Tuberculum Sellae Meningiomas Research Articles

Tuberculum sellae meningioma surgery: visual outcomes and surgical aspects of contralateral approach

The main purpose of surgery for tuberculum sellae meningioma (TSM) is the improvement and/or stabilization of patients' visual function. Options for the side of lateral approaches usually were restricted for nondominant right-sided craniotomy or to the side of impaired vision (ipsilateral approaches). Although the safety and effectiveness of ipsilateral transcranial approach was proved, there are some doubts and discussions about the contralateral craniotomy. We retrospectively analyzed the series of contralateral surgeries of TMS and their visual outcomes comparing with ipsilateral approach. Twenty-six patients with TSM were operated on from 2010 to 2019 (F/M 20/6, mean age 49years), in 17 (65%) we performed contralateral and in 9 (35%) ipsilateral approach. All procedures were performed via fronto-lateral craniotomy. Gross total resection (GTR) was achieved in 21 (81%) cases and in all but one patient we noticed visual improvement after surgery (96%). Optic canal unroofing with mobilization of more affected visual nerve was necessary in 5/9 pts of ipsilateral vs 3/17 pts of contralateral group. We had no significant postoperative complications.There was no difference in outcome between ipsilateral and contralateral fronto-lateral approaches for TSM resection; thus, contralateral approach was at least as safe and effective as ipsilateral.

The extended pterional approach for midline anterior skull base meningiomas

Background: Various surgical approaches for the management of midline anterior skull base meningiomas exist in the literature. The main surgeon target is proper selection the appropriate approach that achieves total removal of the lesion without causing morbidity or mortality and facilitates safe effective removal of the tumour.
 Objectives: To evaluate the role of the extended pterional approach for excision of midline anterior skull base meningiomas as regarding the effectiveness, extent of resection and surgical outcome.
 Patients and methods: This retrospective study involved 23 cases with midline anterior skull base meningiomas resected through the extended pterional approach. Patients' clinical data, operative notes, imaging studies and clinical follow-up data were analyzed and evaluated.
 Results: Tumors studied were 9 olfactory groove meningiomas, 8 tuberculum Sellae meningiomas, 4 planum sphenoidale meningiomas and 2 diaphragma sellae meningiomas. Gross total resection tumour excision in 15 cases (64.5%), subtotal excision in 5 cases (21.5%) and partial excision in 3 cases (14%). Complications were diabetes insipidus (2 cases 8.6%), CSF rhinorrhea (3 cases 12.9%) and visual deterioration (3 cases 12.9%). We had two cases of mortality.
 Conclusion: The extended pterional approach allows safe and effective removal of midline anterior skull base meningiomas. It expands the exposure offered by the classic pterional approach and minimizing the necessity for applying fixed brain retraction with good cosmetic outcome and less approach-related morbidities in comparison with the extensive skull base approaches.

Surgical challenges and outcome of endoscopic endonasal approaches in the management of recurrent pituitary adenomas

Background: Various surgical approaches for the management of midline anterior skull base meningiomas exist in the literature. The main surgeon target is proper selection the appropriate approach that achieves total removal of the lesion without causing morbidity or mortality and facilitates safe effective removal of the tumor.
 Objectives: To evaluate the role of the extended pterional approach for excision of midline anterior skull base meningiomas as regard the effectiveness, extent of resection and surgical outcome.
 Patients and methods: This retrospective study involved 23 cases with midline anterior skull base meningiomas resected through the extended pterional approach. Patients' clinical data, operative notes, imaging studies and clinical follow-up data were analyzed and evaluated.
 Results: Tumors studied were 9 olfactory groove meningiomas, 8 tuberculum Sellae meningiomas, 4 planum sphenoidale meningiomas and 2 diaphragma sellae meningiomas. Gross total resection tumor excision in 15 cases (64.5%), subtotal excision in 5 cases (21.5%) and partial excision in 3 cases (14%). Complications were diabetes insipidus (2 cases 8.6%), CSF rhinorrhea (3 cases 12.9%) and visual deterioration (3 cases 12.9%). We had two cases of mortality.
 Conclusion: The extended pterional approach allows safe and effective removal of midline anterior skull base meningiomas. It expands the exposure offered by the classic pterional approach and minimizing the necessity for applying fixed brain retraction with good cosmetic outcome and less approach related morbidities in comparison with the extensive skull base approaches.

