Neurosurg Focus 36 (4):E14, 2014 ©AANS, 2014

Craniotomy for anterior cranial fossa meningiomas: historical overview

Saul F. Morales-Valero, M.D., Jamie J. Van Gompel, M.D., Ioannis Loumiotis, M.D., and Giuseppe Lanzino, M.D. Department of Neurologic Surgery, Mayo Clinic, Mayo Medical School, Rochester, Minnesota

The surgical treatment of meningiomas located at the base of the anterior cranial fossa is often challenging, and the evolution of the surgical strategy to resect these tumors parallels the development of craniotomy, and neurosur- gery in general, over the past century. Early successful operations to treat these tumors were pioneered by prominent figures such as Sir William Macewen and Francesco Durante. Following these early reports, Harvey Cushing made significant contributions, allowing a better understanding and treatment of meningiomas in general, but particularly those involving the anterior cranial base. Initially, large-sized unilateral or bilateral craniotomies were necessary to approach these deep-seated lesions. Technical advances such as the introduction of electrosurgery, the operating microscope, and refined microsurgical instruments allowed neurosurgeons to perform less invasive surgical proce- dures with better results. Today, a wide variety of surgical strategies, including endoscopic surgery and radiosurgery, are used to treat these tumors. In this review, the authors trace the evolution of craniotomy for anterior cranial fossa meningiomas. (http://thejns.org/doi/abs/10.3171/2014.1.FOCUS13569)

Key Words • intracranial meningiomas • craniotomy • history • anterior cranial fossa

eningiomas of the anterior cranial fossa represent has a few distinct clinical features. However, in practice, 12%–20% of all intracranial meningiomas.5,30 this group of tumors often represents a continuum. Their The large size of these lesions at the time of di- original site of attachment may differ, but given the high agnosis,M as well as their close relation with important neu- compliance of the brain at this location, they can attain rovascular structures (Fig. 1), often makes their resection large sizes and at the time of diagnosis the more anterior challenging. This group of tumors represents an exemplar types (olfactory groove and planum sphenoidale group) of the evolution of craniotomy for surgical approaches to occupy a significant portion of the anterior cranial fossa. the skull base. The first surgical procedures to treat these tumors were performed in the late 19th century and were carried out by prominent and pioneering neurosurgeons. Clinical Presentation Subsequent technical advances have allowed better surgi- At a time when imaging modalities were not widely cal outcomes, and presently these tumors can be treated available, the diagnosis of diseases relied upon accurate safely using a plethora of surgical approaches. Further- observations of clinicians. The identification of intracrani- more, adjuvant therapies not available at the outset of al lesions was particularly difficult because the functional surgical treatment of anterior fossa meningiomas, such as division of the brain was not completely understood. Dr. stereotactic radiation and intensity modulated radiation Robert Foster Kennedy made a significant contribution, therapies, have provided options for treating surgeons. In recognizing a common clinical presentation of space-oc- this review, we trace the evolution of neurosurgery for cupying lesions located in the frontal lobe. These observa- anterior cranial fossa meningiomas. tions, which led him to describe what is now called “Foster Kennedy syndrome,” came from the time he spent at the Classification National Hospital in Queen’s Square in London, working with prominent figures such as Sir William Gowers and Sir According to the site of attachment, the most com- Victor Horsley. Foster Kennedy defined the syndrome in mon meningiomas of the anterior cranial fossa are clas- 191111 and described it further in later publications:11 sified into olfactory groove, planum sphenoidale, and 21 One syndrome when present is diagnostically decisive: a tuberculum sellae meningiomas. Each of these tumors speedy reduction in ipsilateral acuity of vision due to ipsilateral compression neuritis of the optic nerve lying below the frontal Abbreviation used in this paper: ICA = internal carotid artery. lobe, coincident with papilledema and normal vision of the

