Skull Base Surgical Approaches Research Articles

Modified colored three-dimensional posterior and temporal cranial fossa model with mobility of the joint between C1 and occipital condyle

BackgroundSkull base surgery requires anatomical knowledge and appropriate surgical technique in bone drilling. We developed a newly modified three-dimensional (3D) model of the posterior cranial fossa as a learning tool that improves knowledge of skull base anatomy and surgical approaches, including skull base drilling techniques. MethodsThis bone model of the posterior cranial fossa was created based on computed tomography data using a 3D printer, and incorporates artificial cranial nerves, cerebral vessels, bony structures, dura mater, and cerebellar tentorial dura. These anatomical components are differentiated with various colors. In addition, the atlanto-occipital junction can be mobilized to fully expose the surface of the cartilage between the C1 condyle and occipital condyle to allow drilling to open the hypoglossal canal under a wide surgical field. The usefulness of the model for practicing skull base surgical approaches was evaluated. ResultsExperience of bone drilling, dural dissection, and 3D positioning of important structures, including cranial nerves and blood vessels, was identical to that in actual surgery. ConclusionsThis model is designed to facilitate teaching anatomical knowledge and essential epidural procedure-related skills, and is useful for teaching the essential elements of posterior skull base surgery.

Development and Evaluation of a Mixed Reality Model for Training the Retrosigmoid Approach

IntroductionThe use of simulation has the potential to accelerate the learning curves and increase the efficiency of surgeons. However, there is currently a scarcity in models dedicated to skull base surgical approaches. Thus, the objective of this study was to develop a cost-effective mixed reality system consisting of an ultrarealistic physical model and augmented reality (AR) and evaluate its use in training surgeons on the retrosigmoid approach. Materials and methodsThe virtual models were developed from images of patients with vestibular schwannoma. The tumor was mirrored to allow bilateral approaches and the model has drawers for repositioning structures, allowing reuse of the material and cost reduction. Pre and post-test assessments were applied to ten residents and young neurosurgeons, divided into control and test groups. Only the control group was exposed to the model. The difference in scores obtained by participants before and after exposure to the models was considered for analysis and participants in the control group answered self-satisfaction questionnaires. ResultsThe mean differences were 4.80 in the control group (95%CrI = 1.08-9.79) and 5.43 in the test group (95%CrI = 1.67-8.20). The average score of the self-satisfaction questionnaires was 24.0 (23-25). ConclusionThe ultrarealistic model efficiently allowed retromastoid access to the cerebellopontine angle. A tendency towards greater gains in performance in the group exposed to the model was verified. Scores from the self-satisfaction questionnaires demonstrated that participants considered the model relevant for neurosurgical training and increased confidence among surgeons.

Manual Instruments as an Alternative to Drilling for Bony Exposure in Skull Base Surgery: Concept and Technique.

Background Drilling in neurosurgery is an integral part of surgical exposure, especially in skull base approaches and craniovertebral junction (CVJ) surgeries. Most of such drillings are done in close proximity to the neurovascular structures in skull base surgeries and cervical-medullary junction or facet/pedicle in CVJ surgeries. Reluctance to drilling among young neurosurgeons is due to less hands-on experience during training and also, in the early part of the career, due to fear of injury to neurovascular structures. Methods Five commonest bone removals for skull base region and CVJ surgeries that can be safely done using manual instruments were identified based on experiences of senior authors. The authors highlight key technical nuances to widen surgical corridors using manual instruments safely for skull base surgical approaches. Results Basic neuroanatomical concepts and basic physics help in using manual instruments safely for bone removals in various skull base surgical approaches. Conclusions Manual instruments may be used for bone removals in selected skull base surgical approaches, which help young neurosurgeons to perform these surgeries in limited-resource settings.

Automated atlas-based segmentation for skull base surgical planning.