Transpalpebral Approach for Microsurgical Removal of Tuberculum Sellae Meningiomas.

Background:The evolution of skull base approaches associated with individualization of surgical corridor and minimizing the collateral damage. Achieving the radical removal of tumor and preserving the neurological status of the patient is possible, both with the traditional approaches and keyhole approaches. Our work presents experience using the transpalpebral approach (TPA) for microsurgical removal of tuberculum sellae meningioma (TSM).Materials and Methods:A total of 15 patients with meningiomas underwent microsurgical removal of TSM through TPA. Ten patients were women and five were men. The standard preoperative diagnostic protocol includes magnetic resonance imaging with contrast enhancement, brain computed tomography for neuronavigation. We assess surgical complications, functional and cosmetic outcomes, and surgical parameters, including the time of surgery and intraoperative blood loss.Results:Visual impairment was finding in 100% patients, including slight decrease of vision (46,7%, seven patients), partial vision field loss (six patients, 40%), and serious visual impairment (two patients 13.3%). Visual improvement was noted in ten cases (66.7%), there was no improvement in four cases (26.7%), and one case (6.6%) had transient visual worsening for 4 days and slow improvement in 1 month. Headache disappeared in three patients (50%). There were no cases of cerebrospinal fluid leak. Transient frontal hypoesthesia was noted in all patients (100%) without permanent deficit. Transient palsy of the frontal muscle was noted in four patients for 4–6 months. Histological examination revealed WHO Grade I meningioma in 14 cases and in 1 case WHO Grade II meningioma. No deaths were identified in follow-up at 12 months. The average value of the Modified Rankin Scale was 1.4. The mean length of stay in hospital was 5.Conclusion:TPA is technically difficult and requires some experience to work in deep structures in a small surgical corridor. This technique can be good alternative to traditional fronto-lateral, supraorbital keyhole craniotomies, and endoscopic endonasal approaches.

Endoscopic Endonasal Transsphenoidal Approach for Resection of Tuberculum Sella and Planum Sphenoidale Meningiomas: A Snapshot of Our Institutional Experience.

Introduction:Meningiomas of the tuberculum sellae and planum sphenoidale represent a subgroup of anterior skull base tumors that comprise approximately 5%–10% of all intracranial meningiomas. Most of the patients report with failing vision, so early surgical decompression either transcranial and/or endonasal approach is recommended. The endonasal route allows for direct coagulation of the tumor meningeal supply and extensive resection of dural attachments, and importantly, provides an inferior to superior access to the infrachiasmatic region that facilitates complete tumor removal without encountering the optic nerve. This article describes our institutional experience for the endonasal resection of tuberculum sellae and planum sphenoidale meningiomas.Materials and Methods:We retrospectively analyzed eight cases of tuberculum sellae and planum sphenoidale meningiomas who selectively underwent endoscopic endonasal transsphenoidal resection between 2015 and 2018. All patients had ophthalmological, endocrinological, and radiological evaluation both preoperatively and postoperatively.Results:Among the study group, we found age range 22–68 years, male:female 1:2. Among the radiological findings, there were five cases of tuberculum sellae meningioma, while three cases were of planum sphenoidale meningioma. In tumor resection status, we found gross total resection in six cases and debulking in two cases. Postoperative analysis of visual outcome revealed improvement in four cases, constant in three cases, and worsening in one case. We also found the post of nasal complications in four cases, cerebrospinal fluid leak in two cases and transient diabetes insipidus in one case.Conclusion:In this study, we highlighted our experience of a very small group of patients with anterior fossa meningioma specific to tuberculum sella and planum sphenoidale origin.

How I do it: contralateral supraorbital approach for tuberculum sellae meningioma.

The resection of tuberculum sellae meningiomas poses a challenge particularly when dealing with the medial aspect of the optic nerve. Dissection of the tumor off the optic nerve is usually carried out in the blind spot "behind" the optic nerve. We describe a contralateral approach for asymmetric tuberculum sellae meningiomas, allowing direct visualization of the medial optic nerve. Contralateral lateral supraorbital approach was performed, and complete tumor resection was achieved without any injury to the optic nerve. The contralateral approach for asymmetric tuberculum sellae meningioma is an efficient technique allowing improved visualization of the medial optic nerve.

