Lateral transorbital neuroendoscopic approach for tumors of the orbital apex and spheno-orbital region: Technique, feasibility, efficacy, and safety based on a consecutive case series

Abstract

Introduction: Surgical approaches for tumors of the orbital apex and the spheno-orbital region (SOR) comprehend medial and lateral corridors. The TransOrbital NeuroEndoscopic (TONE) approach has recently been reported as a possible effective alternative to the classic lateral corridors, but literature about is still underestimated.

Research question: The aim of this study was to make a critical appraisal of the results of using the lateral TONE approach in a monocentric consecutive series of SOR tumors.

Material and methods: Data from 38 consecutive patients managed surgically by means of a lateral TONE approach for a tumor involving the orbital apex and the SOR were collected and retrospectively reviewed from 2016, January 1st to 2023, December 31st.

Results: Mean age was 57 ± 14,9 years (23 female). 20 tumors were intraconal, with intradural involvement of SOR in 5 cases. Gross total resection was achieved in 82,9% of the 35 cases treated with a curative intent. Average operative time was 94,8 ± 28,5 and 140,2 ± 43,3 min for extraconal and intraconal tumors, respectively. Meningiomas had an overall prevalence of 31,6%. The complication rate was 21%, of which 87,5% transient. The recurrence rate was 0 for meningiomas and 14,3% for malignant tumors based on a follow-up of 55,3 ± 26,3 and 68,6 ± 17 months, respectively.

Discussion and conclusion: The lateral TONE approach is the approach of choice for tumors involving the lateral compartment of the orbital apex. It is also an effective and minimal invasive option in selected cases of spheno-orbital intradural tumors with no encasement of intracranial vessels.

Keywords: Case series; Endoscopic orbitotomy; Intraconal meningiomas; Lateral orbitotomy; Orbital approaches; Spheno-orbital meningiomas; TONE approach.

Fig. 1

(a) Axial CT of the orbital region showing an isodense left intraconal lesion; Axial (b) and sagittal (c) T1-weighted gadolinium contrast-enhanced MRI showing a hyperintense left intraconal meningioma at the orbital apex involving the lateral compartment; (d) Axial head CT revealing hyperpneumatization of the frontal sinus; (e) Intraoperative image showing patient placed in supine position. The head was fixed with a three-point skull clamp; (f) Intraoperative photograph showing the lateral eyebrow skin incision; (g–j) The “two-surgeons and four-hands” technique allowed excision and complete removal of the tumor (Simpson grade I). OR: orbital roof; LW: lateral orbital wall; M: meningioma; P: periorbita; SR: superior rectus muscle; LR: lateral rectus muscle; (k) photograph of the operative specimen; (l) Axial T1-weighted gadolinium contrast-enhanced MRI of the orbits at 6-month follow-up revealing complete tumor removal, preserved integrity of all the intraconal structures, and no evidence of recurrence; (m) Patient photograph obtained 6 months after surgery and showing good cosmetic results in the affected eye.

Fig. 1

(a) Axial CT of the orbital region showing an isodense left intraconal lesion; Axial (b) and sagittal (c) T1-weighted gadolinium contrast-enhanced MRI showing a hyperintense left intraconal meningioma at the orbital apex involving the lateral compartment; (d) Axial head CT revealing hyperpneumatization of the frontal sinus; (e) Intraoperative image showing patient placed in supine position. The head was fixed with a three-point skull clamp; (f) Intraoperative photograph showing the lateral eyebrow skin incision; (g–j) The “two-surgeons and four-hands” technique allowed excision and complete removal of the tumor (Simpson grade I). OR: orbital roof; LW: lateral orbital wall; M: meningioma; P: periorbita; SR: superior rectus muscle; LR: lateral rectus muscle; (k) photograph of the operative specimen; (l) Axial T1-weighted gadolinium contrast-enhanced MRI of the orbits at 6-month follow-up revealing complete tumor removal, preserved integrity of all the intraconal structures, and no evidence of recurrence; (m) Patient photograph obtained 6 months after surgery and showing good cosmetic results in the affected eye.

