Minimally Invasive Management of Recurrent Craniopharyngioma: Intraoperative Real-Time Magnetic Resonance Imaging-Guided Transnasal Cyst Aspiration—A Case-Based Technical Note

Abstract Craniopharyngiomas are rare benign epithelial tumors typically located in the sellar and suprasellar region. Standard management includes surgery and radiotherapy. However, recurrence in the form of isolated cystic lesions presents a unique challenge. Herein, we report a case of recurrent cystic craniopharyngioma treated using intraoperative real-time magnetic resonance imaging (MRI) and neuronavigation-guided transnasal aspiration. The patient was evaluated with MRI, including T1- and T2-weighted sequences with contrast enhancement. A transnasal surgical approach was planned using neuronavigation. Intraoperative real-time MRI was used to guide catheter placement and ensure complete cyst aspiration. The procedure was performed under general anesthesia using standard sterile technique, and histopathological examination of the aspirated material was conducted. A 77-year-old female previously underwent endoscopic transnasal resection for a cystic craniopharyngioma confirmed to be of the adamantinomatous subtype. During follow-up, a recurrent suprasellar cystic lesion was identified. The cyst was aspirated intraoperatively via an external ventricular drainage catheter placed through the transnasal route. Real-time MRI using fast low-angle shot (FLASH) sequences enabled real-time monitoring and confirmation of cyst reduction. This case illustrates a minimally invasive, safe, and effective technique for managing recurrent cystic craniopharyngiomas using real-time MRI guidance. It highlights the potential of image-guided aspiration as a first-line approach in select patients, especially where conventional surgical reintervention may pose significant risks.