Chapter 2 - Tuberculum sellae meningiomas

Tuberculum sellae meningiomas are challenging tumors that can cause significant morbidity for patients because of their proximity to critical neurovascular structures. By studying the anatomy of the tuberculum, the manner in which these tumors grow and cause deficits becomes apparent, as also the challenges associated with surgical removal and management. The necessary preoperative workup and grading scales for preoperative evaluation of tuberculum meningiomas are discussed. Traditional open cranial approaches for resection are discussed and contrasted with the endoscopic endonasal approach. Finally, postoperative management, patient outcomes, and adjuvant therapy for management of residual tumor are considered.

Endoscopic surgical resection of tuberculum sellae meningiomas based on decision-making algorithms proposed in the literature

Recent publications and studies propose using decision-making algorithms in choosing the optimal approach for each individual case of tuberculum sellae meningioma (TSM). Minimally invasive endoscopic approaches offer the possibility of early devascularization, reduced brain and nerve retraction and speedy patient recovery. We used the decision-making algorithm proposed in the literature to choose between the extended endoscopic endonasal approach (EEA) or the classic transcranial approaches for resection of tuberculum sella/planum sphenoidale meningiomas, based on anatomical landmarks and lateral extension. We describe rates of gross-total resection, visual outcomes, as well as complications in four cases of TSMs, where EEA was used based on the proposed algorithm. Over a period of 15 months, we used the algorithm in nine patients with tuberculum sella/planum sphenoidale meningiomas, in four of whom we used the extended EEA. The mean follow-up duration was 3 months. Gross-total resection was achieved in three out of the four cases, the fourth being a second operation a long period of time after the classical transcranial approach had been used. Visual improvement was achieved in three out of the four cases. One patient had stable vision. There were no cerebrospinal fluid leaks or any kind of neurological postoperative deterioration, although a patient developed pulmonary embolism, but recovered successfully and was discharged. The algorithm proposed in the literature that was explored here is simple, minimally invasive and can produce excellent outcomes in the surgical resection of TSMs in carefully selected cases.

Surgical management of Tuberculum sellae Meningiomas: Myths, facts, and controversies.

The optimal management of tuberculum sellae (TS) meningiomas, especially the surgical strategy, continues to be debated along with several controversies that persist. A task force was created by the EANS skull base section committee along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumors on a European perspective. To achieve this, the task force also reviewed in detail the literature in this field and had formal discussions within the group. The constituted task force dealt with the practice patterns that exist with respect to pre-operative radiological investigations, ophthalmological and endocrinological assessments, optimal surgical strategies, and follow-up management. This article represents the consensually derived opinion of the task force with respect to the surgical treatment of tuberculum sellae meningiomas. Areas of uncertainty where further clinical research is required were identified.

Endoscopic Endonasal Removal of Primary/Recurrent Meningiomas in the Medial Optic Canal: Surgical Technique and Long-Term Visual Outcome

Tuberculum sellae meningiomas frequently extend into the optic canals, which leads to a progressive longitudinal visual loss. Therefore, in addition to tumor removal, unroofing and exploration inside the optic canal are important procedures. To perform endoscopic endonasal tumor removal with optic canal decompression for small primary or recurrent meningiomas associated with a progressive visual loss at the inferior-medial optic canal, which corresponded to a blind corner in the ipsilateral pterional/subfrontal approach. We retrospectively reviewed 2 cases of primary meningiomas that arose in the inferior-medial optic canal and 4 recurrent cases from the remnant inside the medial optic canal that had previously undergone craniotomy for tuberculum sellae meningiomas, and were treated by the endoscopic endonasal approach. All tumors were detectable and could be removed without manipulation of the affected optic nerve. The average maximum diameter of the tumor was 8.4 mm (range: 5-12 mm). Two patients who had a long history of progressive visual disturbance and papillary atrophy did not recover from severe visual disturbances postoperatively. However, others showed considerable improvement, maintaining postoperative visual function during follow-up. There were no postoperative complications. Endoscopic endonasal approach has several advantages for meningiomas in the medial optic canal and associated with progressive visual disturbance. In surgery of tuberculum sellae meningiomas, optic canal decompression and exploration inside the optic canal are important procedures to avoid symptomatic recurrence, which may be facilitated by the endoscopic endonasal approach. Papillary atrophy and duration of visual deterioration are predictive factors for postoperative visual outcomes.