Computational surgical planning tools could help develop novel skull base surgical approaches that improve safety and patient outcomes. This defines a need for automated skull base segmentation to improve the usability of surgical planning software. The objective of this work was to design and validate an algorithm for atlas-based automated segmentation of skull base structures in individual image sets for skull base surgical planning. Advanced Normalization Tools software was used to construct a synthetic CT template from 6 subjects, and skull base structures were manually segmented to create a reference atlas. Landmark registration followed by Elastix deformable registration was applied to the template to register it to each of the 30 trusted reference image sets. Dice coefficient, average Hausdorff distance, and clinical usability scoring were used to compare the atlas segmentations to those of the trusted reference image sets. The mean for average Hausdorff distance for all structures was less than 2mm (mean for 95th percentile Hausdorff distance was less than 5mm). For structures greater than 2.5mL in volume, the average Dice coefficient was 0.73 (range 0.59-0.82), and for structures less than 2.5mL in volume the Dice coefficient was less than 0.7. The usability scoring survey was completed by three experts, and all structures met the criteria for acceptable effort except for the foramen spinosum, rotundum, and carotid artery, which required more than minor corrections. Currently available open-source algorithms, such as the Elastix deformable algorithm, can be used for automated atlas-based segmentation of skull base structures with acceptable clinical accuracy and minimal corrections with the use of the proposed atlas. The first publicly available CT template and anterior skull base segmentation atlas being released (available at this link: http://hdl.handle.net/1773/46259 ) with this paper will allow for general use of automated atlas-based segmentation of the skull base.

Pterygopalatine Fossa: Microsurgical Anatomy and its Relevance for Skull Base Surgery

Abstract Introduction The purpose of this study was to define the anatomical relationships of the pterygopalatine fossa (PPF) and its operative implications in skull base surgical approaches. Methods Ten cadaveric heads were dissected at the Dianne and M Gazi Yasargil Educational Center MicrosurgicaLaboratory, in Little Rock, AK, USA. The PPF was exposed through an extended dissection with mandible and pterygoid plate removal. Results The PPF has the shape of an inverted cone. Its boundaries are the pterygomaxillary fissure; the maxilla, anteriorly; the medial plate of the pterygoid process, and greater wing of the sphenoid process, posteriorly; the palatine bone, medially; and the body of the sphenoid process, superiorly. Its contents are the maxillary division of the trigeminal nerve and its branches; the pterygopalatine ganglion; the pterygopalatine portion of the maxillary artery (MA) and its branches; and the venous network. Differential diagnosis of PPF masses includes perineural tumoral extension along the maxillary nerve, schwannomas, neurofibromas, angiofibromas, hemangiomas, and ectopic salivary gland tissue. Transmaxillary and transpalatal approaches require extensive resection of bony structures and are narrow in the deeper part of the approach, impairing the surgical vision and maneuverability. Endoscopic surgery solves this problem, bringing the light source to the center of the surgical field, allowing proper visualization of the surgical field, extreme close-ups, and different view angles. Conclusion We provide detailed information on the fossa's boundaries, intercommunications with adjacent structures, anatomy of the maxillary artery, and its variations. It is discussed in the context of clinical affections and surgical approaches of this specific region, including pterygomaxillary disjunction and skull base tumors.

Psychometric testing of the Skull Base Inventory health-related quality of life questionnaire in a multi-institutional study of patients undergoing open and endoscopic surgery

The skull base inventory (SBI) was developed to better assess health-related quality of life (HR-QOL) in patients with anterior and central skull base neoplasms treated by endoscopic and open approaches. The primary objective of this study was to prospectively assess the psychometric properties of the SBI. This study is part of a multi-center study of patients undergoing endoscopic and open procedures completed between 2012 and 2018. Participants were eligible if they were over 18years of age; had benign or malignant anterior, antero-lateral, or central skull base tumors; and required either an open or endoscopic skull base surgical approach. In order to assess the psychometric properties of the SBI, patients completed the instrument at six time points (preoperative, 2weeks, 3months, 6months, 12months postoperative). Patients also completed the Anterior Skull Base (ASB) questionnaire and the Sinonasal Outcome Test (SNOT-22) to allow comparison to the SBI. One hundred and eighty-seven patients were included across five centers, with 121 having an endoscopic procedure. Internal consistency (Cronbach's alpha = 0.95) and test-retest at 12 months and 12 months plus 2weeks (intraclass correlation > 0.90) were excellent. Concurrent validity was demonstrated by very strong correlation between total SBI scores and ASB scores (r = 0.810 to 0.869, p < 0.001) and moderate correlation between nasal domain SBI scores and SNOT-22 scores (r = -0.616 to -0.738, p < 0.001). Convergent validity was demonstrated by moderate correlation between change in SBI scores and global QOL change (rs = 0.4942, p < 0.001). The minimally important clinical difference (global HR-QOL change of "a little better" or "a little worse") was 6.0. The SBI questionnaire is reliable and valid for patients treated by both endoscopic and open approaches and can be used for assessment of HR-QOL in these settings.

