The Endoscopic-Assisted Supraorbital Approach for Resection of Anterior Skull Base Meningiomas: A Large Single-Center Retrospective Surgical Study

Abstract

Objective The endoscopic-assisted supraorbital approach (eSOA) constitutes a minimally invasive strategy for removing anterior skull base meningiomas (ASBM). We present the largest retrospective single-institution and long-term follow-up study of eSOA for ASBM resection, providing further insight regarding indication, surgical considerations, complications, and outcome.

Methods We evaluated data of 176 patients operated on ASBM via the eSOA over 22 years.

Results Sixty-five tuberculum sellae (TS), 36 anterior clinoid (AC), 28 olfactory groove (OG), 27 planum sphenoidale, 11 lesser sphenoid wing, seven optic sheath, and two lateral orbitary roof meningiomas were assessed. Median surgery duration was 3.35 ± 1.42 hours, being significantly longer for OG and AC meningiomas (p <0.05). Complete resection was achieved in 91%. Complications included hyposmia (7.4%), supraorbital hypoesthesia (5.1%), cerebrospinal fluid fistula (5%), orbicularis oculi paresis (2.8%), visual disturbances (2.2%), meningitis (1.7%) and hematoma and wound infection (1.1%). One patient died due to intraoperative carotid injury, other due to pulmonary embolism. Median follow-up was 4.8 years with a tumor recurrence rate of 10.8%. Second surgery was chosen in 12 cases (10 via the previous SOA and two via pterional approach), whereas two patients received radiotherapy and in five patients a wait-and-see strategy was adopted.

Conclusion The eSOA represents an effective option for ASBM resection, enabling high complete resection rates and long-term disease control. Neuroendoscopy is fundamental for improving tumor resection while reducing brain and optic nerve retraction. Potential limitations and prolonged surgical duration may arise from the small craniotomy and reduced maneuverability, especially for large or strongly adherent lesions.

Keywords

meningioma - supraorbital approach - anterior skull base

Notes

Name of the institution where the study was performed: Mainz University Medical Centre, Langenbeck Str. 1, 55131 Mainz, GERMANY.

Code Availability

Not applicable.

Availability of Data and Material

The data that support the findings of this study are available from the corresponding author, L. Serrano Sponton, upon reasonable request.

Ethics Approval

Given that the study collected retrospective data corresponding to regular diagnostic, therapeutical and follow-up procedures at Mainz University Medical Centre (i.e., no additional study-related measures were performed) and data are not passed on to third parties or only in anonymous form (e.g., publication), no ethical concerns were observed by the local ethics committee and no separate patient consent was required. This is regulated in the Rhineland-Palatinate State by the Hospital Law §36, §37.

Authors' Contributions

L.S.S. contributed toward conceptualization, methodology, data collection, and formal statistical analysis, writing the original draft, review, and editing. F.O. worked on methodology, data collection and formal statistical analysis, writing the original draft, review and editing. A.N. contributed toward writing the original draft, grammar revision, review and editing. E.S., M.G., and E.A. did the review and editing. J.C. did the supervision, review, and editing. S.R.K. contributed toward supervision, writing the original draft, review and editing. A.A. did the conceptualization, project administration, supervision, writing the original draft, review and editing.

^* Contributed equally.