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Fig. 1. Harvey Cushing’s illustration showing the large size attained by certain olfactory groove meningiomas and their relation to the ante- rior cerebral artery (A. Cer. Anterior). A. com. ant. = anterior communi- cating artery. Reproduced from Cushing H: Meningiomas, Their Clas- Fig. 2. Cushing’s depiction of the stages of optic chiasm compres- sification, Regional Behavior, Life History and Surgical End Results, sion by tuberculum sellae meningiomas. I and II: Presymptomatic Charles C. Thomas, 1938. stages. III: Early stage of visual symptoms, surgically favorable. IV: Twenty-gram tumor, surgically unfavorable. A.C. = anterior commis- sure; C. = chiasm; Hy. = hypohysis; I. = infundibulum; O.R. = optic re- opposite eye. From compression of the olfactory tract there is cess. Reproduced from Cushing H: Meningiomas, Their Classification, usually under these circumstances anosmia on the same side on Regional Behavior, Life History and Surgical End Results, Charles C. which retrobulbar neuritis and the primary optic atrophy have Thomas, 1938. occurred. He also described some changes in mental function 11 sa. In 1879, Sir William Macewen (Fig. 3) evaluated a that could be caused by these tumors: “First, is seen 14-year-old girl with a swelling at the upper and inner a lessening in power of attention; irrelevant replies are portion of the left orbital cavity; she complained of oc- made. There develops a trivial and meaningless jocosity. casional frontal headache and was found to have a miotic Short periods of excitement occur, with foolish, inept and left pupil with no response to light.14 Macewen suspected causeless laughter.” an intracranial lesion and admitted her for observation. With modern imaging and earlier diagnosis, the During this period she developed seizures, initially local- Foster Kennedy syndrome is only seen in a minority of ized to the right side of her body but later generalized patients and in some series it has been found in approxi- 10 and associated with loss of consciousness. The presence mately 5% of cases. A change in mental function (such of seizures and their prolonged duration prompted Mace- as loss of inhibition, memory deterioration, and person- wen to proceed with resection.14 He described the surgical ality changes) is reported as the primary symptom in procedure in an article published in 1881:14 20%–70% of patients harboring olfactory groove menin- 1 A trephine having a disc an inch in diameter was chosen giomas. These symptoms, which are often attributed to and a portion of bone was elevated. The skull was thicker aging and depression, are occasionally overlooked by the 10 than normal, and attached to the undersurface of the disc was patients and are mainly noticed by family members. a tumour of a gummatous aspect. A portion of the tumour Visual impairment is among the primary symptoms adhered to the disc which was removed. The remainder was of patients with meningiomas of the anterior cranial attached to the dura mater and spread over that membrane in fossa, especially those located in the tuberculum sellae15 a downward direction towards the base of the frontal lobes... (Fig. 2). In patients harboring olfactory groove meningio- The tumor was removed from the dura mater as far down as the mas, the incidence of preoperative visual deficits ranges orbital portion of the frontal bone. between 15% and 60%.1 Compression of the ipsilateral However, this is not a typical case in presentation and optic apparatus in a posteroinferior direction results in demographics and the exact pathology is not known. painless visual blurring and defects in the inferior visual More celebrated and definitely typical in presenta- field. When the tumor arises from the tuberculum sellae, tion is the case described by Francesco Durante (Fig. 4) bitemporal visual field deficits are common.15,25 in 1887, but operated on in 1884.6 Durante’s patient on inspection:6 Early Surgical Experience …showed no abnormality, except as to her left eye, which appeared somewhat low and drawn outwardly, otherwise the Sir William Macewen and Francesco Durante movements as well as the functions of the globe were normal. For a year or more, however, she had entirely lost her sense There is some controversy regarding the first suc- of smell; her memory had become impaired, particularly as to cessful operation for a tumor of the anterior cranial fos- remembering names… From her husband I learnt that she had

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ig F . 3. Photograph of Sir William Macewen at about 30 years of age. Fig. 4. Francesco Durante at the age of 28 (photograph circa 1898, Reprinted with permission from the Royal College of Physicians and in the public domain). Surgeons of Glasgow.