The clinical relevance of performing a day seven post-operative absolute CD4 count in elective brain tumor surgery – A prospective cohort study from a single South African neurosurgical center

IntroductionThe co-morbid presence of a neoplastic brain tumor, in a patient who is HIV positive, is not uncommon in South Africa. The day-7 post-operative absolute CD4 count offers a unique window into the immunological status of an individual post elective brain tumor surgery. Materials and methodsWe performed a prospective cohort study consecutively enrolling all elective adult patients admitted tom our wards from the 01 July 2018–30 March 2020, with neoplastic brain tumors. In total 19 subjects that underwent elective operative intervention had a day seven post-operative absolute CD4 count performed. Data collected and analyzed in this study included age, HIV status, pre-operative corticosteroid therapy, pre-operative day CD4 count, timing of prophylactic antibiotic administration, craniotomy type, blood loss, duration of surgery, extent of resection, day seven post-operative CD4 count, post-operative corticosteroid therapy, histology, day-7 nosocomial infection incidence, Gram-stain result, and Glasgow Outcome Score. ResultsSignificance was demonstrated between the pre-operative day CD4 count and the day 7 post-operative CD4 count (p = 0.03). This allowed us to conclude the immunological impact of the surgery to have been insignificant. Significance was demonstrated between craniotomy type and day-7 post-operative CD4 count (p = 0.04). Significance was also demonstrated between extent of resection and the day-7 post-operative absolute CD4 count (p = 0.0018). A clinical trend was demonstrated for subjects with a lower day-7 post-operative CD4 count to have an increased risk of acquiring a day-7 nosocomial infection and a trend that this would be a Gram- negative infection. ConclusionAs per a PubMed review of the literature we are the first to report the relationship of the skull base surgical approaches, and a subtotal resection, and the statistically significantly delirious effect that these have on a day-7 absolute CD4 count. We further exclude increased intra-operative blood loss as an underlying cause behind the significance of these relationships.

Development of a Novel Canine Model of Ischemic Stroke: Skull Base Approach with Transient Middle Cerebral Artery Occlusion

Although canine stroke models have several intrinsic advantages, establishing consistent and reproducible territorial stroke in these models has been challenging because of the abundance of collateral circulation. We have described a skull-base surgical approach that yields reproducible stroke volumes. Ten male beagles were studied. In all 10 dogs, a craniectomy was performed to expose the circle of Willis. Cerebral aneurysm clips were temporarily applied to the middle cerebral artery (MCA), anterior cerebral artery (ACA), posterior cerebral artery, and/or ophthalmic artery (OA) for 1 hour, followed by cauterization of the distal MCA pial collateral vessels. Indocyanine green angiography was performed to assess the local blood flow to the intended area of infarction. The dogs' neurologic examination was evaluated, and the stroke burden was quantified using magnetic resonance imaging. High mortality was observed after 1-hour clip occlusion of the posterior cerebral artery, MCA, ACA, and OA (n= 4). Without coagulation of the MCA collateral vessels, 1-hour occlusion of the MCA and/or ACA and OA yielded inconsistent stroke volumes (n= 2). In contrast, after coagulation of the distal MCA pial collateral vessels, 1-hour occlusion of the MCA, ACA, and OA yielded consistent territorial stroke volumes (n= 4; average stroke volume, 9.13 ± 0.90 cm3; no surgical mortalities), with reproducible neurologic deficits. Consistent stroke volumes can be achieved in male beagles using a skull base surgical approach with temporary occlusion of the MCA, ACA, and OA when combined with cauterization of the distal MCA pial collateral vessels.

