal lobe and right lateral ventricle, associated with significant vasogenic edema. The patient underwent an interhemispheric transcallosal approach subtotal resection of the interventricular portion of the mass. Pathological analysis revealed glioblastoma, MGMT partially methylated, with a BRAF V600E mutation.
CONCLUSIONS: Malignant glioblastomas can mimic benign suprasellar masses and should remain on the differential for a diverse set of brain masses with a broad range of radiological and clinical features. For complex cases accessible from the ventricle where the pituitary complex cannot be confidently preserved via a transsphenoidal approach, an interhemispheric approach is also a practical initial surgical option. In addition to providing diagnostic value, molecular profiling may also reveal therapeutically significant gene alterations such as BRAF mutations.

Eosinophilic angiocentric fibrosis (EAF) is a rare progressive fibrosing lesion involving the nasal cavity, paranasal sinuses, and the upper respiratory tract. There are few reports that it rarely involves the orbit; however, there is no report of intracranial involvement. Here, we report and share our experience with a rare case of primary intracranial EAF. A 33-year-old woman with a history of a suprasellar mass and unsuccessful surgical and medical treatment referred to us. Physical examination demonstrated right-sided blindness and ptosis, left-sided decreased visual acuity, and visual field defect. The brain imaging revealed an extra-axial intradural well-defined large suprasellar mass with parasellar (more on the right side) and retrosellar extension. Via pterional craniotomy and subfrontal approach, a very firm creamy-brownish well-defined fibrotic mass was encountered. The tumour texture was too firm to be totally resected. The microscope exited the surgical field off, and the tumour was incompletely resected using a rongeur. The histopathology finding favoured EAF. Further histopathology evaluation failed to show histologic features of IgG4-related disease. Although the preoperative diagnosis of EAF is impossible, in the setting of an indolent slow-growing lesion demonstrating hypointensity on the T2 image sequence of MRI (magnetic resonance imaging), EAF should be considered a differential diagnosis. In the setting of this diagnosis, the systemic and other organ involvement for a diagnosis of IgG4-RD should be evaluated. However, more cases are needed to illustrate the relation between these two entities.

The sellar, suprasellar, and parasellar space contain a vast array of pathologies, including neoplastic, congenital, vascular, inflammatory, and infectious etiologies. Symptoms, if present, include a combination of headache, eye pain, ophthalmoplegia, visual field deficits, cranial neuropathy, and endocrine manifestations. A special focus is paid to key features on CT and MRI that can help in differentiating different pathologies. While most lesions ultimately require histopathologic evaluation, expert knowledge of skull base anatomy in combination with awareness of key imaging features can be useful in limiting the differential diagnosis and guiding management. Surgical techniques, including endoscopic endonasal and transcranial neurosurgical approaches are described in detail.

The pedicled nasoseptal flap (NSF) is the mainstay for endoscopic skull base reconstruction. We present a novel technique using a semirigid chondromucosal NSF that improves the reinforcement and protection of intracranial structures.
Composite NSFs were performed to repair intraoperative high-flow cerebrospinal fluid leaks in 2 patients who had undergone endoscopic endonasal resection of a suprasellar mass. The surgical technique and postoperative outcomes are described.
The flaps were sufficient for defect coverage, and the patients did not experience any cerebrospinal fluid leak in the immediate and delayed postoperative periods. No complications related to the composite flap had developed.
The composite chondromucosal NSF is a reliable reconstruction option for select ventral cranial base reconstruction cases with the potential to improve the protection of intracranial structures. Additional surgical cases and longer follow-up are required for a better assessment of long-term outcomes.

UNASSIGNED: To illustrate the structure-function relationship of compressive optic neuropathy (CON) at the time of diagnosis.
UNASSIGNED: Thirty-two eyes of newly diagnosed suprasellar CON and 60 healthy eyes were included in the study. The peripapillary retinal nerve fiber layer (RNFL) thickness and macular ganglion cell-inner plexiform layer (GCIPL) thickness were obtained using Cirrus spectral domain optical coherence tomography (SD-OCT). CON eyes were stratified based on the similar degree and pattern of both RNFL and GCIPL.
UNASSIGNED: From 32 eyes of newly diagnosed suprasellar CON eyes, 27 eyes had a predominantly nasal hemiretina thinning of macular GCIPL, 4 eyes showed a generalized macular thinning, and 1 eye showed a predominantly superior macular thinning. The corresponding temporal peripapillary RNFL thinning with nasal hemiretina GCIPL thinning were inconsistently manifested. Structure-function analysis of stratified CON eyes with similar thinning profiles showed that a range rather than a fixed value of visual field loss based on mean deviation (MD) index was associated to each thinning profile. The maximal limit of visual field loss range was ubiquitously nonrestricted to any structural thinning profile. While the minimal limit of the associated MD range was gradually reduced from 0 to about -16.0 dB, the nasal hemiretina macular GCIPL thinning was the only manifestation and decreased from 75 to 45 µm. However, the different degrees of temporal hemiretina macular GCIPL and superior-inferior peripapillary RNFL thinning were only seen in 10 of 32 eyes of which their nasal hemiretina GCIPL and temporal RNFL thinning had reached significant thinning. Interestingly when present, the minimal limit of associated MD range continued to decrease from -16.0 to -32.0 dB.
UNASSIGNED: CON eyes can present with variable structure and function relationship at the time of diagnosis. Using structural parameters at the time of diagnosis to predict the prognosis should be used with caution.