Fig. 1

(a) Axial CT of the orbital region showing an isodense left intraconal lesion; Axial (b) and sagittal (c) T1-weighted gadolinium contrast-enhanced MRI showing a hyperintense left intraconal meningioma at the orbital apex involving the lateral compartment; (d) Axial head CT revealing hyperpneumatization of the frontal sinus; (e) Intraoperative image showing patient placed in supine position. The head was fixed with a three-point skull clamp; (f) Intraoperative photograph showing the lateral eyebrow skin incision; (g–j) The “two-surgeons and four-hands” technique allowed excision and complete removal of the tumor (Simpson grade I). OR: orbital roof; LW: lateral orbital wall; M: meningioma; P: periorbita; SR: superior rectus muscle; LR: lateral rectus muscle; (k) photograph of the operative specimen; (l) Axial T1-weighted gadolinium contrast-enhanced MRI of the orbits at 6-month follow-up revealing complete tumor removal, preserved integrity of all the intraconal structures, and no evidence of recurrence; (m) Patient photograph obtained 6 months after surgery and showing good cosmetic results in the affected eye.

Fig. 1

(a) Axial CT of the orbital region showing an isodense left intraconal lesion; Axial (b) and sagittal (c) T1-weighted gadolinium contrast-enhanced MRI showing a hyperintense left intraconal meningioma at the orbital apex involving the lateral compartment; (d) Axial head CT revealing hyperpneumatization of the frontal sinus; (e) Intraoperative image showing patient placed in supine position. The head was fixed with a three-point skull clamp; (f) Intraoperative photograph showing the lateral eyebrow skin incision; (g–j) The “two-surgeons and four-hands” technique allowed excision and complete removal of the tumor (Simpson grade I). OR: orbital roof; LW: lateral orbital wall; M: meningioma; P: periorbita; SR: superior rectus muscle; LR: lateral rectus muscle; (k) photograph of the operative specimen; (l) Axial T1-weighted gadolinium contrast-enhanced MRI of the orbits at 6-month follow-up revealing complete tumor removal, preserved integrity of all the intraconal structures, and no evidence of recurrence; (m) Patient photograph obtained 6 months after surgery and showing good cosmetic results in the affected eye.

Fig. 1

(a) Axial CT of the orbital region showing an isodense left intraconal lesion; Axial (b) and sagittal (c) T1-weighted gadolinium contrast-enhanced MRI showing a hyperintense left intraconal meningioma at the orbital apex involving the lateral compartment; (d) Axial head CT revealing hyperpneumatization of the frontal sinus; (e) Intraoperative image showing patient placed in supine position. The head was fixed with a three-point skull clamp; (f) Intraoperative photograph showing the lateral eyebrow skin incision; (g–j) The “two-surgeons and four-hands” technique allowed excision and complete removal of the tumor (Simpson grade I). OR: orbital roof; LW: lateral orbital wall; M: meningioma; P: periorbita; SR: superior rectus muscle; LR: lateral rectus muscle; (k) photograph of the operative specimen; (l) Axial T1-weighted gadolinium contrast-enhanced MRI of the orbits at 6-month follow-up revealing complete tumor removal, preserved integrity of all the intraconal structures, and no evidence of recurrence; (m) Patient photograph obtained 6 months after surgery and showing good cosmetic results in the affected eye.

Fig. 1

(a) Axial CT of the orbital region showing an isodense left intraconal lesion; Axial (b) and sagittal (c) T1-weighted gadolinium contrast-enhanced MRI showing a hyperintense left intraconal meningioma at the orbital apex involving the lateral compartment; (d) Axial head CT revealing hyperpneumatization of the frontal sinus; (e) Intraoperative image showing patient placed in supine position. The head was fixed with a three-point skull clamp; (f) Intraoperative photograph showing the lateral eyebrow skin incision; (g–j) The “two-surgeons and four-hands” technique allowed excision and complete removal of the tumor (Simpson grade I). OR: orbital roof; LW: lateral orbital wall; M: meningioma; P: periorbita; SR: superior rectus muscle; LR: lateral rectus muscle; (k) photograph of the operative specimen; (l) Axial T1-weighted gadolinium contrast-enhanced MRI of the orbits at 6-month follow-up revealing complete tumor removal, preserved integrity of all the intraconal structures, and no evidence of recurrence; (m) Patient photograph obtained 6 months after surgery and showing good cosmetic results in the affected eye.