An updated assessment of morbidity and mortality following skull base surgical approaches

ObjectivesUpdated multi-institutional database studies assessing perioperative risk factors on 30-day morbidity and mortality after skull base surgeries are limited. We aim to identify perioperative risk factors and report the incidence of 30-day morbidity and mortality in adult patients after skull base surgery. Patients and MethodsWe queried the 2007–2016 American College of Surgeons National Surgical Quality Improvement program database to identify patients who underwent anterior, middle, or posterior skull base surgery. We performed multivariable logistic regression to identify risk factors associated with 30-day morbidity and mortality. Postoperative events were compared between propensity score matched cohorts (no morbidity versus 30-day morbidity). ResultsThe final analysis included 1028 adult (≥18 years old) patients. The incidence of 30-morbidity and mortality was 14.6% and 1.6%, respectively. Postoperative ventilator dependence (52.9%) followed by pneumonia (23.5%) and unplanned intubation (23.5%) had the highest prevalence among those with 30-day mortality. The adjusted odds of 30-day morbidity was significantly higher among patients with functional dependency, American Society of Anesthesiologists Physical Status ≥4, hyponatremia, and anemia (p < 0.05). The adjusted odds of 30-day mortality was significantly increased among patients with sepsis, bleeding disorder, disseminated cancer, and older age (p < 0.05). ConclusionClinical perioperative factors are significantly associated with 30-day morbidity and mortality after skull base surgery. The reported rate of 30-day morbidity and mortality was similar to earlier studies and therefore highlights the need for continued quality improvement.

The treatment of cavernous sinus meningiomas: evolution of a modern approach

Cavernous sinus meningiomas (CSMs) are challenging lesions for the skull base neurosurgeon to manage given their close association with cranial nerves II-VI and the internal carotid artery. In the 1980s and early 1990s, with advancements in microsurgical techniques, increasing knowledge of the relevant microsurgical neuroanatomy, and the advent of advanced skull base surgical approaches, the treatment of CSMs involved attempts at gross-total resection (GTR). Initial fervor for a surgical cure waned, however, as skull base neurosurgeons demonstrated the limits of complete resection in this region, the ongoing issue of potential tumor recurrences, and the unacceptably high cranial nerve and vascular morbidity associated with this strategy. The advent of radiosurgery and its documented success for tumor growth control and limited morbidity in cavernous lesions has helped to shift the treatment goals for CSMs from GTR to tumor control and symptom relief while minimizing treatment- and lesion-associated morbidity. The authors review the relevant microanatomy of the cavernous sinus with anatomical and radiographic correlates, as well as the various treatment options. A modernized, multimodality treatment algorithm to guide management of these lesions is proposed.

Computer Planning in the Research, Analysis and Design of Skull Base Surgical Approaches

Objectives: No integrated system exists to plan skull base operations, nor to design and test new surgical approaches. Our objective was to develop a method of surgical planning, selection of optimal surgical approach(es), and design of surgical corridor geometry using a computer model that creates physical models for iterative optimization, pre-surgery approach trial, and surgical education and evaluation. Methods: The analysis was applied to a specific clinical scenario of accessing the lateral cavernous sinus. A computer analysis was performed to select the optimal surgical approach portal. Once derived, the specific geometry of the surgical corridor was designed for optimal visualization and instrumentation, while applying retraction limit constraints on specific soft tissue structures. A physical model of the surgical pathway was produced for testing, and the resultant approach was performed on 4 cadaver specimens. Results: A lateral retrocanthal transorbital approach was selected based on computer analysis. The pathway length was 55.6 mm (SD: 4.4) to 67.1 mm (SD: 0.7), retraction distance away from orbital rim was 8.2 mm (SD: 0.1), corridor volume was 2,751 mm3 (SD: 736), and cross sectional areas at the portal entrance and greater wing of sphenoid were 127 mm2 (SD: 19.2) and 210 mm2 (SD: 14.0), respectively. Dry lab and cadaver testing validated the computer planning analysis. Conclusions: A method was created and validated to determine the optimal surgical approach and pathway geometry for accessing a specific target pathology. It was robust and is applicable to many clinical scenarios. Initial evaluation in surgical cases has begun.

