Approach Strategy in Anterior Fossa and Parasellar Meningiomas

Introduction: Skull base tumors that originate or extend into parasellar area are challenging lesions due to the fact that they often surrounds vital nerves and vessels. To protect them each case should be analyzed meticulously and the best approach chosen accordingly. Despite the evolution of refined microsurgical instrumentation and techniques and shift toward minimal invasive approaches complex tumors requires more than straightforward approach. We report our experience and analyze the effectiveness of different approaches for safe and complete removal of anterior fossa and parasellar meningiomas.

Material and Methods: We analyzed our series of patients operated for anterior skull base meningiomas, or meningiomas that extends into sellar and parasellar region via different approaches. Clinical and radiology parameters, tumor location and size, extent of surgical resection, pre- and postoperative results are presented and discussed. We report the technical nuances of the procedures based on our experience which are of fundamental value for the safety and efficacy in applying those approaches.

Results: As most of the meningiomas are approachable with pterional approach, in some of tumor locations other approaches are selected as better options regarding invasiveness, complication rate and safety. Huge numbers of meningiomas were treated through keyhole craniotomy, but other approaches gives different perspectives and easier protection to vital structures. Although radical surgery to at least Simpson 2 grade was achieved, new technology as gamma knife surgery is an adjunct which can reduce the morbidity and mortality.

Conclusion: Different approaches are available for skull base meningiomas and the selection of the approaches depend on the location, tumor spread, surrounding of vital structures and size of tumors. The supraorbital eyebrow keyhole approach had been adopted in our institution in 1996 and has since been developed and refined so that today it represents the common route in addressing various pathology of anterior circulation and anterior fossa and parasellar tumors, but other approaches are used in tumors that spread out of selected area of anterior skull base fossa, especially where there is a chance to provide better functional results and better protection of vital structures as nerves and vessels.