The endoscopic endonasal approach is not superior to the microscopic transcranial approach for anterior skull base meningiomas-a meta-analysis

Ivo S Muskens^{1

2

3}, Vanessa Briceno⁴, Tom L Ouwehand^{5

6}, Joseph P Castlen⁷, William B Gormley⁷, Linda S Aglio⁸, Amir H Zamanipoor Najafabadi⁹, Wouter R van Furth⁹, Timothy R Smith⁷, Rania A Mekary^{7

4}, Marike L D Broekman^{5

6

7

10}

Affiliations

¹ Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands. ivo_muskens@live.nl.
² Department of Neurosurgery, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508GA, Utrecht, The Netherlands. ivo_muskens@live.nl.
³ Cushing Neurosurgery Outcomes Center, Department of Neurosurgery Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. ivo_muskens@live.nl.
⁴ School of Pharmacy, Department of Pharmaceutical Business and Administrative Sciences, MCPHS University, Boston, MA, USA.
⁵ Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands.
⁶ Department of Neurosurgery, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508GA, Utrecht, The Netherlands.
⁷ Cushing Neurosurgery Outcomes Center, Department of Neurosurgery Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
⁸ Department of Anesthesiology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
⁹ Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands.
¹⁰ Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

PMID: 29127655
PMCID: PMC5735207
DOI: 10.1007/s00701-017-3390-y

Meta-Analysis

The endoscopic endonasal approach is not superior to the microscopic transcranial approach for anterior skull base meningiomas-a meta-analysis

Ivo S Muskens et al. Acta Neurochir (Wien). 2018 Jan.

. 2018 Jan;160(1):59-75.

doi: 10.1007/s00701-017-3390-y. Epub 2017 Nov 10.

Authors

Affiliations

¹ Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands. ivo_muskens@live.nl.
² Department of Neurosurgery, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508GA, Utrecht, The Netherlands. ivo_muskens@live.nl.
³ Cushing Neurosurgery Outcomes Center, Department of Neurosurgery Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. ivo_muskens@live.nl.
⁴ School of Pharmacy, Department of Pharmaceutical Business and Administrative Sciences, MCPHS University, Boston, MA, USA.
⁵ Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands.
⁶ Department of Neurosurgery, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508GA, Utrecht, The Netherlands.
⁷ Cushing Neurosurgery Outcomes Center, Department of Neurosurgery Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
⁸ Department of Anesthesiology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
⁹ Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands.
¹⁰ Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

PMID: 29127655
PMCID: PMC5735207
DOI: 10.1007/s00701-017-3390-y

Abstract

Object: In the past decade, the endonasal transsphenoidal approach (eTSA) has become an alternative to the microsurgical transcranial approach (mTCA) for tuberculum sellae meningiomas (TSMs) and olfactory groove meningiomas (OGMs). The aim of this meta-analysis was to evaluate which approach offered the best surgical outcomes.

Methods: A systematic review of the literature from 2004 and meta-analysis were conducted in accordance with the PRISMA guidelines. Pooled incidence was calculated for gross total resection (GTR), visual improvement, cerebrospinal fluid (CSF) leak, intraoperative arterial injury, and mortality, comparing eTSA and mTCA, with p-interaction values.

Results: Of 1684 studies, 64 case series were included in the meta-analysis. Using the fixed-effects model, the GTR rate was significantly higher among mTCA patients for OGM (eTSA: 70.9% vs. mTCA: 88.5%, p-interaction < 0.01), but not significantly higher for TSM (eTSA: 83.0% vs. mTCA: 85.8%, p-interaction = 0.34). Despite considerable heterogeneity, visual improvement was higher for eTSA than mTCA for TSM (p-interaction < 0.01), but not for OGM (p-interaction = 0.33). CSF leak was significantly higher among eTSA patients for both OGM (eTSA: 25.1% vs. mTCA: 10.5%, p-interaction < 0.01) and TSM (eTSA: 19.3%, vs. mTCA: 5.81%, p-interaction < 0.01). Intraoperative arterial injury was higher among eTSA (4.89%) than mTCA patients (1.86%) for TSM (p-interaction = 0.03), but not for OGM resection (p-interaction = 0.10). Mortality was not significantly different between eTSA and mTCA patients for both TSM (p-interaction = 0.14) and OGM resection (p-interaction = 0.88). Random-effect models yielded similar results.

Conclusion: In this meta-analysis, eTSA was not shown to be superior to mTCA for resection of both OGMs and TSMs.

Keywords: Complications; Endoscopic transsphenoidal surgery; Gross total resection; Meta-analysis; Microscopic transcranial surgery; Olfactory groove meningioma; Tuberculum sellae meningioma.

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Conflict of interest statement

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Human participants

This article does not contain any studies with human participants performed by any of the authors.

Ethical approval

Ethical approval was not necessary because of the nature of the study (meta-analysis).

Informed consent

Not applicable as this study did not involve individual patient data.

Figures

**Fig. 1**
Flowchart. Abreviations: OGM: olfactory groove meningioma, TSM: tuberculum sellae meningioma

**Fig. 2**
Pooled prevalence of gross total resection by approach for olfactory groove meningioma resection: endoscopic transsphenoidal approach vs. microscopic transcranial approach. P-interaction value < 0.01. eTSA, endoscopic transsphenoidal approach; mTCA, microscopic transcranial approach

**Fig. 3**
a Pooled prevalence of cerebrospinal fluid leak by approach for tuberculum sellae meningioma resection: endoscopic transsphenoidal approach vs. microscopic transcranial approach. P-interaction value < 0.01. CSF, cerebrospinal fluid; eTSA, endoscopic transsphenoidal approach; mTCA, microscopic transcranial approach. b Pooled prevalence rates of cerebrospinal fluid leak by approach for olfactory groove meningioma resection: endoscopic transsphenoidal approach vs. microscopic transcranial approach. P-interaction value < 0.01; CSF, cerebrospinal fluid; eTSA, endoscopic transsphenoidal approach; mTCA, microscopic transcranial approach

**Fig. 4**
Pooled prevalence rates of intraoperative arterial injury by approach for tuberculum sellae meningioma resection: endoscopic transsphenoidal approach vs. microscopic transcranial approach. P-interaction value: 0.03. eTSA, endoscopic transsphenoidal approach; mTCA, microscopic transcranial approach

See this image and copyright information in PMC

Comment in

The endoscopic endonasal approach or microscopic transcranial approach for anterior skull base meningiomas-It is all about right indication rather than superiority.
Cohen DM, Borghei-Razavi H, Kshettry VR, Recinos PF. Cohen DM, et al. Acta Neurochir (Wien). 2020 Jan;162(1):77-78. doi: 10.1007/s00701-019-04080-3. Epub 2019 Nov 6. Acta Neurochir (Wien). 2020. PMID: 31691852 No abstract available.
The endoscopic endonasal approach or microscopic transcranial approach for anterior skull base meningiomas-it is all about right indication rather than superiority.
Muskens IS, Zamanipoor Najafabadi AH, Broekman MLD. Muskens IS, et al. Acta Neurochir (Wien). 2020 Jan;162(1):75-76. doi: 10.1007/s00701-019-04085-y. Epub 2019 Nov 19. Acta Neurochir (Wien). 2020. PMID: 31745623 No abstract available.

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