Fig. 1

(a) Axial CT of the orbital region showing an isodense left intraconal lesion; Axial (b) and sagittal (c) T1-weighted gadolinium contrast-enhanced MRI showing a hyperintense left intraconal meningioma at the orbital apex involving the lateral compartment; (d) Axial head CT revealing hyperpneumatization of the frontal sinus; (e) Intraoperative image showing patient placed in supine position. The head was fixed with a three-point skull clamp; (f) Intraoperative photograph showing the lateral eyebrow skin incision; (g–j) The “two-surgeons and four-hands” technique allowed excision and complete removal of the tumor (Simpson grade I). OR: orbital roof; LW: lateral orbital wall; M: meningioma; P: periorbita; SR: superior rectus muscle; LR: lateral rectus muscle; (k) photograph of the operative specimen; (l) Axial T1-weighted gadolinium contrast-enhanced MRI of the orbits at 6-month follow-up revealing complete tumor removal, preserved integrity of all the intraconal structures, and no evidence of recurrence; (m) Patient photograph obtained 6 months after surgery and showing good cosmetic results in the affected eye.

Fig. 1

(a) Axial CT of the orbital region showing an isodense left intraconal lesion; Axial (b) and sagittal (c) T1-weighted gadolinium contrast-enhanced MRI showing a hyperintense left intraconal meningioma at the orbital apex involving the lateral compartment; (d) Axial head CT revealing hyperpneumatization of the frontal sinus; (e) Intraoperative image showing patient placed in supine position. The head was fixed with a three-point skull clamp; (f) Intraoperative photograph showing the lateral eyebrow skin incision; (g–j) The “two-surgeons and four-hands” technique allowed excision and complete removal of the tumor (Simpson grade I). OR: orbital roof; LW: lateral orbital wall; M: meningioma; P: periorbita; SR: superior rectus muscle; LR: lateral rectus muscle; (k) photograph of the operative specimen; (l) Axial T1-weighted gadolinium contrast-enhanced MRI of the orbits at 6-month follow-up revealing complete tumor removal, preserved integrity of all the intraconal structures, and no evidence of recurrence; (m) Patient photograph obtained 6 months after surgery and showing good cosmetic results in the affected eye.

Fig. 1

(a) Axial CT of the orbital region showing an isodense left intraconal lesion; Axial (b) and sagittal (c) T1-weighted gadolinium contrast-enhanced MRI showing a hyperintense left intraconal meningioma at the orbital apex involving the lateral compartment; (d) Axial head CT revealing hyperpneumatization of the frontal sinus; (e) Intraoperative image showing patient placed in supine position. The head was fixed with a three-point skull clamp; (f) Intraoperative photograph showing the lateral eyebrow skin incision; (g–j) The “two-surgeons and four-hands” technique allowed excision and complete removal of the tumor (Simpson grade I). OR: orbital roof; LW: lateral orbital wall; M: meningioma; P: periorbita; SR: superior rectus muscle; LR: lateral rectus muscle; (k) photograph of the operative specimen; (l) Axial T1-weighted gadolinium contrast-enhanced MRI of the orbits at 6-month follow-up revealing complete tumor removal, preserved integrity of all the intraconal structures, and no evidence of recurrence; (m) Patient photograph obtained 6 months after surgery and showing good cosmetic results in the affected eye.

Fig. 1

(a) Axial CT of the orbital region showing an isodense left intraconal lesion; Axial (b) and sagittal (c) T1-weighted gadolinium contrast-enhanced MRI showing a hyperintense left intraconal meningioma at the orbital apex involving the lateral compartment; (d) Axial head CT revealing hyperpneumatization of the frontal sinus; (e) Intraoperative image showing patient placed in supine position. The head was fixed with a three-point skull clamp; (f) Intraoperative photograph showing the lateral eyebrow skin incision; (g–j) The “two-surgeons and four-hands” technique allowed excision and complete removal of the tumor (Simpson grade I). OR: orbital roof; LW: lateral orbital wall; M: meningioma; P: periorbita; SR: superior rectus muscle; LR: lateral rectus muscle; (k) photograph of the operative specimen; (l) Axial T1-weighted gadolinium contrast-enhanced MRI of the orbits at 6-month follow-up revealing complete tumor removal, preserved integrity of all the intraconal structures, and no evidence of recurrence; (m) Patient photograph obtained 6 months after surgery and showing good cosmetic results in the affected eye.

Fig. 1

(a) Axial CT of the orbital region showing an isodense left intraconal lesion; Axial (b) and sagittal (c) T1-weighted gadolinium contrast-enhanced MRI showing a hyperintense left intraconal meningioma at the orbital apex involving the lateral compartment; (d) Axial head CT revealing hyperpneumatization of the frontal sinus; (e) Intraoperative image showing patient placed in supine position. The head was fixed with a three-point skull clamp; (f) Intraoperative photograph showing the lateral eyebrow skin incision; (g–j) The “two-surgeons and four-hands” technique allowed excision and complete removal of the tumor (Simpson grade I). OR: orbital roof; LW: lateral orbital wall; M: meningioma; P: periorbita; SR: superior rectus muscle; LR: lateral rectus muscle; (k) photograph of the operative specimen; (l) Axial T1-weighted gadolinium contrast-enhanced MRI of the orbits at 6-month follow-up revealing complete tumor removal, preserved integrity of all the intraconal structures, and no evidence of recurrence; (m) Patient photograph obtained 6 months after surgery and showing good cosmetic results in the affected eye.

