Anterior and Posterior Ethmoidal Artery Ligation in Anterior Skull Base Meningiomas: A Review on Microsurgical Approaches

Abstract

Anterior skull base neoplastic and vascular lesions can receive significant blood supply from the anterior and posterior ethmoidal artery. Although useful in preoperative embolization of middle meningeal artery branches, endovascular techniques for the occlusion of anterior ethmoidal artery expose the parent vessel, the ophthalmic artery, to possible embolic complications, which can cause loss of vision. When dealing with anterior fossa giant meningiomas, moreover, it is not always possible to gain direct intracranial access to anterior ethmoidal arteries because of dimensions and invasiveness of these neoplasms. The aim of this review is to illustrate the anterior and posterior ethmoidal artery anatomy and the microsurgical approaches for extracranial ligation. We performed a literature review of the relevant microsurgical anatomy of these arteries; particular attention is given to anterior cranial fossa and medial orbital wall anatomy. Our research found two surgical sites of arterial occlusion that can be best exposed with five microsurgical approaches. A combination of different surgical and endovascular techniques before resection of hypervascular giant olfactory groove and planum sphenoidale meningiomas should always be considered. Microsurgical extracranial ligation of anterior and sometimes posterior ethmoidal arteries provides a safe and feasible option to limit blood loss during anterior skull base surgery.