Endoscopic transnasal resection of tuberculum sellae meningioma - case report

Introduction: Tuberculum sellae meningiomas (TSM) represent 5-10% of all intracranial meningiomas. Tumours are located on tuberculum sellae or chiasmatic sulcus of the sphenoid bone. These suprasellar lesions often displace the optic nerves causing visual impairment that is commonly the presenting symptom. Tuberculum sellae meningiomas are traditionally operated by transcranial approach. There is an alternative method to remove tumours of anterior skull base by using endoscopic transnasal surgery. Methods: In this article we describe a case of the patient with tuberculum sellae meningioma. Results: 63-year old women was diagnosed due to a headache, facial sensation defects on the right and peripheral vision loss. Ophthalmology examination showed bitemporal vision loss up to 10-15%. Using magnetic resonance imaging scan the tumour of diameter 8.1x8.0mm was located in tuberculum sellae. The endoscopic transsphenoidal operation was made confirming diagnosis of meningioma. In postoperative period the symptoms was almost completely minimalized. Conclusion: The treatment of choice for tuberculum sellae meningiomas is a surgery. Neurosurgeons have two options to remove the tumour: by transcranial approaches or via endoscopic transsphenoidal surgery with rhinologist. The decision of the optimal surgical technique should be individually made. Knowing possible complications during endoscopic approach, the benefits prevail. Cerebrospinal fluid leak is still challenging but using nasoseptal flap (Hadad’s flap) makes reconstruction easier. Recovery is quicker and postoperative results are promising.

Tuberculum sellae meningioma with possible tacrolimus neurotoxicity manifesting as manic-like psychosis after kidney transplantation

BackgroundAlthough kidney transplantation is the best treatment option for chronic kidney disease, the accompanying immunosuppressive treatment can induce severe neurotoxicity presenting, on rare occasions, as psychosis. However, a brain tumor synchronous with immunosuppressant neurotoxicity has never been reported in a kidney transplant recipient. Herein, we report the first case of possible tacrolimus neurotoxicity with a meningioma manifesting as manic-like psychosis after kidney transplantation.Case presentationA 63-year-old male presenting with acute psychotic mania was admitted to a psychiatric ward approximately 2 years after kidney transplantation. On brain magnetic resonance imaging, a tuberculum sellae meningioma was found, and hyperintense white matter lesions with possible tacrolimus-induced neurotoxicity were seen on fluid-attenuated inversion recovery images. Interestingly, the patient showed no visual field defects, and his blood tacrolimus concentration was within therapeutic ranges. After 3 weeks of adjunctive treatment with blonanserin, most of the symptoms had abated.ConclusionsThe present case highlights the fact that neuroimaging studies are necessary to investigate underlying causes, as well as immunosuppressant neurotoxicity, which should all be considered when atypical psychiatric symptoms develop after organ transplantation. Further, this case suggests that the additional use of atypical antipsychotics while maintaining immunosuppressants may be effective for manic-like psychotic symptoms secondary to possible immunosuppressant neurotoxicity synchronous with a meningioma.

Folate Receptor Overexpression in Human and Canine Meningiomas—Immunohistochemistry and Case Report of Intraoperative Molecular Imaging

Meningiomas are well-encapsulated benign brain tumors and surgical resection is often curative. Nevertheless, this is not always possible due to the difficulty of identifying residual disease intraoperatively. We hypothesized that meningiomas overexpress folate receptor alpha (FRα), allowing intraoperative molecular imaging by targeting FRα with a near-infrared (NIR) dye. To determine FRα expression in both human and canine meningioma cohorts to prepare for future clinical studies. Present a case study of a meningioma resection with intraoperative NIR fluorescence imaging. Tissue samples of 27 human meningioma specimens and 7 canine meningioma specimens were immunohistochemically stained for FRα along with normal dura, skeletal muscle, and kidney tissue. We then enrolled a patient with a pituitary adenoma and tuberculum sella meningioma in a clinical trial in which the patient received an infusion of folate-linked, NIR fluorescent dye prior to surgery. In the cohort of human meningiomas, 9 WHO grade I, 12 grade II, and 6 grade III tumors were identified. Eighty-nine percent of WHO grade I, 67% of grade II, and 50% of grade III tumors overexpressed FRα. In the 7 canine meningioma samples, 100% stained positively for FRα. Both human and canine normal dura from autopsy samples demonstrated no evidence of FRα overexpression. In the case study, the meningioma demonstrated a high NIR signal-to-background-ratio of 4.0 and demonstrated strong FRα immunohistochemistry staining. This study directly demonstrates FRα overexpression in both human and canine meningiomas. We also demonstrate superb intraoperative imaging of a meningioma using a FRα-targeting dye.