Publication History

Received: 17 February 2022

Accepted: 23 May 2022

Article published online:
29 June 2022

• References

• 1 Al-Mefty O, Smith R. Tuberculum Sellae Meningiomas. New York: Raven Press; 1991: 395-411
• 2 Fahlbusch R, Schott W. Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: surgical results with special consideration of ophthalmological and endocrinological outcomes. J Neurosurg 2002; 96 (02) 235-243
• 3 Laufer I, Anand VK, Schwartz TH. Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions. J Neurosurg 2007; 106 (03) 400-406
• 4 Li-Hua C, Ling C, Li-Xu L. Microsurgical management of tuberculum sellae meningiomas by the frontolateral approach: surgical technique and visual outcome. Clin Neurol Neurosurg 2011; 113 (01) 39-47
• 5 Mielke D, Mayfrank L, Psychogios MN, Rohde V. The anterior interhemispheric approach: a safe and effective approach to anterior skull base lesions. Acta Neurochir (Wien) 2014; 156 (04) 689-696
• 6 Rachinger W, Grau S, Tonn J-C. Different microsurgical approaches to meningiomas of the anterior cranial base. Acta Neurochir (Wien) 2010; 152 (06) 931-939
• 7 Fernandes YB, Maitrot D, Kehrli P, Tella Jr OI, Ramina R, Borges G. Supraorbital eyebrow approach to skull base lesions. Arq Neuropsiquiatr 2002; 60 (2-A): 246-250
• 8 Reisch R, Marcus HJ, Hugelshofer M, Koechlin NO, Stadie A, Kockro RA. Patients' cosmetic satisfaction, pain, and functional outcomes after supraorbital craniotomy through an eyebrow incision. J Neurosurg 2014; 121 (03) 730-734
• 9 Reisch R, Perneczky A. Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision. Neurosurgery 2005; 57 (Suppl. 04) 242-255 , discussion 242–255
• 10 Reisch R, Perneczky A, Filippi R. Surgical technique of the supraorbital key-hole craniotomy. Surg Neurol 2003; 59 (03) 223-227
• 11 Telera S, Carapella CM, Caroli F. et al. Supraorbital keyhole approach for removal of midline anterior cranial fossa meningiomas: a series of 20 consecutive cases. Neurosurg Rev 2012; 35 (01) 67-83 , discussion 83
• 12 van Lindert E, Perneczky A, Fries G, Pierangeli E. The supraorbital keyhole approach to supratentorial aneurysms: concept and technique. Surg Neurol 1998; 49 (05) 481-489 , discussion 489–490
• 13 Czirják S, Szeifert GT. The role of the superciliary approach in the surgical management of intracranial neoplasms. Neurol Res 2006; 28 (02) 131-137
• 14 Romani R, Lehecka M, Gaal E. et al. Lateral supraorbital approach applied to olfactory groove meningiomas: experience with 66 consecutive patients. Neurosurgery 2009; 65 (01) 39-52 , discussion 52–53
• 15 Ansari SF, Eisenberg A, Rodriguez A, Barkhoudarian G, Kelly DF. The supraorbital eyebrow craniotomy for intra-and extra-axial brain tumors: a single-center series and technique modification. Oper Neurosurg (Hagerstown) 2020; 19 (06) 667-677
• 16 Avery MB, Mallari RJ, Barkhoudarian G, Kelly DF. Supraorbital and mini-pterional keyhole craniotomies for brain tumors: a clinical and anatomical comparison of indications and outcomes in 204 cases. J Neurosurg 2021; 1: 1-11
• 17 Khan DZ, Muskens IS, Mekary RA. et al. The endoscope-assisted supraorbital “keyhole” approach for anterior skull base meningiomas: an updated meta-analysis. Acta Neurochir (Wien) 2021; 163 (03) 661-676
• 18 Louis DN, Perry A, Reifenberger G, von Deimling A, Figarella-Branger D, Cavenee WK, Ohgaki H, Wiestler OD, Kleihues P, Ellison DW. The 2016 World Health Organization Classification of Tumors of the Central Nervous System: a summary. Acta Neuropathol 2016; Jun; 131 (06) 803-820
• 19 Simpson D. The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry 1957; 20 (01) 22-39
• 20 Czirják S, Szeifert GT. Surgical experience with frontolateral keyhole craniotomy through a superciliary skin incision. Neurosurgery 2001; 48 (01) 145-149 , discussion 149–150
