Surgical Approaches to the Hypothalamus: A Systematic Review of Anatomical Corridors and Postoperative Outcomes.

Abstract

The hypothalamus is a vital neuroanatomical structure involved in endocrine, autonomic, and homeostatic regulation. Its deep location near critical neural and vascular structures makes surgical access complex. This review aims to evaluate and compare these surgical approaches, focusing on anatomical access and their clinical and functional outcomes. This review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. A comprehensive search of PubMed and Scopus was performed for studies published between January 2000 and July 2025. Eligible studies included primary research on human patients undergoing surgical procedures targeting the hypothalamus. Where applicable, meta-analyses were conducted using random-effects models to pool outcome data and evaluate heterogeneity. Twenty-seven studies (n = 562) were included. By pathology, pooled postoperative improvement was 74% for hypothalamic hamartoma (95% confidence interval [CI] 0.640-0.838), 66.7% for craniopharyngioma (0.553-0.782), and 44.2% for glioma (0.288-0.596). Endoscopic approaches showed higher improvement than open surgery (88% vs. 61%; odds ratio [OR] 1.82, 95% CI 0.95-3.50, P = 0.072), but higher mortality (3.0% vs. 0.5%; OR 3.34, 95% CI 1.18-9.48, P = 0.023). Compared with the transcallosal (TC) route, the orbitozygomatic approach carried significantly greater risks of postoperative deterioration (OR 3.36, 95% CI 1.27-8.90, P = 0.015) and mortality (OR 3.94, 95% CI 1.49-10.46, P = 0.006); pterional versus TC differences were not significant for improvement (OR 1.59, 95% CI 0.80-3.19, P = 0.189) or mortality (OR 2.33, 95% CI 0.90-6.01, P = 0.081). Endoscopic approaches showed the highest clinical improvement, while TC routes offered the safest profile. Skull base approaches, such as orbitozygomatic, were associated with higher morbidity and should be used selectively.