“My diagnosis and the operation, apparently so hazard- somewhat changed in disposition; that from being generally ous at the time, are therefore justified by the result.”6 Dr. happy and bright, she had become sad, melancholic, and taci- Durante presented the patient 3 months after the surgery turn, although she did not seem to brood over the state of her health. at a local meeting in Perugia, where she narrated her ex- perience. The case was later published in the Lancet6 and Finally he concluded: presented in the International Medical Congress held in The course of the disease, the loss of memory and of the Washington, D.C., in 1887. The patient is known to have sense of smell, and the objective and subjective state of the suffered a recurrence and underwent another operation patient led me to believe in the presence of a tumour within the 7 cranium, the pressure of which affected the anterior lobes of the in 1896 with good results; she was last known to be in brain and paralysed or destroyed the olfactory nerve. Moreover, good condition in 1905, more than 20 years after the first the displacement of the globe of the left eye led me to believe surgery. also that the tumour had penetrated the superior arch of the orbital cavity. Contributions by Harvey Cushing Durante reported that: “Such being my diagnosis, I Although the tumors described by Macewen and now proposed to the patient an operation that would re- Durante were most likely meningiomas, the term “me- move the offending object, explaining to her the gravity ningioma” to describe this type of neoplasms was later of the operation without reserve. She was brave, and she introduced by Harvey Cushing. In 1927, he dedicated the consented.” Macewen Memorial Lecture to illustrate two cases of ol- The tumor was approached through a left frontal cra- factory groove meningiomas.4 In the lecture, titled “Me- niectomy: “It occupied the anterior fossa at the base of ningiomas arising from the olfactory groove and their the left cranium, extending to the right and upon the crib- removal by the aid of electro-surgery,” Cushing demon- riform lamina, which it destroyed. Posteriorly it extended strated the utility of the recently introduced electrocau- to the glenoid tubercles before the sella turcica. The left tery, comparing the treatment of two tumors before and anterior cerebral lobe was greatly atrophied; the orbital after this tool was available.4 Cushing stated: “…with Dr. arch was much depressed, but not perforated by the tumor Bovie’s co-operation, during the past few months I have as I had anticipated.” gained sufficient familiarity with the instrument to real- Chloroform was used for anesthesia and surprisingly, ize that it holds out untold possibilities for the future of the entire procedure lasted only an hour; the patient was neurosurgery”4 (Fig. 5). discharged home on the 15th day and Durante concluded, The first patient was a 62-year-old woman who pre-