Cavernous malformations are benign vascular lesions that can arise throughout the central nervous system. The occurrence of a cavernous malformation within the optic nerve or chiasm, however, is extremely uncommon. The case described in this video involved a 36-yr-old woman who presented 3 mo after undergoing a left frontotemporal craniotomy for resection of an optic nerve cavernous malformation. She had initially presented to an outside hospital with vision loss, and the left optic nerve lesion was identified and resected. Although her vision had reportedly improved slightly postoperatively, she awoke 3 mo later with bilateral subjective blurriness and new visual field deficits. Magnetic resonance imaging revealed enlargement of the left optic apparatus hemorrhagic lesion, corresponding to residual cavernous malformation. Given the recurrence of hemorrhage and the associated visual symptoms, the patient underwent a redo left frontotemporal craniotomy for resection of the optic nerve and chiasmal lesion. Histopathologic evaluation revealed thick-walled vessels with focal intervening glial tissue, an absence of neoplastic cells, and hemorrhage, consistent with a cavernous malformation. The patient tolerated the procedure well. Postoperatively, she experienced immediate amelioration in her visual symptoms. She was discharged home on postoperative day 3, and her bitemporal visual field deficit continued to progressively improve through her last ophthalmologic appointment 14 mo after surgery. Postoperative and subsequent surveillance neuroimaging demonstrated complete resection of the cavernous malformation without evidence of recurrence. This case demonstrates the techniques utilized to ensure complete resection of the malformation in this very eloquent region. The patient provided consent for publication.

The orbitopterional approach provides an excellent combination of basal access and suprasellar access. This approach also allows for less brain retraction when resecting larger suprasellar tumors that are more superiorly projecting due to a more frontal and inferior trajectory. In this operative video, the authors thoroughly detail an orbitopterional craniotomy utilizing a one-piece modified orbitozygomatic technique. This technique involves opening the craniotomy through a standard pterional incision. The craniotomy is performed using the standard three burr holes of a pterional approach; however, the osteotomy is extended anteriorly through the frontal process of the zygomatic bone as well as through the supraorbital rim. In this operative video atlas, the authors illustrate the operative anatomy, as well as surgical strategy and techniques to resect a large suprasellar craniopharyngioma in a 4-year-old male. Other reasonable approach options for a lesion of this size would include a standard pterional approach, a supraorbital approach, or expanded endoscopic transsphenoidal approach. The lesion was quite high and thus, the supraorbital approach may confine access to the superior portion of the tumor. While recognizing that some groups may have chosen the endoscopic expanded transsphenoidal approach for this lesion, the authors describe more confidence in achieving the goal of a safe and maximal resection with the orbitopterional approach. The link to the video can be found at: https://youtu.be/eznsK16BzR8 .

Hemangioblastomas are rare vascular tumors most often found in the posterior fossa and cervical spinal cord and commonly associated with von Hippel-Lindau Disease. We report a case of sporadic hemangioblastoma in a patient without von Hippel-Lindau Disease. Imaging characteristics included a solid, suprasellar mass that was homogeneously enhancing. These findings most resembled a pituicytoma or choroid glioma because of the close association with the infundibulum and the homogeneous avid enhancement. Microscopically, the neoplasm was seen to be composed of vascular channels associated with foamy stromal cells, containing clear cytoplasmic vacuoles. Microscopic and immunohistochemical findings were consistent with hemangioblastoma. Hemangioblastomas are a rare form of vascular tumor most commonly associated with von-Hippel Lindau disease. Our finding of non-cystic hemangioblastoma arising from the infundibulum demonstrates that, while rare, hemangioblastomas should be considered on the differential diagnosis for an avidly enhancing suprasellar mass.

Masses in the sella and parasellar region comprise about 10% of all pediatric brain tumors but type and frequency differs from those in adults. Imaging is critical for diagnosis and characterization of these lesions. By assessing the site of origin, signal and contrast enhancement characteristics, and the presence or absence of characteristic patterns, differential diagnosis can narrow the possibilities. The clinical presentation is often characteristic for lesion type and should be considered. This article summarizes the characteristic imaging features of the most frequent pediatric tumors and tumor-mimicking lesions in children in this region.

Desmoplastic small round cell tumors (DSRCTs) are rare, aggressive neoplasms that typically arise from abdominal and pelvic peritoneum in young adults. Other primary sites are uncommon, and an intracranial origin is exceptionally rare. Here the authors report the first case of a DSRCT presenting as a primary suprasellar tumor causing panhypopituitarism and severe bitemporal hemianopia in a young man. Macroscopic debulking of the tumor was undertaken, and histology revealed features of DSRCT. Reverse transcription polymerase chain reaction confirmed the presence of Ewing\'s sarcoma-Wilms tumor 1 (EWS-WT1) gene rearrangement specific to DSRCT. Postoperative whole-body imaging showed no primary malignancy elsewhere. The tumor recurred 4 months after surgery, and this was followed by cervical and mediastinal lymph node metastases. The patient died 20 months after initial presentation of rapidly progressive disease. DSRCTs should be included in the differential diagnosis of an unusual suprasellar mass in young adults. Early diagnosis is essential, and once the tumor is identified histologically, gross-total resection and radical postoperative treatment involving radiotherapy, chemotherapy, and close surveillance are required because of the lesion\'s potential for rapidly progressive malignancy.