When to shunt and when to aspirate? Long-term outcomes from a large stereotactic cohort of cystic craniopharyngiomas
Introduction Stereotactic surgery of predominantly cystic craniopharyngiomas (CC) is a minimally invasive alternative to microsurgical or endoscopic resection. Both cyst aspiration (CA) and internal cyst shunting (CS) have been proposed as stereotactic treatment strategies, yet comparative data remain limited. Research question Do CA and CS differ in clinical, radiological, visual, endocrine, and recurrence outcomes in predominantly cystic craniopharyngiomas? Material and methods A retrospective cohort of patients treated between 2000 and 2025 was analyzed. Volumetric MRI was performed preoperatively and at ≤6 weeks, 4–6 months, and 9–12 months postoperatively. Clinical, radiological, visual, endocrine, and recurrence outcomes were evaluated using uni- and multivariate analyses. Results A total of 42 patients were included (15 CA, 27 CS). Baseline characteristics were largely comparable, although optic nerve sheath dilation was more frequent in the CS group. Preoperative cyst volumes were similar (14.2 ± 10.3 cm3 vs. 16.5 ± 9.7 cm3; p = 0.5), as were final postoperative volumes (3.2 ± 3.4 cm3 vs. 4.2 ± 5.9 cm3; p = 0.6). Both techniques achieved significant and durable cyst reduction (all p < 0.001). Visual outcomes favored CS (85.2% vs. 53.3% without deficit; p = 0.02), whereas corticotropic (p = 0.02), thyreotropic insufficiency, and diabetes insipidus (both p = 0.03) were more frequent. Recurrence correlated with preoperative cyst volume (p = 0.008), independent of treatment modality. Discussion and conclusion Both techniques provide effective cyst decompression. CS may improve visual outcomes but appears associated with higher endocrine risk. Findings support individualized treatment selection and warrant prospective validation.