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this patient was unremarkable and there was immediate improvement in both visual and mental symptoms.3 These cases were later included in his renowned book Meningiomas, Their Classification, Regional Be- havior, Life History and Surgical End Results, which was published in 1938 and summarized data on patients with intracranial meningiomas in different locations.5 Among the 313 cases presented in this publication, 28 were su- prasellar and 29 olfactory groove meningiomas. Cushing provided details about the clinical history and diagnostic approach as well as the surgical procedures to treat these tumors. In most cases, the tumor was approached via a unilateral frontal craniotomy with resection of part of the frontal lobe (Fig. 6).5 However, he considered some me- ningiomas to be inoperable due to their size, and in those cases a subtemporal decompression was performed.5 He provided follow-up data of the surviving patients up to 10 Fig. 5. Cushing’s piecemeal removal (Steps I–IV) of a meningioma years and demonstrated good functional outcomes. using electrosurgery. Reproduced from Cushing H: Meningiomas, Their Classification, Regional Behavior, Life History and Surgical End Re- sults, Charles C. Thomas, 1938. Evolution of Modern Approaches to Anterior Cranial Fossa Meningiomas sented with impaired vision for 1 year, frontal headaches, Since the initial experience of these pioneering neu- loss of sense of smell, and mental deterioration. Skull ra- rosurgeons, multiple advances have taken place allowing diographs revealed an enlarged sella and erosion of the a safer and more effective treatment of this group of tu- left wing of the sphenoid. A left frontal tumor was di- mors. The unilateral frontal craniotomy used by Cush- agnosed and she underwent surgical treatment. However, ing evolved to a bifrontal craniotomy and a transbasal the resection was not simple; in fact, 3 different opera- approach described by Dandy, but a continued necessity tions were required to remove the entire tumor due to dif- 4 4 of frontal lobe resection. Subsequently, Tonnis reported ficulty achieving hemostasis. Cushing described: his successful experience with the bifrontal approach pre- …the intra-capsular method of enucleation, long put in use serving the brain tissue, which was followed by multiple in the surgical treatment of acoustic tumors, was called upon surgeons. The introduction of the operating microscope to get us out of difficulties. Accordingly, with a sharp spoon, cup-shaped fragments were scooped out of the anterior pole of in the 1970s and the refinement of surgical instruments the tumor until a large cavity was produced. This was a tedious improved the ability of neurosurgeons to carefully dissect procedure since it was necessary, after the removal of each these neoplasms.20,26 The unilateral and bifrontal crani- fragment, to delay until bleeding from the raw surface could be otomies have been further modified and currently some checked. craniofacial approaches are used to treat tumors invading The second case, in contrast, involved a relatively the nasal cavity and/or paranasal sinuses. The endoscope, straightforward treatment. A 45-year-old man present- which has been available for a long time for the treatment ing with progressive loss of vision and altered personality of other neurosurgical entities, was introduced recently in was found to have complete loss of smell and bilateral op- the treatment of anterior cranial fossa meningiomas and tic atrophy on examination. Radiographs showed a small is acquiring more advocates as supporting evidence be- area of calcification lying above the left olfactory groove. comes available. The tumor was approached by a frontal craniotomy, and The ideal surgical approach should provide enough in Cushing’s words:4 exposure of the tumor and the surrounding structures, in- …to make a long story short, it was finally possible so far to cluding its dural attachment, to interrupt its blood supply excavate the chief mass of the tumor lying to the left of the falx early in the procedure. In addition, brain retraction and that the outer border of the growth could be drawn forward and manipulation of critical neurovascular structures should freed from its dense site of attachment along the deepened and be minimized as much as possible to avoid procedure-re- widened olfactory groove underlying the ethmoidal plate. Only lated morbidity. Sufficient access to the skull base is also in this area was any troublesome bleeding encountered, and it was easily controlled by using a desiccating current which desirable in cases in which bone resection and subsequent charred the dura and, at the same time, it is to be expected, cranial base reconstruction are necessary. The selection destroyed any remaining nests of tumor cells which remained of the most appropriate approach depends on multiple adherent to it. factors, including surgeon’s preference and experience, Cushing finally concludes: “As can be appreciated, this tumor size and location, extent of dural attachment, and was not a procedure to be done hurriedly, nor could it pos- relation with the surrounding neurovascular structures. sibly have been carried through in a single session by any Subfrontal Approaches other method I can conceive of… from the time when the scalp was novocainized to the final closure and dressing, Anterior cranial fossa meningiomas can be ap­ seven hours were consumed.” The postoperative course of proached by a subfrontal route using either bifrontal or

