Postoperative Cerebrospinal Fluid Leak Following Craniopharyngioma Resection: Review of A Multicenter Experience and Survey of Current Practice

Background: Postoperative cerebrospinal fluid (CSF) leak is a significant complication following endoscopic transsphenoidal surgery (ETS) for craniopharyngioma. This study aimed to identify risk factors associated with CSF leak in patients undergoing craniopharyngioma resection. Methods: A retrospective review was conducted on 363 patients who underwent ETS for craniopharyngioma. Preoperative and intraoperative factors, including tumor consistency, tumor size, and repair techniques, were analyzed. Univariate analyses were performed to compare these variables between patients with and without postoperative CSF leak. A multivariate logistic regression model was used to identify significant independent risk factors. Results: Out of 363 patients, 50 experienced a postoperative CSF leak (14%). Primarily cystic tumors had a significantly higher (p = 0.022) leak rate than mixed or solid tumors. Larger tumors (>5.1 cm) were associated with a higher (p = 0.026) CSF leak rate (5/15 patients, 33%) compared to smaller tumors ([ Fig. 1 ]). The inclusion of a nasoseptal flap (NSF) in the preferred layered approaches was associated with a lower CSF leak rate compared to iother materials, though this was not a statistically significant finding (p=0.052) ([ Fig. 1 ]). A multivariate logistic regression model found cystic tumor consistency (OR=2.25, p = 0.021) and a tumor diameter >5.1 cm (OR=3.31, p = 0.048) to be significant independent risk factors. Conclusion: Cystic tumor consistency and larger tumor diameter are significant independent risk factors for postoperative CSF leak following ETS for craniopharyngioma. These findings underscore the importance of tumor characteristics as predictors of complication risk, demonstrating that both the consistency of the tumor and its absolute size independently increase the risk of CSF leakage. This data can be used to improve pre-operative risk stratification and inform tailored intraoperative repair strategies. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany