Surgical Outcomes and Long-Term Postoperative Sleep Quality in Patients with Craniopharyngioma: A Prospective Cohort Study of Hypothalamic-Sparing Techniques

Abstract Craniopharyngiomas (CPs) are benign parasellar tumors with significant morbidity related to hypothalamic syndrome, including sleep disorders. The relationship between surgical techniques and postoperative sleep outcomes remains incompletely characterized. This article evaluates sleep quality and circadian rhythm dysfunction in CP patients treated with hypothalamic-sparing endoscopic endonasal approaches (EEAs) versus transcranial microsurgical approaches (TCs) and identifies the risk factors for postoperative sleep disturbances. This prospective cohort study enrolled 118 adult patients with suprasellar/intrasellar CPs treated between January 2020 and December 2023. Patients underwent preoperative and postoperative evaluation (3 months, 12 months, and extended follow-up at 24–36 months) using standardized sleep assessment tools including the Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Multiple Sleep Latency Test (MSLT), and polysomnography. Circadian rhythm assessment included salivary melatonin concentrations and dim light melatonin onset (DLMO) measurements were measured at baseline and 12-month follow-up. EEA resulted in significantly lower rates of postoperative excessive daytime somnolence (EDS) compared with TC (18.6% vs. 41.2%, p = 0.008). Mean MSLT sleep latency improved in the EEA group (11.4 ± 3.2 minutes at baseline to 15.8 ± 4.1 minutes at 12 months) versus the TC group (10.2 ± 2.8 to 11.9 ± 3.5 minutes, p = 0.002). Nocturnal salivary melatonin concentrations were significantly higher in the EEA group at 12-month follow-up (38.2 ± 12.4 vs. 26.4 ± 11.8 pg/mL, p < 0.001). DLMO showed significant phase advancement toward normal in the EEA group (from 2247 ± 108 to 2138 ± 64 minutes, p < 0.001) but minimal change in the TC group (2251 ± 112 to 2224 ± 98 minutes, p = 0.31). Posterior hypothalamic involvement identified on preoperative magnetic resonance imaging emerged as an independent risk factor for postoperative EDS (odds ratio 3.24, 95% confidence interval 1.18–8.94, p = 0.022). Secondary narcolepsy developed in 8.5% of patients overall, more commonly in the TC group (14.4% vs. 3.4%, p = 0.041). Hypothalamic-sparing EEAs significantly reduce postoperative sleep disturbances in CP patients through preservation of melatonin-producing mechanisms, restoration of circadian phase timing, and orexinergic pathways. Preoperative imaging assessment of posterior hypothalamic involvement should guide surgical planning to minimize sleep disorder morbidity.