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Fig. 6. Preferred approach by Cushing for lesions of the anterior cranial fossa. Reproduced from Cushing H: Meningiomas, Their Classification, Regional Behavior, Life History and Surgical End Results, Charles C. Thomas, 1938. unilateral craniotomies. Bifrontal craniotomy is frequent- complete resection have been reported even for large tu- ly used for large tumors and offers advantages such as mors (> 6 cm) with minimal morbidity and no mortal- wide symmetrical exposure that is useful when cranial ity. 23,24 Nakamura et al. directly compared the bifrontal base reconstruction has to be performed. However, this and frontolateral approaches in a series of patients with strategy requires ligation of part of the superior sagittal olfactory groove meningiomas and found comparable sinus and exposes both frontal lobes to the risk of postop- rates of complete tumor removal but higher morbidity in erative edema from retraction.16,21,28 Other disadvantages the group treated with the bifrontal approach as there was include the opening of the frontal sinuses and, more im- a greater incidence of cerebral edema in this group.16 portantly, late visualization of important structures such To provide a wider exposure and to avoid excessive as the optic apparatus, the internal carotid arteries (ICAs), brain retraction, some modifications to these approaches and the anterior cerebral–anterior communicating artery have been proposed.2,19 Persing and colleagues described complex. an approach through the frontal sinus that provides ad- Compared with the bifrontal approach, a unilateral equate exposure of the anterior cranial base and is es- frontal craniotomy allows sparing of the superior sagit- pecially useful to resect tumors with extension to the tal sinus and minimizes manipulation of the contralateral facial region.19 This approach can be extended by using frontal lobe. The optic chiasm and ipsilateral carotid ar- a larger frontal craniotomy or including orbital osteoto- tery can be identified early during the surgical procedure mies. More recently, Chi et al. reported their successful and the more lateral view of the tumor/optic nerve and experience treating midline anterior fossa meningiomas tumor/neurovascular complex favors precise microsurgi- with an extended bifrontal approach that included or- cal dissection. However, the view is limited, which can bital osteotomies.2 Simpson Grade 1 or 2 resection was be problematic when treating large tumors and dealing achieved in 80% of patients, and postoperative cerebral with their superior portion. Nevertheless, high rates of edema was observed in only 7% of patients. Disadvan-

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Unauthenticated | Downloaded 10/07/21 01:54 PM UTC S. F. Morales-Valero et al. tages of approaches combining craniotomy with orbital cranial base expand, displacing the critical neurovascular osteotomies include a higher risk of CSF fistula caused by structures superiorly and laterally. This anatomical relation wide opening of the frontal sinus and their complex and makes a ventral approach appropriate for small “midline” time-consuming nature. Furthermore, infection of this tumors without significant lateral extension. In relation to large free bone flap is difficult to reconstruct if needed. endoscopic approaches, lateral extension is defined as lat- eral to the supraclinoid carotid, or lateral to the midpor- The Pterional Approach and its Variations tion of the superior orbit. The transsphenoidal approach, The use of the pterional approach was popularized initially used to treat intrasellar lesions, was modified to by Yaşargil and first described specifically for the resec- gain access to lesions located beyond the boundaries of the tion of anterior skull base meningiomas by Hassler and sella turcica. For instance, this approach may be extended Zentner.9 This approach constitutes a short route to the anteriorly to reach tumors of the anterior cranial base by parasellar region and allows early visualization of impor- removing the anterior part of the sella turcica, and part of tant structures such as the optic apparatus and the ICA the planum sphenoidale. In circumstances in which olfac- and its branches.9,29 The patient’s nondominant side is tory groove meningiomas are approached in this manner, usually approached, unless the tumor extends predomi- anterior extension to the posterior table of the frontal sinus nantly to the left side with significant encasement of the can