AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Background

Craniopharyngioma is a histologically benign, extra-axial, slow-growing tumor that predominately involves the sella and suprasellar space. Despite its histologic appearance, craniopharyngiomas occasionally behave like malignant tumors, they can metastasize, and patients can have severe symptoms that usually require surgery and/or radiation therapy (with intracystic chemotherapy in some pediatric patients). Recurrence, both local and along surgical tracts, has been reported, as has meningeal seeding. Characteristic radiographic findings help in differentiating craniopharyngiomas from other tumors that can occur in the same anatomic region. Zenker first described craniopharyngioma in 1857.

Pathophysiology

Craniopharyngiomas are dysodontogenic epithelial tumors derived from the Rathke cleft, which is the embryonal precursor to the adenohypophysis. The craniopharyngeal duct is the embryonal structure along which the eventual adenohypophysis and infundibulum migrate. Tumors can occur anywhere along the course of this duct from the pharynx to the sella turcica and third ventricle, which partially explains the location of the tumor (see Anatomy). The trigger for tumor growth is not clear; however, 3 distinct subtypes primarily based on histologic appearance have been described: adamantinomatous, papillary, and mixed.

Regarding adamantinomatous tumor (pediatric type), the classic and most common appearance of this tumor is that of a cystic tumor, usually with a solid component. A wide variation in size is observed. The cyst contains fluid that can vary in color, but it usually has a tan appearance similar to that of motor oil. The color is the result of suspended blood products, protein contents, and cholesterol crystals within the cyst fluid and may be secondary to repeated hemorrhage within the cystic cavity. Histologically, the cyst has a multistratified squamous epithelium with nuclear palisade, and the solid component demonstrates clumps of wet keratin, dystrophic calcifications, trabeculae, nests, and squamous or columnar epithelium.

An extensive fibrosis and inflammation (which is considerably more severe with recurrent tumors than with others) are also observed. These findings may result in dense adhesion to adjacent structures and vessels, which accounts for the difficulty in resecting craniopharyngiomas. Intimate interdigitation of the tumor tissue and encasement of the vasculature of the circle of Willis are often present. Gliosis can make the differentiation of these tumors from a primary glial tumor difficult. The tumoral interdigitation also explains why, recurrence is frequent in these tumors that are histologically benign and that appear to have been totally resected on intraoperative visual inspection.

The classic appearance of the papillary variant (adult type) is different from that of the other forms and involves only a solid component, which is typically seen without calcifications. The papillary type is frequently located in the third ventricle. These tumors are usually more encapsulated than the others and therefore more amenable to surgical resection. They demonstrate extensive squamous differentiation with the formation of pseudopapillae.

Unless otherwise indicated, the more common adamantinomatous type is the subtype referred to in this article.

Frequency

United States

Craniopharyngioma represents approximately 3-5% of intracranial tumors and 6-10% of pediatric brain tumors. In pediatric patients, craniopharyngiomas represent the most common intracranial tumor of nonglial origin and account for approximately 54% of all sellar and prechiasmatic tumors.

International

The international frequency is identical to that reported in the United States.

Mortality/Morbidity

A 5-year survival rate of more than 80% is observed in children when the tumor is treated with surgery and radiation. The overall 10-year survival rate is 64-96%.

• Many patients have permanent endocrinologic deficits after treatment, though visual disturbances are usually reversible.
• Craniopharyngiomas are slow-growing tumors in which morbidity results from the compression of nearby structures.
• In both children and adults, early intervention significantly reduces the recurrence rate. In adults, surgical morbidity is low (¡Ü12% with microsurgical techniques), and the mortality rate has been reported to be 0-3%. The size of the tumor at presentation determines the recurrence rate, which is approximately 83% for tumors larger than 5 cm and 20% for tumors smaller than 5 cm.

Race

No racial predominance is recognized.

Sex

The male-to-female ratio is equal.

Age

A bimodal age distribution is seen, with the first peak occurring in childhood and early adolescence, predominately at age 5-10 years. The second peak (for papillary types) occurs at age 40-60 years. A nearly even distribution in incidences is observed between both age groups.

Anatomy

Craniopharyngiomas have been surgically divided into 3 groups: sellar, prechiasmatic, and retrochiasmatic.

The tumors occur in suprasellar (75%), suprasellar and infrasellar (21%), or entirely intrasellar (4%) locations. Adamantinomatous-type tumors commonly can grow entirely within the sella, the third ventricle, the sphenoid sinus, or the nasal cavity (in rare cases). Craniopharyngiomas are usually avascular on angiography and may encase or displace vessels forming the circle of Willis. The internal carotid artery (ICA) is displaced laterally, the anterior cerebral artery (ACA) is displaced anteriorly, and the basilar artery is displaced posteriorly.

