The strictly third ventricle craniopharyngioma topography (strictly 3V CP) defines the subgroup of lesions developed above an anatomically intact third ventricle floor (3VF). The true existence of this exceedingly rare topographical category is highly controversial owing to the presumed embryological CP origin from Rathke’s pouch, a structure developmentally situated outside the neural tube. This study thoroughly analyzes the largest series of strictly 3V CPs ever collected. From 5346 CP reports published between 1887 and 2021, we selected 245 cases with reliable pathological, surgical, and/or neuroradiological verification of an intact 3VF beneath the tumor. This specific topography occurs predominantly in adult (92.6%), male (64.4%) patients presenting with headache (69.2%), and psychiatric disturbances (59.2%). Neuroradiological features defining strictly 3V CPs are a tumor-free chiasmatic cistern (95.9%), an entirely visible pituitary stalk (86.4%), and the hypothalamus positioned around the tumor’s lower pole (92.6%). Most are squamous papillary (82%), showing low-risk severity adhesions to the hypothalamus (74.2%). The adamantinomatous variant, however, associates a higher risk of severe hypothalamic adhesion (p < .001). High-risk attachments are also associated with psychiatric symptoms (p = .013), which represented the major predictor for unfavorable prognoses (83.3% correctly predicted) among cases operated from 2006 onwards. CP recurrence is associated with infundibulo-tuberal symptoms (p = .036) and incomplete surgical removal (p = .02). The exclusive demographic, clinico-pathological and neuroradiological characteristics of strictly 3V CPs make them a separate, unique topographical category. Accurately distinguishing strictly 3V CPs preoperatively from those tumors replacing the infundibulum and/or tuber cinereum (infundibulo-tuberal or not strictly 3V CPs) is critical for proper, judicious surgical planning.

严格的第三脑室颅咽管瘤地形图（严格的 3V CP）定义了在解剖学上完整的第三脑室底（3VF）上方发展的病变亚组。由于推测的胚胎 CP 起源于 Rathke 的囊，这种极其罕见的地形类别的真实存在存在很大争议，这是一种发育上位于神经管外的结构。这项研究彻底分析了有史以来收集的最大系列的严格 3V CP。从 1887 年至 2021 年间发表的 5346 份 CP 报告中，我们选择了 245 例对肿瘤下方完整的 3VF 进行可靠病理学、手术和/或神经放射学验证的病例。这种特殊的地形主要发生在成人 (92.6%)、男性 (64.4%) 患者中，表现为头痛 (69.2%) 和精神障碍 (59.2%)。严格定义 3V CP 的神经放射学特征是无肿瘤的交叉池 (95.9%)、完全可见的垂体柄 (86.4%) 和位于肿瘤下极周围的下丘脑 (92.6%)。大多数是鳞状乳头状（82%），显示低风险严重程度的下丘脑粘连（74.2%）。然而，金刚瘤变体与严重下丘脑粘连的风险较高有关。p  <  . 001)。高风险依恋也与精神症状有关 ( p  = .013)，这代表了从 2006 年起手术的病例中不良预后的主要预测因素（正确预测为 83.3%）。CP 复发与漏斗结节症状 ( p  = .036) 和不完全手术切除 ( p  = .02) 相关。严格 3V CP 的独特人口统计学、临床病理学和神经放射学特征使其成为一个独立的、独特的地形类别。术前准确区分严格的 3V CP 与替代漏斗部和/或结节灰烬的肿瘤（漏斗-结节或不严格的 3V CP）对于正确、明智的手术计划至关重要。