Endoscopic management of anterior cranial fossa meningiomas

Abstract

Meningiomas of the anterior skull base have been traditionally approached through transcranial or combined craniofacial routes. While these approaches offer wide exposure and working space, brain retraction, neurovascular manipulation, sinus obliteration, wound healing, and cosmesis can be significant issues. With the evolution of endoscope-assisted surgery, transnasal endoscopic approaches have developed as useful alternatives. These approaches can provide visualization comparable to or better than microscope-assisted surgery, as the endoscope provides excellent resolution of anatomic and pathologic details down these narrow corridors. Moreover, the use of angled endoscopes and instruments enables the surgeon to visualize and remove structures around the corners and avoid brain retraction. Potential disadvantages include narrow working spaces and reduced degrees of freedom with the dissecting instruments. In addition, operating through the nose carries with it the theoretical risk of intracranial infection and CSF leak, given the challenge of reconstructing the dura and skull base from below. With these issues in mind, a balanced approach to the resection of these tumors can be used to maximize tumor removal while minimizing operative time, trauma to surrounding structures, and procedure-related complications. This review will discuss the indications and limitations, technical nuances, postoperative care, and potential complications associated with endonasal endoscopic treatment of anterior cranial fossa meningiomas. Meningiomas of the anterior skull base have been traditionally approached through transcranial or combined craniofacial routes. While these approaches offer wide exposure and working space, brain retraction, neurovascular manipulation, sinus obliteration, wound healing, and cosmesis can be significant issues. With the evolution of endoscope-assisted surgery, transnasal endoscopic approaches have developed as useful alternatives. These approaches can provide visualization comparable to or better than microscope-assisted surgery, as the endoscope provides excellent resolution of anatomic and pathologic details down these narrow corridors. Moreover, the use of angled endoscopes and instruments enables the surgeon to visualize and remove structures around the corners and avoid brain retraction. Potential disadvantages include narrow working spaces and reduced degrees of freedom with the dissecting instruments. In addition, operating through the nose carries with it the theoretical risk of intracranial infection and CSF leak, given the challenge of reconstructing the dura and skull base from below. With these issues in mind, a balanced approach to the resection of these tumors can be used to maximize tumor removal while minimizing operative time, trauma to surrounding structures, and procedure-related complications. This review will discuss the indications and limitations, technical nuances, postoperative care, and potential complications associated with endonasal endoscopic treatment of anterior cranial fossa meningiomas.