• 21 Perneczky A. Keyhole Concept in Neurosurgery: with Endoscope-Assisted Microsurgery and Case Studies. Thieme; 1999
• 22 Wiedemayer H, Sandalcioglu IE, Wiedemayer H, Stolke D. The supraorbital keyhole approach via an eyebrow incision for resection of tumors around the sella and the anterior skull base. Minim Invasive Neurosurg 2004; 47 (04) 221-225
• 23 Zhang MZ, Wang L, Zhang W. et al. The supraorbital keyhole approach with eyebrow incisions for treating lesions in the anterior fossa and sellar region. Chin Med J (Engl) 2004; 117 (03) 323-326
• 24 Chen H-C, Tzaan W-C. Microsurgical supraorbital keyhole approach to the anterior cranial base. J Clin Neurosci 2010; 17 (12) 1510-1514
• 25 Rychen J, Croci D, Roethlisberger M. et al. Minimally invasive alternative approaches to pterional craniotomy: a systematic review of the literature. World Neurosurg 2018; 113: 163-179
• 26 Thaher F, Hopf N, Hickmann A-K. et al. Supraorbital keyhole approach to the skull base: evaluation of complications related to CSF fistulas and opened frontal sinus. J Neurol Surg A Cent Eur Neurosurg 2015; 76 (06) 433-437
• 27 Bassiouni H, Asgari S, Stolke D. Tuberculum sellae meningiomas: functional outcome in a consecutive series treated microsurgically. Surg Neurol 2006; 66 (01) 37-44 , discussion 44–45
• 28 Fatemi N, Dusick JR, de Paiva Neto MA, Malkasian D, Kelly DF. Endonasal versus supraorbital keyhole removal of craniopharyngiomas and tuberculum sellae meningiomas. Neurosurgery 2009;64(5, suppl 2):269–284, discussion 284–286
• 29 Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH. Endoscopic skull base surgery: a comprehensive comparison with open transcranial approaches. Br J Neurosurg 2012; 26 (05) 637-648
• 30 Kotecha RS, Junckerstorff RC, Lee S, Cole CH, Gottardo NG. Pediatric meningioma: current approaches and future direction. J Neurooncol 2011; 104 (01) 1-10
• 31 Rubin G, Ben David U, Gornish M, Rappaport ZH. Meningiomas of the anterior cranial fossa floor. Review of 67 cases. Acta Neurochir (Wien) 1994; 129 (1-2): 26-30
• 32 Stafford SL, Perry A, Suman VJ. et al. Primarily resected meningiomas: outcome and prognostic factors in 581 Mayo Clinic patients, 1978 through 1988. Paper presented at: Mayo Clinic Proceedings. Elsevier 1998:936–942
• 33 Sughrue ME, Rutkowski MJ, Shangari G. et al. Incidence, risk factors, and outcome of venous infarction after meningioma surgery in 705 patients. J Clin Neurosci 2011; 18 (05) 628-632
• 34 Symon L, Rosenstein J. Surgical management of suprasellar meningioma. Part 1: The influence of tumor size, duration of symptoms, and microsurgery on surgical outcome in 101 consecutive cases. J Neurosurg 1984; 61 (04) 633-641
• 35 Couldwell WT, Weiss MH, Rabb C, Liu JK, Apfelbaum RI, Fukushima T. Variations on the standard transsphenoidal approach to the sellar region, with emphasis on the extended approaches and parasellar approaches: surgical experience in 105 cases. Neurosurgery 2004; 55 (03) 539-547 , discussion 547–550
• 36 de Divitiis E, Esposito F, Cappabianca P, Cavallo LM, de Divitiis O. Tuberculum sellae meningiomas: high route or low route? A series of 51 consecutive cases. Neurosurgery 2008; 62 (03) 556-563 , discussion 556–563
• 37 Dusick JR, Esposito F, Kelly DF. et al. The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 2005; 102 (05) 832-841
• 38 Gardner PA, Kassam AB, Thomas A. et al. Endoscopic endonasal resection of anterior cranial base meningiomas. Neurosurgery 2008; 63 (01) 36-52 , discussion 52–54
• 39 Jane Jr JA, Dumont AS, Vance ML. et al. The transsphenoidal transtuberculum sellae approach for suprasellar meningiomas. Paper presented at: Seminars in Neurosurgery. Copyright© 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New; 2003:211–218
• 40 Wang Q, Lu X-J, Ji W-Y. et al. Visual outcome after extended endoscopic endonasal transsphenoidal surgery for tuberculum sellae meningiomas. World Neurosurg 2010; 73 (06) 694-700