Three specific growth categories based on the relationship of the tumor to the vascular structures and the optic chiasm have been described: type A, type B, and type C.

In type A, the anterior communicating artery and the A1 segment of the anterior cerebral artery are not disturbed. This appearance occurs in tumors with little or no suprasellar bulge (ie, they are contained almost entirely within the sella). In type B, the anterior communicating artery and the A1 segment of the anterior cerebral artery are elevated, but no posterior displacement of the basilar artery is observed. The tumor protrudes anteriorly between the optic nerves and pushes the optic chiasm posteriorly. In type C, the anterior communicating artery and the A1 segment of the anterior cerebral artery are elevated, with posterior displacement of the basilar artery and stretching of the posterior communicating arteries. The tumor protrudes posteriorly, pushing the chiasm forward and causing it to abut the tuberculum sellae. These tumors typically obstruct the third ventricle and cause hydrocephalus.

Clinical Details

The clinical presentation of patients with craniopharyngioma consists of a broad spectrum of symptoms that range from asymptomatic to endocrine, visual, or psychological disorders. Many patients remain asymptomatic, while others have a progressively deteriorating clinical course. Because of the associated and frequent endocrine dysfunction, a complete endocrine pretreatment workup is frequently performed.

The most common presenting symptoms are headache, nausea, vomiting, and visual disturbances. The most common visual disturbances are bitemporal hemianopsia, homonomous hemianopsia, and amblyopia. Other common findings include oculomotor palsies, bizarre scotomas, blindness, asymmetric acuity deficiencies, and optic atrophy. Hydrocephalus may result from a tumor that obstructs the third ventricle. Papilledema frequently occurs. Visual disturbances usually improve after treatment, whereas most endocrine dysfunctions do not.

In children, growth failure and headaches are part of the most common presentation of pediatric patients with craniopharyngioma, and 5 years is the most common age when children present.

Other presenting symptoms are those of pituitary and adrenal hypofunction, diabetes insipidus, obesity, weakness, ataxia, coma, chemical meningitis (from rupture of cyst contents into subarachnoid space), and seizures. In particular, children can present with growth failure, obesity (one third to one half), and hypothyroidism (two thirds). Precocious puberty has been reported, as has diabetes insipidus (which affects up to one fifth of patients). Poor school performance is also common, as are psychological problems. Tumors larger than 5 cm have higher postoperative recurrence and morbidity rates than those of smaller tumors.

Preferred Examination

CT and MRI are the complementary examinations of choice. Today, the best imaging tool is MRI without and with contrast enhancement.

CT can clearly demonstrate the characteristic calcifications and size of the tumor, while MRI exquisitely demonstrates the size and extent of the tumor and involvement of the third ventricle. MRI results can confirm cystic features of the tumor. Sequences such as fluid-attenuated inversion recovery (FLAIR), gradient-echo (GRE), diffusion-weighted imaging, as well as MR spectroscopy, can be used to make a confident and correct diagnosis.

Plain radiography may show abnormalities; however, CT or MRI is still needed regardless of the plain radiographic findings. CT and MRI have supplanted angiography as the primary diagnostic technique; and today, magnetic resonance angiography (MRA) or CT angiography (CTA) may be helpful in differentiating the tumor from an aneurysm of the anterior communicating artery.

In the later postoperative period, CT can be performed to establish the baseline for future follow-up scans and to determine the number and size of residual flecks of calcification. In the immediate postoperative period (first 48 h) and later, gadolinium-enhanced MRI may be performed to establish a baseline appearance and to determine whether residual tumor is present.

Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have recently been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. As of late December 2006, the FDA had received reports of 90 such cases. Worldwide, over 200 cases have been reported, according to the FDA. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble movingor straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.

Limitations of Techniques

Nonenhanced CT may be required to detect calcifications if typical MRI findings are absent. A papillary-type lesion can be missed on MRI or CT when no characteristic cystic component is present or when lesions are not enhancing after the administration of intravenous (IV) contrast material (as in approximately 10% of patients).

MRI cannot be used in patients with pacemakers or implanted ferromagnetic metallic objects or in those with metallic foreign bodies in the brain, spinal cord, or soft tissues near important vascular structures. The use of MRI also is limited in patients with claustrophobia and in those unable to remain stationary for the required time. Both CT and MRI evaluations require IV contrast enhancement; therefore, IV access is needed.