Can Intraoperative Magnetic Resonance Imaging Be Helpful in the Surgical Resection of Parasellar Meningiomas? A Case Series

The surgery of parasellar meningiomas is crucial. There are only a few reports of the use of intraoperative magnetic resonance imaging (iMRI) for resection of these lesions. We discuss the safety and usefulness of this technique in achieving the planned surgical goal and analyze patients' outcomes. Nineteen cases of parasellar meningioma were treated in our institution using iMRI. We classified the tumors according to their primary location: tuberculum sellae, clinoidal, and cavernous sinus meningiomas. We evaluated the history of previous surgery, outcome, residual (if present) tumor volume, degree of resection, achievement of the surgical goal, and number of iMRI scans. The preoperative surgical goal was achieved in all patients. In 7 of 19 patients, (37%) further tumor resection was performed after the first iMRI scan. Regarding the cavernous sinus group, the surgical resection was continued after the first iMRI in 56% of patients, obtaining substantial additional volume reduction. No complications were found related to the use of iMRI scan. iMRI has been effective in safely increasing the extent of parasellar meningioma resection mainly for recurrent and invasive tumors. Its usefulness has been seen mostly in cavernous sinus lesions, in which it allowed the further safe resection in 56% of cases. Moreover, this tool was particularly useful in recurrent or residual meningiomas with extension in extracranial compartments.

In Reply to the Letter to the Editor Regarding “Treatment Strategy for Tuberculum Sellae Meningiomas Based on Preoperative Radiologic Assessment”

In Reply to the Letter to the Editor Regarding “Treatment Strategy for Tuberculum Sellae Meningiomas Based on Preoperative Radiologic Assessment”

The Evolution of Endoscopic Skull Base Surgery Outcomes: Defining the Edge of the Envelope

Endoscopic skull base surgery is a relatively new approach in the neurosurgical armamentarium and its usefulness is still being explored. As the field has evolved, so too have the results. For this reason, it is important to re-examine the outcomes of surgery for a variety of diseases individually over time to determine the appropriate indications for these approaches. We performed a systematic review of recent literature (since 2012) of all studies using the endoscopic endonasal approach (EEA) for craniopharyngioma, olfactory groove, planum sphenoidale, tuberculum sellae meningioma, esthesioneuroblastoma, chordoma, and chondrosarcoma and discuss outcomes compared with a transcranial approach (TCA). These results are also compared with a series of reviews of the literature that were performed before 2012 to see how results have evolved over time. For chordomas, craniopharyngioma and planum sphenoidale/tuberculum sellae meningiomas, EEA has shown superior outcomes to TCA for well-selected cases. Olfactory groove meningiomas still have a better outcome when performed using TCA. Esthesioneuroblastoma requires consideration of tumor stage and extent to select the appropriate approach, although with time, more advanced tumors have become approachable with EEA. Chondrosarcoma is a rare lesion that may be resectable by EEA when anatomy is favorable, although its rarity makes comparison difficult. Advances in EEA make it a useful tool that is at times superior to TCA for specific diseases based on recently published literature reporting rates of resection and complications. Ongoing re-evaluation of outcomes is essential to providing the best information to surgeons choosing an approach in each patient.

Transsphenoidal versus Transcranial Approach for Treatment of Tuberculum Sellae Meningiomas: A Systematic Review and Meta-analysis of Comparative Studies

