Indications and Limitations of the Endoscopic Endonasal Approach for Anterior Cranial Base Meningiomas

OBJECTIVE: To describe the decision-making and the surgical strategy in the resection of anterior skullbase meningiomas. METHODS: Details of the microsurgical and endoscopic approach to anterior skullbase meningiomas are presented. RESULTS: Small and midsize olfactory groove, planum sphenoidale, and tuberculum sellae meningiomas can be removed via an endonasal endoscopic approach, an alternative option to the transcranial microsurgical approach. The choice of approach depends on tumor size and location, involvement of important neurovascular structures, and, most importantly, the surgeon's preference and experience. In my opinion, in most meningiomas, the endonasal approach has no advantage compared with the transcranial approach. Disadvantages of the endonasal approach are the discomfort after surgery and the prolonged recovery phase because of the nasal morbidity, which requires intensive nasal care. Compared with the eyebrow approach, the trauma to the nasal cavity, paranasal sinuses, and skull base is greater, and the risk of cerebrospinal fluid leak is higher. CONCLUSION: For most skull base meningiomas, I usually prefer the endoscope-assisted microsurgical transcranial approach which combines the advantages of the operating microscope with the advantages of the endoscope. The endonasal approach is beneficial for small tumors located below or behind the chiasm.