A Low Subfrontal Dural Opening for Anterior Skull Base Lesions

Background: A recent technical note (https://youtu.be/Jc7wvR4PTFk) described a low subfrontal dural opening for resection of an anterior clinoid meningioma. The efficacy of this technique is further described in a series of patients with a variety of skull base pathologies.

Methods: A retrospective analysis of medical records for patients that underwent an operation via a low subfrontal dural opening was conducted. Data collected included demographic information, size, and location of lesions, extent of resection, ophthalmological and neurological examinations, imaging studies, and clinical course.

Results: Data were analyzed from 24 patients (17 females and 7 males) in which a low subfrontal dural opening was used. Median age was 54 years (range: 23–81 years) and median length of follow-up was 5.7 months (range: 2.2–57.8 months). Twenty-two patients were treated for meningiomas (12 tuberculum sellae, 9 anterior clinoid, and 1 medial sphenoid wing). Gross total resection was achieved in 16 patients, near total in 1 patient, and subtotal in 5 patients. A representative gross total resection is shown in [Fig. 1]. An additional patient was treated for an optic nerve cavernous malformation. Two patients were treated for aneurysms, One of the internal carotid artery (ICA), and one of the anterior communicating artery. Both aneurysms were completely obliterated and show no signs of recurrence at long-term follow-up. Of note, the patient treated for an ICA aneurysm also underwent meningioma resection in the same operation.

Postoperative intensive care unit stays ranged from 0 to 3 days with an average stay of 1.3 days. Average and median total hospital stays were 3.8 and 3 days, respectively, and ranged from 2 to 8 days. No intraoperative complications were observed. Two patients developed chronic subdural hematomas which required burr hole drainage in the postoperative period. Two patients also required placement of ventriculoperitoneal shunts for management of hydrocephalus.

Prior to surgery, 18 patients presented with visual impairment (17 unilateral and 1 bilateral). Postoperatively, seven patients experienced rapid visual recovery and four additional patients experienced a delayed visual recovery (>30 days postoperatively). Three patients experienced worsening of their visual impairment and four remained stable.

Conclusion: A low subfrontal dural opening is a safe and effective technique that allows access to a variety of anterior fossa lesions. This technique allows for early cerebrospinal fluid release and brain relaxation. A subfrontal dural opening can be utilized with minimal exposure of the frontal and temporal lobes or sylvian fissure and without the use of fixed retractors while offering excellent visualization of the local anatomy. This technique helps to minimize surgical risk while offering favorable extent of resection, visual outcomes, and low complication rates.

Fig. 1

Publication History

Article published online:
12 February 2021