be managed with this technique. left ICA.23,24 The basal cisterns are opened early to allow Couldwell et al. pioneered the extended endonasal CSF release and brain relaxation and thus an adequate transsphenoidal approach and emphasized its utility to exposure is possible before the tumor is dissected. The treat lesions such as tuberculum sellae and planum sphe- main disadvantage of this approach is the difficulty in noidale meningiomas.3 The advantages of this approach removing tumor located underneath the ipsilateral optic include the avoidance of brain exposure and retraction, nerve without considerable manipulation. Tomasello and early devascularization of the tumor at its base, and re- colleagues described the pterional route to treat giant ol- moval of the tumor beneath the chiasm and optic nerves factory groove meningiomas with high rates of complete with minimal manipulation of these delicate structures. macroscopic removal, minimal morbidity, and a low re- Thus, this ventral approach constitutes a valid alternative currence rate at long-term follow-up.29 to transcranial approaches and is particularly useful in There are multiple variations of the pterional ap- elderly patients or properly selected patients. proach; for instance, the frontoorbitozygomatic21 ap- proach that involves a more extensive craniotomy and Endoscopic Approaches includes osteotomies of the roof and lateral wall of the The introduction of the endoscope to the realm of orbit as well as a part of the zygoma and supraorbital rim. neurosurgery led to successful treatment of deep-seated This variant combines the advantages of the subfron- lesions with minimal brain retraction. To gain access to tal approaches allowing a more basal exposure, and the the anterior skull base, the endoscope can be used mainly pterional approach providing early neurovascular control through two of the previously described approaches: via a and a better inferior to superior view than other anterolat- ventral, midline approach through the skull base, such as eral approaches. the extended endonasal approach, or using a small supra- orbital craniotomy. The endoscopic endonasal approach Supraorbital Approach for the treatment of anterior cranial fossa meningiomas is Modern neuroimaging techniques allow proper char- relatively new and has been increasingly reported during acterization of brain tumors and their relation to sur- the last decade, with significant contributions from differ- rounding structures. This characterization is helpful in ent study groups.8,27,31,32 presurgical planning and in the intraoperative setting The advantages of the endoscopic endonasal removal and makes it possible to approach deep-seated lesions include its minimally invasive nature and the early medi- through very small openings. Perneczky and colleagues al optic canal decompression, when necessary. However, introduced the concept of a supraorbital “keyhole” crani- an important disadvantage of this approach is the high otomy to approach a variety of skull base lesions, includ- incidence of postoperative CSF leakage, which has been ing meningiomas of the anterior cranial fossa.18,22 This ap- reported in as many as 40% of cases.8 A recent systematic proach represents the frontobasal portion of the pterional review compared transcranial approaches with the endo- approach with the advantage of greatly reducing the size nasal endoscopic approach for the treatment of olfactory of the skin incision (made typically within the eyebrow groove, tuberculum sellae, and planum sphenoidale me- or palpebral fissure) and the craniotomy.22 With adequate ningiomas with more favorable results in the transcra- patient positioning and brain relaxation there is minimal nial approaches. The endonasal endoscopic approach was need of brain retraction to obtain adequate visualization. found to be associated with a lower percentage of gross- In the series of 1125 lesions treated by Reisch and Per- total resection and a higher rate of postoperative CSF neczky during a 10-year period using this approach, 93 leakage.12 Increased experience, better instrumentation, represented anterior cranial base meningiomas.22 The and the use of multilayer closure and nasoseptal flaps may majority of tumors (80.2%) were completely resected in a minimize and reduce the risk of this complication.13,17 piecemeal fashion regardless of their size. Extended Endonasal Transsphenoidal Approach Conclusions Most tumors arising in the midline of the anterior Diagnosis and surgical treatment of anterior cranial

