Unusual Intracranial Lesions Managed with Skull Base Neurosurgical Approaches—Why We Must Continually Emphasize Cerebrovascular/Skull Base Training in Neurological Surgery

Abstract

Introduction: Neurosurgery in the United States has evolved mainly into surgery for spinal fusion, primarily because of economic incentives. Contemporaneously, the introduction of “minimally invasive” treatments such as radiosurgery and endovascular therapy has resulted in a marked de-emphasis on the microsurgery of complex intracranial diagnoses. Statements rife in the current neurosurgical environment such as “the death of cerebrovascular neurosurgery” are unjustified and underscore a need to further emphasize cerebrovascular/skull base training. This resurgence of emphasis would facilitate the appropriate continuing treatment of complex intracranial diagnoses that present in everyday clinical scenarios in the neurosurgical care of the populations being served. Methods: The author presents the microneurosurgical management of 13 unusual intracranial diagnoses with skull base microsurgical approaches ranging the gamut from cerebellomedullary angle arachnoid cyst to bilateral distal anterior cerebral artery aneurysms. Results: Five major intracranial approaches and variations were used in this clinical series: pterional transylvian approach with skull base modifications, anterior and posterior interhemispheric approaches, subtemporal approach with modifications, and far lateral transcondylar approach which subsumes other posterior fossa approaches. Conclusions: Adequate exposure and control of hemorrhage are the major tenets of any intracranial operation. The author contends that technical mastery of the aforementioned five major intracranial approaches satisfactorily addresses most if not all conditions likely to be encountered by a neurosurgeon in intracranial neurosurgical practice. It is easy to abdicate responsibility of “difficult” intracranial cases to minimally invasive and “novel” therapeutic modalities. However, under such circumstances, a highly variable fraction of patients will receive suboptimal care, particularly based on current trends in neurosurgery in the United States. Future progress in intracranial neurosurgery requires a revival in enthusiasm and commitment to push the frontiers of surgical progress by further emphasizing the critical elements of cerebrovascular/skull base neurosurgery.