Advanced Endoscopic Approaches for Skull-Base Surgery: A Contemporary Imaging-Focused Review, From the AJR Special...

Endoscopic skull-base surgery has become widely accepted due to the advantages of the minimally invasive approach and achievement of outcomes that are comparable with those from open approaches. Given limited visualization of this region on clinical examination, preoperative planning relies heavily on diagnostic imaging to determine the optimal surgical approach and the intended extent of resection. Within this context, high-resolution CT and MRI provide valuable information regarding the pathology, its relationship to critical structures, and other pertinent anatomic considerations. This Special Series Review describes the role of imaging in advanced endoscopic endonasal skull-base surgeries, addressing clinically relevant normal and variant anatomy, key surgical landmarks, and pertinent red flags that serve as cautionary imaging findings. We discuss common pathologies occurring along these anatomic corridors and outline the core steps for specific surgical approaches. Interpreting radiologists must have a thorough understanding of the key anatomic structures and their relationships to pathology to help surgeons select the appropriate endoscopic endonasal approach corridor, optimize the extent of resection, minimize surgical risk, and determine reconstruction options.