DIFFERENTIALS

Section 3 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Other Problems to be Considered

Aneurysm
Germinoma
Teratoma
Dermoid/epidermoid
Ecchordosis
Choristoma
Eosinophilic granuloma
Inflammatory lesion
Sarcoidosis

RADIOGRAPH

Section 4 of 12  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

A lateral radiogram of the skull may demonstrate calcifications in either the sella turcica or suprasellar space (see Image 7), or it may demonstrate sellar expansion or erosion of clinoid process or dorsum sella (see Image 10). These calcifications can be confused with curvilinear calcifications observed with large aneurysms (occasionally referred to as egg-shell calcifications). An aneurysm can be differentiated on contrast-enhanced CT, which demonstrates characteristic enhancement of the remainder of the lumen of the aneurysm, and on MRI, which shows heterogeneity of signal intensity and misregistration artifact from turbulent or pulsatile flow in the aneurysm. MRA further helps to elucidate the diagnosis in questionable cases.

Degree of Confidence

The degree of confidence for a negative result is low because small calcifications can be missed easily. When observed, calcifications are a nonspecific finding. Soft-tissue visualization on plain radiography is poor; therefore, differentiation of the type of tumor present is not possible without further imaging.

False Positives/Negatives

The rate of false-negative results is high because calcified lesions can be missed easily.

CT SCAN

Section 5 of 12  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

On CT, the adamantinomatous-type tumor appears as a predominately cystic mass (see Image 8) with a solid component (>90%). The solid component appears isoattenuating and usually contains calcifications (>80%). The sella may be expansile, and hydrocephalus may be present, depending on the exact location of the tumor (see Anatomy). Papillary type is usually solid, isoattenuating, and rarely calcified. Occasionally, craniopharyngioma may appear as an intraventricular, homogeneous soft-tissue mass without calcifications but possibly with hypoattenuating regions; this is observed in the papillary subtype.

The location of the adamantinomatous subtype is characteristic because most are located in the sella or suprasellar region. Contrast enhancement is characteristic of the solid component (see Image 9) and cyst wall (90% cases), and an enhanced study may demonstrate displacement of the A1 segment of the anterior cerebral artery (see Image 12). Displacement of the optic chiasm also may be observed.

On CT, the cystic component of the tumor can be seen to extend anteriorly and/or laterally and typically wraps around the solid component. Conversely, the solid component characteristically extends posteriorly and laterally.

Degree of Confidence

The degree of confidence is high because CT is sensitive for calcifications and for visualizing the cystic nature of masses.

False Positives/Negatives

The noncalcified, papillary variant can be missed sometimes, as with MRI.

A Rathke cleft cyst is rarely calcified, whereas more than 90% of craniopharyngiomas are calcified.

Please refer to specific findings in the MRI section below for other differential diagnostic findings.

MRI

Section 6 of 12  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

On MRI, the more common adamantinomatous subtype appears as a predominately cystic suprasellar mass with a solid component (see Image 1). Characteristic calcifications may not be discernible, though gradient-echo (GRE) images may show susceptibility effects from calcified components. Cystic areas appear hyperintense on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images with heterogeneous isointense-to-hypointense solid components.

Changes in signal intensity vary on T1-weighted images depending on the cystic contents, which can appear hyperintense if they have a high protein, blood product, and/or cholesterol content in the classic adamantinomatous type. In the papillary variety, solid components appear isointense on T1-weighted images.

Magnetic resonance (MR) spectroscopy shows a prominent lipid spectrum (around 1 ppm) in terms of the cystic contents. Diffusion-weighted images demonstrate variable signal intensity, which reflects the cystic contents.

The sella may be expansile, and hydrocephalus may be present depending on the exact location of the tumor (see Anatomy). Occasionally, craniopharyngiomas appear as intraventricular, homogeneous, soft-tissue masses without calcifications. They may contain low-signal-intensity regions; this is observed in the papillary subtype.

The location of the adamantinomatous subtype is characteristic, with most tumors located in the sellar or suprasellar region (see Images 13-15). Contrast enhancement is characteristic (see Image 2, Image 6), and MR angiography may demonstrate displacement of the A1 segment of the anterior cerebral artery. Displacement of the optic chiasm may also be observed.

On MRI, the cystic component of the tumor can be observed to extend anteriorly and/or laterally and typically wraps around the solid component (see Images 4-5). Conversely, the solid component of the tumor characteristically extends posteriorly and laterally (see Image 3).