There is controversy regarding the surgical route selection for tuberculum sellae meningiomas (TSMs): the transsphenoidal (TS) or transcranial (TC) approach? We conducted a systematic review and meta-analysis to compare clinical outcomes and postoperative complications between two surgical approaches. Literature search was performed. Relevant articles were selected and evaluated. Data were extracted and analyzed. Eight articles comprising 550 patients met the inclusion criteria. Traditionally, the rates of gross total resection, tumor recurrence, visual improvement, and cerebrospinal fluid leakage were the most common outcomes of interest. We demonstrated that the TS approach was significantly associated with better visual outcomes but more frequent cerebrospinal fluid leakage, while the rates of tumor resection and recurrence showed no significant difference between groups. In addition to surgical results that were consistent with previous studies, we further evaluated the impact of approach selection on common postoperative complications, which were closely related to the recovery course and quality of life. We revealed that the risk of dysosmia was significantly higher in the TS group. There was no significant difference between groups regarding infection, intracranial hemorrhage, and endocrine disorders. Because of the relatively low evidence levels of included retrospective studies, it was difficult to reach a categorical conclusion about the optimal surgical approach for TSMs. Finally, we recommended that the TS approach was an alternative option in patients with smaller TSMs (<30 mm) and limited invasion of optic canals in experienced neurosurgical centers.

Trans-eyebrow supraorbital keyhole approach to tuberculum sellae meningiomas: a series of 30 cases with long-term visual outcomes and recurrence rates.

Approach selection paradigm for tuberculum sellae meningiomas (TSMs) is still a point of discussion. The trans-eyebrow supraorbital keyhole approach (TSKA) is a minimally invasive transcranial approach and has been used for the treatment of TSMs during recent years. In this study, we presented a series of 30 cases of TSMs treated via TSKA with a long-term follow-up. Thirty patients with TSMs underwent surgery via TSKA between December 2006 and August 2018. The medical data and follow-up results were retrospectively analyzed. A total of 5 males and 25 females were included in this study. Three patients presented with recurrent TSMs. The mean tumor size was 25.3 ± 7.3mm (range, 10-48mm). The mean follow-up period was 58.0months (interquartile range, 33.5-86.3months). Gross total resection (GTR) was achieved in 27 patients (90.0%). One recurrence (3.3%) occurred 9years after surgery. Out of 29 patients with preoperative visual impairment, 17 (58.6%) improved, eight (27.6%) remained stable, and four (13.8%) deteriorated. No peri-operative death, CSF rhinorrhea, or permanent endocrine dysfunction occurred. All patients exhibited satisfactory cosmetic results. At the last follow-up, the glasgow outcome scale score was five in 27 patients (90.0%). The TSKA is characterized by minimal invasion with a satisfactory cosmetic outcome. Based on the tumor characteristics and surgeon's experience, this approach can be employed as an alternative minimally invasive approach for the treatment of TSMs.

Letter to the Editor Regarding “Treatment Strategy for Tuberculum Sellae Meningiomas Based on Preoperative Radiologic Assessment”

Letter to the Editor Regarding “Treatment Strategy for Tuberculum Sellae Meningiomas Based on Preoperative Radiologic Assessment”

Small Extended Bifrontal Approach for Midline Anterior Skull Base Meningiomas: Our Experience with 54 Consecutive Patients

To describe the technique of a small extended bifrontal approach and review the clinical outcome of patients with midline anterior skull base (MASB) meningiomas treated using this technique. The small extended bifrontal craniotomy extends inferiorly to the nasofrontal suture without entering the orbit, superiorly 3 cm above the supraorbital rim, and laterally 3 cm to the midline on both sides. A review of a prospectively acquired database was performed of 54 consecutive patients with MASB meningiomas who underwent this craniotomy. Twenty-nine patients with olfactory groove meningiomas, 2 with planum sphenoidale meningiomas (PSMs), and 23 with tuberculum sellae meningiomas (TSMs) were treated using this technique. Gross total resection was achieved in all patients. Of 29 patients with olfactory groove meningiomas, 12 (41.4%) had normal olfaction at presentation and 8 had preservation of olfaction postoperatively. Of 25 patients with TSMs/PSMs, 23 (92.0%) had preoperative visual impairment, with 13 showing improved vision (56.5%), 8 unchanging (34.8%), and 2 deteriorating (8.7%) after surgery. The most common complications were anosmia and hyposmia, which occurred in 5 patients (20.0%) and 3 patients (12.0%) with TSMs/PSMs, respectively. No mortality was reported. There was no recurrence in all patients after a mean follow-up of 39.5 months (range, 16-64 months). The small extended bifrontal approach is a safe and effective technique for resection of MASB meningiomas, which provides adequate surgical exposure with less approach-related morbidity. It is an excellent alternative for surgeons who favor the bifrontal approach and its extended variations.