Early postoperative complication profile and acute hypothalamic dysfunction grading after surgery for adult intraventricular craniopharyngiomas: a single-center retrospective cohort study.

Abstract

Background: Intraventricular craniopharyngiomas in adults are rare lesions, and their surgical treatment is associated with a risk of hypothalamic, cognitive, and seizure-related morbidity. Early postoperative complications in this subgroup remain insufficiently characterized.

Objective: To characterize the frequency and pattern of early postoperative complications in adults with intraventricular craniopharyngiomas, with particular focus on early postoperative MMSE change, new-onset seizures, and the severity of acute diencephalic syndrome (DS) according to an original four-stage grading scale.

Materials and methods: We retrospectively analyzed 62 adult patients older than 45 years who underwent microsurgical treatment via either a transcallosal approach (n = 30) or a transcortical transventricular approach (n = 32) between 2015 and 2025. Early postoperative outcomes included MMSE change, new-onset seizures within 30 days, and DS severity. DS was graded using a four-stage scale incorporating level of consciousness, thermoregulation, water-electrolyte and endocrine disturbances, autonomic-hemodynamic instability, and respiratory dysfunction. Comparisons between surgical approaches were considered exploratory because approach selection was non-randomized.

Results: In the overall cohort, the mean MMSE score decreased from 27.4 ± 2.1 preoperatively to 24.8 ± 3.5 in the early postoperative period (p < 0.05). Early postoperative MMSE decline ≥ 3 points was observed in 17 patients (27%). This decline was numerically more frequent after the transcallosal approach than after the transcortical approach (33% vs. 22%), but the difference was not statistically significant (p = 0.29). New-onset postoperative seizures occurred in 9 patients (15%) and were numerically more frequent after the transcortical approach (22% vs. 7%, p = 0.09), particularly in patients with large tumors. Acute DS of varying severity developed in 47 patients (76%). Severe-to-critical DS, defined as stages III-IV, occurred in 5 patients (8%) and was associated with destruction of the third ventricular floor (p = 0.02). No severe-to-critical DS was observed when the third ventricular floor was preserved, whereas after gross-total resection with floor destruction, severe-to-critical DS occurred in 4 of 13 patients (31%), including two fatal stage IV cases.

Conclusions: Early postoperative morbidity after surgery for adult intraventricular craniopharyngiomas includes screening-based MMSE decline, new-onset seizures, and acute diencephalic dysfunction. Approach-related differences in MMSE decline and seizure incidence were numerical and should be interpreted cautiously because of baseline differences between groups. Severe-to-critical DS was closely related to destruction of the third ventricular floor and was most frequent after gross-total resection in this anatomical subgroup. The proposed four-stage DS grading scale may provide a practical framework for early monitoring and risk stratification, but it should be regarded as an exploratory clinical tool requiring prospective validation.