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Unauthenticated | Downloaded 10/07/21 01:54 PM UTC History of craniotomy for anterior cranial fossa meningiomas base meningiomas has paralleled the dramatic advances 15. Mahmoud M, Nader R, Al-Mefty O: Optic canal involvement in neurosurgery over the past century. Pioneering neuro- in tuberculum sellae meningiomas: influence on approach, surgeons such as Sir William McEwen, Francesco Du- recurrence, and visual recovery. Neurosurgery 67 (3 Suppl Operative):ons108–ons119, 2010 rante, and Harvey Cushing made significant contributions 16. Nakamura M, Struck M, Roser F, Vorkapic P, Samii M: Olfacto- to this area. Since then, approaches to these tumors have ry groove meningiomas: clinical outcome and recurrence rates evolved, and the recent explosion of interest for minimal- after tumor removal through the frontolateral and bifrontal ap- ly invasive techniques has opened a new chapter in the proach. Neurosurgery 62 (6 Suppl 3):1224–1232, 2008 treatment of these formidable lesions. 17. Nyquist GG, Anand VK, Singh A, Schwartz TH: Janus flap: bilateral nasoseptal flaps for anterior skull base reconstruc- Disclosure tion. Otolaryngol Head Neck Surg 142:327–331, 2010 18. Perneczky A, Müller-Forell W, van Lindert E, Fries G: Keyhole Dr. Lanzino serves as a consultant to Covidien/ev3, Edge Concept in Neurosurgery. Stuttgart: Thieme Medical Pub- Therapeutics, and Codman/Johnson and Johnson. lishers, 1999 Author contributions to the study and manuscript preparation 19. Persing JA, Jane JA, Levine PA, Cantrell RW: The versatile include the following. Conception and design: Lanzino, Morales- frontal sinus approach to the floor of the anterior cranial fossa. Valero. Acquisition of data: Lanzino, Morales-Valero. Analysis and Technical note. J Neurosurg 72:513–516, 1990 interpretation of data: Lanzino, Morales-Valero. Drafting the article: 20. Pia HW: The microscope in neurosurgery—technical im- all authors. Critically revising the article: all authors. Reviewed provements. Acta Neurochir (Wien) 26:251–255, 1972 submitted version of manuscript: all authors. Approved the final 21. Rachinger W, Grau S, Tonn JC: Different microsurgical ap- version of the manuscript on behalf of all authors: Lanzino. Study proaches to meningiomas of the anterior cranial base. Acta supervision: Lanzino. Neurochir (Wien) 152:931–939, 2010 22. Reisch R, Perneczky A: Ten-year experience with the supra- References orbital subfrontal approach through an eyebrow skin incision. Neurosurgery 57 (4 Suppl):242–255, 2005 1. Bassiouni H, Asgari S, Stolke D: Olfactory groove meningio- 23. Romani R, Laakso A, Kangasniemi M, Niemelä M, Hernesni- mas: functional outcome in a series treated microsurgically. emi J: Lateral supraorbital approach applied to tuberculum Acta Neurochir (Wien) 149:109–121, 2007 sellae meningiomas: experience with 52 consecutive patients. 2. 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Br Alafaci C: Giant olfactory groove meningiomas: extent of Med J 2:1822–1825, 1902 frontal lobes damage and long-term outcome after the pteri- 8. Gardner PA, Kassam AB, Thomas A, Snyderman CH, Carrau onal approach. World Neurosurg 76:311–317, 2011 RL, Mintz AH, et al: Endoscopic endonasal resection of ante- 30. Tuna H, Bozkurt M, Ayten M, Erdogan A, Deda H: Olfactory rior cranial base meningiomas. Neurosurgery 63:36–54, 2008 groove meningiomas. J Clin Neurosci 12:664–668, 2005 9. Hassler W, Zentner J: Pterional approach for surgical treatment 31. Van Gompel JJ, Frank G, Pasquini E, Zoli M, Hoover J, Lan- of olfactory groove meningiomas. Neurosurgery 25:942–947, zino G: Expanded endonasal endoscopic resection of anterior 1989 fossa meningiomas: report of 13 cases and meta-analysis of 10. Hentschel SJ, DeMonte F: Olfactory groove meningiomas. the literature. Neurosurg Focus 30(5):E15, 2011 Neurosurg Focus 14(6):E4, 2003 32. Webb-Myers R, Wormald PJ, Brophy B: An endoscopic endo- 11. Kennedy F: Retrobulbar neuritis as an exact diagnostic sign of nasal technique for resection of olfactory groove meningioma. certain tumors and abscesses in the frontal lobes. Am J Med J Clin Neurosci 15:451–455, 2008 Sci 142:355–368, 1911 12. Komotar RJ, Starke RM, Raper DM, Anand VK, Schwartz TH: Endoscopic endonasal versus open transcranial resection of anterior midline skull base meningiomas. World Neurosurg 77:713–724, 2012 Manuscript submitted December 15, 2013. 13. Leng LZ, Brown S, Anand VK, Schwartz TH: “Gasket-seal” Accepted January 24, 2014. watertight closure in minimal-access endoscopic cranial base Please include this information when citing this paper: DOI: surgery. Neurosurgery 62:ONSE342–ONSE343, 2008 10.3171/2014.1.FOCUS13569. 14. Macewen W: Intra-cranial lesions: illustrating some points in Address correspondence to: Giuseppe Lanzino, M.D., Mayo connexion with the localization of cerebral affections and the Clinic, Department of Neurologic Surgery, 200 1st St. NW, Roches- advantages of antiseptic trephining. Lancet 2:581–583, 1881 ter, MN 55905. email: [email protected].

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