• 41 Eddleman CS, Liu JK. Optic nerve sheath meningioma: current diagnosis and treatment. Neurosurg Focus 2007; 23 (05) E4
• 42 Saraf S, McCarthy BJ, Villano JL. Update on meningiomas. Oncologist 2011; 16 (11) 1604-1613
• 43 Hamilton SN, Nichol A, Truong P. et al. Visual outcomes and local control after fractionated stereotactic radiotherapy for optic nerve sheath meningioma. Ophthal Plast Reconstr Surg 2018; 34 (03) 217-221
• 44 Ratnayake G, Oh T, Mehta R. et al. Long-term outcomes of patients with primary optic nerve sheath meningioma treated with stereotactic radiotherapy in an Australian institution. Paper presented at: 2019 Annual Scientific Meeting; 2019
• 45 Raco A, Bristot R, Domenicucci M, Cantore G. Meningiomas of the tuberculum sellae. Our experience in 69 cases surgically treated between 1973 and 1993. J Neurosurg Sci 1999; 43 (04) 253-260 , discussion 260–262
• 46 Schick U, Hassler W. Surgical management of tuberculum sellae meningiomas: involvement of the optic canal and visual outcome. J Neurol Neurosurg Psychiatry 2005; 76 (07) 977-983
• 47 Arai H, Sato K, Okuda O. et al. Transcranial transsphenoidal approach for tuberculum sellae meningiomas. Acta Neurochir (Wien) 2000; 142 (07) 751-756 , discussion 756–757
• 48 Conforti P, Moraci A, Albanese V, Rotondo M, Parlato C. Microsurgical management of suprasellar and intraventricular meningiomas. Neurochirurgia (Stuttg) 1991; 34 (03) 85-89
• 49 Yasargil M. Anterior Cranial Fossa Meningiomas. Microneurosurgery, vol. IVB. Stuttgart: Thieme Verlag; 1996: 141-142
• 50 Romani R, Silvasti-Lundell M, Laakso A, Tuominen H, Hernesniemi J, Niemi T. Slack brain in meningioma surgery through lateral supraorbital approach. Surg Neurol Int 2011; 2: 167
• 51 Romani R, Elsharkawy A, Laakso A, Kangasniemi M, Hernesniemi J. Tailored anterior clinoidectomy through the lateral supraorbital approach: experience with 82 consecutive patients. World Neurosurg 2012; 77 (3-4): 512-517
• 52 El-Maghraby H, Awad M, Kockro R. et al. 3D simulation (Dextroscope) for virtual reality surgical planning of skull base and vascular surgery. Skull Base 2009; 19: A040 DOI: 10.1055/s-2009-1222155.
• 53 Kockro RA, Killeen T, Ayyad A. et al. Aneurysm surgery with preoperative three-dimensional planning in a virtual reality environment: technique and outcome analysis. World Neurosurg 2016; 96: 489-499
• 54 Kockro RA, Stadie A, Schwandt E. et al. A collaborative virtual reality environment for neurosurgical planning and training. Neurosurgery 2007;61(5, suppl 2):379–391, discussion 391
• 55 Jallo GI, Benjamin V. Tuberculum sellae meningiomas: microsurgical anatomy and surgical technique. Neurosurgery 2002; 51 (06) 1432-1439 , discussion 1439–1440
• 56 Borg A, Kirkman MA, Choi D. Endoscopic endonasal anterior skull base surgery: a systematic review of complications during the past 65 years. World Neurosurg 2016; 95: 383-391
• 57 Ruggeri AG, Cappelletti M, Fazzolari B, Marotta N, Delfini R. Frontobasal midline meningiomas: is it right to shed doubt on the transcranial approaches? Updates and review of the literature. World Neurosurg 2016; 88: 374-382
• 58 Dedeciusova M, Svoboda N, Benes V, Astl J, Netuka D. Olfaction in olfactory groove meningiomas. J Neurol Surg A Cent Eur Neurosurg 2020; 81 (04) 310-317
• 59 Welge-Luessen A, Temmel A, Quint C, Moll B, Wolf S, Hummel T. Olfactory function in patients with olfactory groove meningioma. J Neurol Neurosurg Psychiatry 2001; 70 (02) 218-221
• 60 Ciurea AV, Iencean SM, Rizea RE, Brehar FM. Olfactory groove meningiomas: a retrospective study on 59 surgical cases. Neurosurg Rev 2012; 35 (02) 195-202 , discussion 202
• 61 Figueiredo EG, Deshmukh V, Nakaji P. et al. An anatomical evaluation of the mini-supraorbital approach and comparison with standard craniotomies. Neurosurgery 2006;59(4, suppl 2):ONS212–ONS220, discussion ONS220