Related Experiment Video
Updated: Jul 24, 2025
Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas
Published on: January 17, 2018
Pterional Approach for Anterior Skull Base Midline Meningiomas against "The More The Merrier" Approach: An
Matham Gowtham1, Akhilesh G B Gowda1, Sreenath Prabha Rajeev1
1Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
Abstract:
Objective Anterior midline skull base meningiomas involving olfactory groove, planum sphenoidale, and tuberculum sellae were usually managed with bifrontal craniotomy until the dawn of advanced microsurgical techniques. With the emergence of microsurgical techniques, midline meningiomas could be tackled solely from a unilateral pterional approach. We present our experience with pterional approach in managing anterior skull base midline meningiomas, including the technical nuances and outcomes. Methods Fifty-nine patients who underwent excision of anterior skull base midline meningiomas through a unilateral pterional craniotomy between 2015 and 2021 were retrospectively analyzed. The surgical technique and patient outcomes in the context of visual, behavioral, olfaction, and quality of life were evaluated during the follow-up. Results A total of 59 consecutive patients were assessed over an average follow-up period of 26.6 months. Twenty-one (35.5%) patients had planum sphenoidale meningioma. Olfactory groove and tuberculum sellae meningioma groups consist of 19 (32%) patients each. Visual disturbance was the predominant symptom with almost 68% of patients presented with it. A total of 55 (93%) patients had complete excision of the tumor with 40 patients (68%) achieving Simpson grade II excision, and 11 (19%) patients had Simpson grade I excision. Among operated cases, 24 patients (40%) had postoperative edema among which 3 (5%) patients had irritability and 1 patient had diffuse edema requiring postoperative ventilation. Only 15 (24.6%) patients had contusion of the frontal lobe and were managed conservatively. Five patients (50%) with seizures had an association with contusion. Sixty-seven percent of patients had improvements in vision and 15% of patients had a stable vision. Only eight (13%) patients had postoperative focal deficits. Ten percent of patients had new-onset anosmia. The average Karnofsky score was improved. Only two patients had recurrence during follow-up. Conclusion A unilateral pterional craniotomy is a versatile approach for the excision of anterior midline skull base meningioma, even for the larger lesions. The ability of this approach in the visualization of posterior neurovascular structures at the earlier stages of surgery while avoiding the opposite frontal lobe retraction and frontal sinus opening makes this approach more preferable over the other approaches.
Insights
The unilateral pterional approach is effective for anterior midline skull base meningiomas, offering good outcomes. This microsurgical technique provides excellent visualization and avoids extensive brain retraction for these challenging tumors.
Area of Science:
- Neurosurgery
- Skull Base Surgery
- Oncology
Background:
- Anterior midline skull base meningiomas traditionally required bifrontal craniotomy.
- Advancements in microsurgical techniques enable unilateral approaches for these tumors.
Purpose of the Study:
- To evaluate the efficacy and outcomes of the unilateral pterional approach for anterior midline skull base meningiomas.
- To detail the technical nuances and patient results, including visual, behavioral, and quality of life assessments.
Main Methods:
- Retrospective analysis of 59 patients who underwent unilateral pterional craniotomy for anterior midline skull base meningiomas (2015-2021).
- Evaluation of surgical technique, tumor excision extent (Simpson grade), and postoperative outcomes.
- Assessment of visual function, olfaction, behavior, and quality of life during follow-up.
Main Results:
- Complete tumor excision was achieved in 93% of patients (Simpson grade I/II in 87%).
- Significant improvement in vision was observed in 67% of patients; 13% experienced new focal deficits.
- Average Karnofsky score improved, with low recurrence rates (2 patients) and manageable postoperative complications.
Conclusions:
- The unilateral pterional craniotomy is a versatile and effective approach for anterior midline skull base meningiomas, including larger lesions.
- This technique offers superior visualization of neurovascular structures and minimizes frontal lobe retraction and sinus manipulation compared to bifrontal approaches.