OP100: Craniomaxillofacial approaches to skull base tumours

Introduction This study’s aim is to present our experience in the use of craniomaxillofacial approaches to skull base used for the treatment of tumours involving nasal cavity, paranasal sinuses, oral cavity and tumours extending to the skull base or intracranially with dura or brain involvement or vice versa. The complex anatomy of the vital structures at the base of the skull makes surgical resection of this area’s tumours extremely difficult particularly in cases of malignancy. The study’s material is from one centre over a 10-year period and the surgical technique; the contraindications; the complications and patients’ treatment outcome are presented. Materials and methods Forty-one patients surgically treated were included in the study. Complete data regarding the demographic details of the patients, presence of regional/distant metastases, tumour histology and follow up were compiled. Surgical approaches regarding intracranial tumours were performed by a combined surgical team of maxillofacial surgeons and neurosurgeons. With reference to the type of skull base surgical approach, anterior and lateral approaches were used. In particular 15 patients were treated with anterior and 26 with lateral approaches. Results The surgical aim was achieved in all cases. Various complications occurred, including CFS leakage, olfactory nerve damage, malocclusion, infra-orbital nerve compulsory sacrifice and infection, while tumour recurrences also occurred. Discussion Skull base tumour surgery is very demanding and requires team-work. The goals of the surgical approach design must be maximum exposure, minimal morbidity and good aesthetic result. The selection of the appropriate surgical approach must always be individualized and based on tumour size, anatomical location of the tumour, histopathology of the tumour, age and general condition of the patient.

Editorial: Skull base surgery

In their paper in this issue, Hayhurst et al.1 report a single-institutional retrospective review over a 10-year period of 23 children with tumors of varying types who required skull base surgical approaches. The children ranged from 1 to 15 years of age. Fifty-seven percent of the children had benign histology, and half underwent complete resection of their tumors. At a mean follow-up of 60 months, the authors reported 1 perioperative death and 2 children who died of disease progression. Progression-free survival was 95% at 1 year and 68% at 5 years. Fifty-nine percent of patients required adjuvant therapy. Interestingly, 1 child underwent subtotal resection of a clival chordoma, but did not receive adjuvant therapy and has not shown tumor progression during follow-up. Two children suffered the complication of postoperative CSF leakage followed by meningitis, postmeningitic hydrocephalus, and shunt placement, and are cognitively impaired as a result. This result emphasizes the fact that CSF leakage, the most common complication of skull base surgery in children, can have serious long-term consequences. Alternatively, the authors report that 85% of the children remain in mainstream schooling without the need for special educational assistance. This review, as have others, reminds us that recent technical advances—such as image guidance, better neurophysiological monitoring, endoscope-assisted minimally invasive surgery, and intraoperative imaging—can further reduce morbidity from these operations. The development of dedicated pediatric skull base surgical teams further improves the cosmetic and functional outcomes of these children by avoiding injury to rudimentary teeth, minimizing injury to the developing facial skeleton, and limiting radiation doses to growing basicranial structures. The last 3 columns of Table 2 demonstrate the relative insensitivity of the Late Effects Severity Score (LESS) in rating the functional outcomes of these children. (http://thejns.org/doi/abs/10.3171/2012.10.PEDS12479)

Computer Modeled Multiportal Approaches to the Skull Base

Skull base surgical approaches have evolved significantly to minimize collateral tissue damage and improve access to complex anatomic regions. Many endoscopic surgical portals have been described, and these can be combined in multiportal approaches that permit improved angles for visualization and instrumentation. To assist in the choice of entry portal and surgical pathway analysis, a three-dimensional computer model with virtual endoscopy was created. The model was evaluated on transnasal and transorbital approaches to access 11 specified sellar and parasellar target locations on 14 computed tomography (CT) scans. Data were collected on length of approach, angle between instruments, and approach angle with respect to anatomical planes. Optimal multiportal approach combinations were derived. The data demonstrated that the shortest, most direct pathway to many sellar and parasellar targets was through transorbital portals. Distances were reduced by 35% for certain target locations; combining transorbital and transnasal portals increased the angle between instruments 4-fold for many targets. The predicted values from the model were validated on four cadaver specimens. Computer modeling holds the potential to play an integral role in the design, analysis, and testing of new surgical approaches, as well as in the selection of optimal approach strategies for the unique pathology of individual patients.

Extraordinary effects of liquid capsule application after resection of a giant meningioma

Extraordinary effects of liquid capsule application after resection of a giant meningioma