Adjacent brain parenchyma may show hyperintensity on T2-weighted or FLAIR images, which indicates edema from compression of optic chiasm and/or tracts, gliosis, or tumor invasion. Recurrence in both local tumor bed and along surgical tracts may be due to implantation of craniopharyngioma tissue. Therefore, long-term follow-up should be performed, even in patients whose primary tumor was resected completely.

Degree of Confidence

The degree of confidence is high. Although MRI without a GRE sequence can be insensitive for calcifications, it is sensitive for determining the fluid or soft-tissue content of a given area.

False Positives/Negatives

False-positive results may be secondary to misinterpretation of a similar lesion in the differential diagnoses.

A Rathke cleft cyst (RCC) can usually be differentiated because it is rarely calcified, whereas 64-92% of craniopharyngiomas are calcified. An RCC is also usually associated with anterior infundibular displacement and does not have a solid component. In addition, it shows contrast enhancement less frequently than other tumors. Small RCCs may be indistinguishable from the rare intrasellar craniopharyngiomas.

A suprasellar arachnoid cyst has angular margins, entirely cystic, with no solid component or enhancement.

Hypothalamic or chiasmatic astrocytoma arise at their respective locations and appear solid with areas of necrosis. The pilocytic variety may show cystic changes; however, calcification is less common with this tumor than with others. A moderate degree of enhancement may be seen.

Meningiomas demonstrate the dural tail sign, which is absent with craniopharyngiomas. Meningiomas also have a wide dural base and densely adhere to the dura. A craniopharyngioma can grow to more than 5 cm, but most are smaller. Conversely, a germinoma is almost always large, and its signal intensity and enhancement is homogenous. A cystic component rarely is observed, and a pineal satellite lesion may be present.

Pituitary adenoma is rare in children and mostly intrasellar in the microadenoma variety. Macroadenomas may have suprasellar components with cystic, hemorrhagic, and enhancing areas, closely mimicking the findings of a craniopharyngioma. However, calcification is rare.

Teratomas contain mixed solid and cystic components, as do craniopharyngiomas, but teratomas typically contain some fat.

Epidermoids can be distinguished by their characteristic scalloped margins and no or minimal peripheral pattern of enhancement. Epidermoids are typically strongly hyperintense on diffusion-weighted images. Dermoids also contain a fatty component.

ULTRASOUND

Section 7 of 12  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

A few case reports have described the potential use of ultrasonography with color Doppler imaging in antenatal diagnosis of fetal craniopharyngiomas. Adult craniopharyngiomas have also been evaluated by using color Doppler and ultrasonographic contrast agents.

Degree of Confidence

Ultrasonography may be useful for prenatal imaging; however, the modality is operator dependent, it can be limited due to beam attenuation by the bony skull vault, and lesions can be missed.

With the wide availability and documented accuracy of CT and MRI, ultrasonography has not been accepted as a universal tool for the evaluation of pituitary masses.

NUCLEAR MEDICINE

Section 8 of 12  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

Although evidence of increased metabolic activity in the tumor mass and surrounding brain has been observed, nuclear evaluation is not preferred for the diagnosis of craniopharyngioma.

ANGIOGRAPHY

Section 9 of 12  

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• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Findings

Most of the findings relate to displacement of the cerebral vasculature secondary to mass effect. Specifically, the position of the anterior cerebral artery is well correlated with the location of the tumor. When the A1 segment of the anterior cerebral artery and the anterior communicating artery are in the usual position, the tumor is contained entirely or almost entirely within the sella.

When the A1 segment and the anterior communicating artery are elevated (see Image 11) but the basilar artery is in the usual position, the tumor protrudes anteriorly and projects between the optic nerves, deviating the chiasm posteriorly. When the A1 segment and the anterior communicating artery are elevated and the basilar artery is displaced posteriorly, the tumor protrudes posteriorly and pushes the chiasm anteriorly. Stretching of the posterior communicating arteries also may be noted. An unreliable finding is a small, vascular blush in the region of the tumor.

CTA and MRA have supplanted angiography as the primary diagnostic techniques, and angiography is now rarely needed to differentiate the tumor from an aneurysm of the anterior communicating artery.

Degree of Confidence

Angiography findings are nonspecific.

False Positives/Negatives

Other tumors can produce similar angiographic findings.

INTERVENTION

Section 10 of 12  

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• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Primary treatments include radical surgery or limited surgery, such as subtotal resection and radiation therapy. Some success has been observed with intracystic chemotherapeutic (Bleomycin) injection or stereotactic radiotherapy.