Postoperative Acute Sialadenitis after Skull Base Surgery

During retrosigmoid and far-lateral skull base surgical approaches, the head may be positioned at the extreme limits of rotation and flexion. In rare instances, patients may develop acute sialadenitis after surgery as a result of this positioning technique. Over a 4-year period, five patients developed postoperative sialadenitis after undergoing either a retrosigmoid craniotomy in the supine position (n = 4) or a far-lateral craniotomy in the park-bench position. Based on all the retrosigmoid and far-lateral approaches performed by the senior author (RFS), the incidence of sialadenitis was 0.84%. In all five patients, the acute sialadenitis was not clinically apparent at the conclusion of the operation. However, the diagnosis was evident within 4 hours of surgery. In each case, the neck swelling in the vicinity of the submandibular gland was contralateral to the craniotomy site. All patients were treated with intravenous hydration and antibiotic therapy. One patient was extubated immediately after surgery with no obvious evidence of sialadenitis. However, she required emergent reintubation due to airway compromise. The mechanism of acute sialadenitis in these patients was obstruction of the salivary duct caused by surgical positioning. This previously unreported observation in patients undergoing skull base surgery deserves consideration during perioperative and postoperative management.

Corridor surgery: the current paradigm for skull base surgery

Clival chordomas are rare tumors, especially in the pediatric population. In this report, we present the case of a 3-year-old boy who was found to have a large posterior pharyngeal, clival, and posterior fossa tumor detected on a CT scan after a closed head injury. Further questioning revealed a history of ataxia and dysphagia. Imaging confirmed severe extrinsic brain stem compression. The tumor was resected in multiple stages utilizing a minimally invasive endoscopic endonasal technique along with open transfacetal, transcondylar approach through the carotid-vertebral window. The child suffered no permanent complications as a result of our treatment and his dysphagia significantly improved. Although a complete resection was not feasible due to vascular encasement by the tumor, extensive decompression was obtained with minimal morbidity. We present this case to illustrate a new paradigm of skull base surgical approaches for large clival lesions in pediatric patients that allows aggressive resection with minimal morbidity.

Treatment of meningioma: an update.

Aggressive surgical resection continues to be the mainstay of current meningioma management, with advances in microsurgical techniques facilitating the safety and effectiveness of this approach. Complete surgical removal of meningiomas provides the optimal opportunity for long-term remission. Advances in skull base surgical approaches have greatly improved patient outcomes for tumors in precarious locations once thought to be inoperable. For tumors that recur or are unresectable, stereotactic radiosurgery and conformal fractionated radiation therapy can provide safe, palliative treatment with favorable long-term outcomes. Additionally, advances in the understanding of molecular biologic and biochemical mechanisms underlying meningioma growth offer unique opportunities for potential treatment adjuncts for atypical and malignant tumors. This review discusses current understanding of meningioma pathology and accepted meningioma treatment paradigms. The technologic advances and experimental strategies for the future treatment of complex intracranial meningiomas are also discussed.

Pediatric Skull Base Surgery

In the second of these two articles, we will discuss our clinical experience with skull base surgery in the pediatric population. We present a retrospective analysis of 55 patients less than 16 years of age who underwent skull base surgical approaches at the Primary Children’s Medical Center or the University of Utah Medical Center between January 1992 and April 1999. There were 30 boys and 25 girls (mean age 9.8 years). Patient follow-up averaged 58 months. Most patients had pathology that required either an anterior or anterolateral approach; 6 patients underwent a far-lateral or a transpetrosal exposure. Thirty-five procedures were performed by a neurosurgeon, a pediatric otolaryngologist performed 11 procedures, and 10 procedures were performed by both services together. Ninety-six percent of patients (n = 53) had a Glasgow Outcome Score of 4 or 5. Complications included 4 sustained cranial nerve palsies and 2 hemipareses. There were no CSF leaks, infections or deaths. Patients with sellar region pathology had a disproportionately higher incidence of postoperative morbidity. We conclude that in selected pediatric cases, skull base surgical techniques can be performed effectively and safely with the use of multidisciplinary teams. To implement these techniques, knowledge of their limitations and of the anatomical differences between the adult and pediatric cranial base is essential.

Complication avoidance in the treatment of malignant tumors of the skull base

The treatment of malignant skull base tumors has improved with the development of skull base surgical approaches that allow en bloc resection of a lesion and increase the efficacy of adjuvant therapies. The anatomical complexity of these lesions and their surroundings has led to a relatively high complication rate. Infection and cerebrospinal fluid fistulas are the most common serious procedure-related complications. They result from the frequent necessity of working in a contaminated space such as the paranasal sinuses as well as from the creation of large dural and skull base defects. The authors have reviewed the literature regarding complications of surgery for malignant skull base lesions and present several techniques and strategies for minimizing their incidence by performing the craniofacial approach to anterior skull base lesions.