Medical/Legal Pitfalls

• Failure to make the diagnosis is a pitfall because tumor calcifications on CT may be misinterpreted as enhancing aneurysms, and correlation with cerebral angiographic findings may be needed to differentiate the 2 entities.
• In addition, calcifications appear as signal voids on MRI and can be misinterpreted as aneurysms. MRA should be done in questionable cases.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

Media file 1:  Contrast-enhanced T1-weighted image demonstrates a complex cystic mass (arrow) in the suprasellar space.
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Media type:  MRI

Media file 2:  Sagittal contrast-enhanced T1-weighted MRI demonstrates a complex cystic, suprasellar mass that is heterogeneously enhancing (arrow).
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Media type:  MRI

Media file 3:  Axial contrast-enhanced T1-weighted MRI demonstrates enhancement of the solid component (arrows) of the lesion.
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Media type:  MRI

Media file 4:  T1-weighted MRI in a 23-year-old woman (same patient as in Images 5-7) demonstrates a suprasellar mass with characteristic intermediate-to-high signal material in the cystic material (arrows).
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Media type:  MRI

Media file 5:  Sagittal T1-weighted MRI in a 23-year-old woman (same patient as in Image 4) demonstrates the high signal intensity of the cystic material (yellow arrow).
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Media type:  MRI

Media file 6:  Gadolinium-enhanced parasagittal T1-weighted MRI in a 23-year-old woman (same patient as in Image 4) demonstrates the characteristic enhancement of the solid component (arrow) of craniopharyngioma.
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Media type:  MRI

Media file 7:  Digital radiograph in a 23-year-old woman (same patient as in Image 4) demonstrates characteristic calcifications (arrow) in the suprasellar space. This appearance can easily be misinterpreted as that of an aneurysm.
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Media type:  X-RAY

Media file 8:  Axial CT scan in a 39-year-old man (same patient as in Images 9-10) obtained without contrast enhancement demonstrates a large, cystic mass (arrow) in the suprasellar space that has predominately fluid attenuation.
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Media type:  CT

Media file 9:  CT scan in a 39-year-old man (same patient as in Image 8) obtained with intravenous contrast agent shows enhancement of the anterior, solid component (arrows).
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Media type:  CT

Media file 10:  Digital radiograph in a 39-year-old man (same patient as in Image 8) demonstrates characteristic expansion of the sella turcica (arrows).
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Media type:  X-RAY

Media file 11:  Angiogram obtained at the same time as Image 11 in anteroposterior projection clearly shows elevations of the A1 segment of the anterior cerebral artery (arrows) and anterior communicating artery (in the same patient as in Image 8).
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Media type:  X-RAY

Media file 12:  Axial contrast-enhanced CT scan in a 65-year-old man demonstrates a large, calcified suprasellar mass with anterior displacement of the A1 segment of the anterior cerebral arteries (yellow arrows). The anterior communicating artery is not well depicted.
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Media type:  CT

Media file 13:  Coronal T1-weighted image in a 65-year-old man (same patient as in Image 12) obtained through the sella turcica. Image demonstrates a predominantly sellar lesion (arrows) with some suprasellar extension.
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Media type:  MRI

Media file 14:  Contrast-enhanced T1-weighted image in a 66-year-old woman obtained in a slightly lateral parasagittal plane demonstrates irregular enhancement of the solid components (arrow) and the outer rim of the tumor, which has a predominantly cystic composition.
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Media type:  MRI

Media file 15:  Sagittal nonenhanced T1-weighted image demonstrates a heterogeneous, cystic mass (arrows) in the suprasellar space (in the same patient as in Image 14).
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Media type:  MRI

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT SCAN
• Mri
• Ultrasound
• Nuclear Medicine
• Angiography
• Intervention
• Multimedia
• References

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• Osborn AG. Diagnostic Neuroradiology. St Louis: Mosby-Year Book;1994:654-6.
• Saeki N, Nagai Y, Matsuura I. Histologic characteristics of normal perivascular spaces along the optic tract: new pathogenetic mechanism for edema in tumors in the pituitary region. AJNR Am J Neuroradiol. Aug 2004;25(7):1218-22. [Medline].
• Sanford RA, Muhlbauer MS. Craniopharyngioma in children. Neurol Clin. May 1991;9(2):453-65. [Medline].
• Srinivasan S, Ogle GD, Garnett SP. Features of the metabolic syndrome after childhood craniopharyngioma. J Clin Endocrinol Metab. 2004;Jan;89(1):81-6. [Medline].
• Van Effenterre R, Boch AL. Craniopharyngioma in adults and children: a study of 122 surgical cases. J Neurosurg. 2002;Jul;97(1):3-11. [Medline].

Article Last Updated: Feb 21, 2007