Fig. 1

(a) Axial CT of the orbital region showing an isodense left intraconal lesion; Axial (b) and sagittal (c) T1-weighted gadolinium contrast-enhanced MRI showing a hyperintense left intraconal meningioma at the orbital apex involving the lateral compartment; (d) Axial head CT revealing hyperpneumatization of the frontal sinus; (e) Intraoperative image showing patient placed in supine position. The head was fixed with a three-point skull clamp; (f) Intraoperative photograph showing the lateral eyebrow skin incision; (g–j) The “two-surgeons and four-hands” technique allowed excision and complete removal of the tumor (Simpson grade I). OR: orbital roof; LW: lateral orbital wall; M: meningioma; P: periorbita; SR: superior rectus muscle; LR: lateral rectus muscle; (k) photograph of the operative specimen; (l) Axial T1-weighted gadolinium contrast-enhanced MRI of the orbits at 6-month follow-up revealing complete tumor removal, preserved integrity of all the intraconal structures, and no evidence of recurrence; (m) Patient photograph obtained 6 months after surgery and showing good cosmetic results in the affected eye.

Fig. 1

(a) Axial CT of the orbital region showing an isodense left intraconal lesion; Axial (b) and sagittal (c) T1-weighted gadolinium contrast-enhanced MRI showing a hyperintense left intraconal meningioma at the orbital apex involving the lateral compartment; (d) Axial head CT revealing hyperpneumatization of the frontal sinus; (e) Intraoperative image showing patient placed in supine position. The head was fixed with a three-point skull clamp; (f) Intraoperative photograph showing the lateral eyebrow skin incision; (g–j) The “two-surgeons and four-hands” technique allowed excision and complete removal of the tumor (Simpson grade I). OR: orbital roof; LW: lateral orbital wall; M: meningioma; P: periorbita; SR: superior rectus muscle; LR: lateral rectus muscle; (k) photograph of the operative specimen; (l) Axial T1-weighted gadolinium contrast-enhanced MRI of the orbits at 6-month follow-up revealing complete tumor removal, preserved integrity of all the intraconal structures, and no evidence of recurrence; (m) Patient photograph obtained 6 months after surgery and showing good cosmetic results in the affected eye.

Fig. 2

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the orbit showing a hyperintense left extraconal meningioma of the lateral wall involving the orbital apex; (c) Endoscopic intraoperative photograph obtained during tumor excision. OR: orbital roof; M: meningioma; LW: lateral orbital wall; (d) Patient photograph obtained 6 months after surgery and showing a good cosmetic result in the affected eye; (e) Post-op T1-weighted gadolinium contrast.enhanced MRI of the orbit.

Fig. 2

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the orbit showing a hyperintense left extraconal meningioma of the lateral wall involving the orbital apex; (c) Endoscopic intraoperative photograph obtained during tumor excision. OR: orbital roof; M: meningioma; LW: lateral orbital wall; (d) Patient photograph obtained 6 months after surgery and showing a good cosmetic result in the affected eye; (e) Post-op T1-weighted gadolinium contrast.enhanced MRI of the orbit.

Fig. 2

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the orbit showing a hyperintense left extraconal meningioma of the lateral wall involving the orbital apex; (c) Endoscopic intraoperative photograph obtained during tumor excision. OR: orbital roof; M: meningioma; LW: lateral orbital wall; (d) Patient photograph obtained 6 months after surgery and showing a good cosmetic result in the affected eye; (e) Post-op T1-weighted gadolinium contrast.enhanced MRI of the orbit.

Fig. 2

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the orbit showing a hyperintense left extraconal meningioma of the lateral wall involving the orbital apex; (c) Endoscopic intraoperative photograph obtained during tumor excision. OR: orbital roof; M: meningioma; LW: lateral orbital wall; (d) Patient photograph obtained 6 months after surgery and showing a good cosmetic result in the affected eye; (e) Post-op T1-weighted gadolinium contrast.enhanced MRI of the orbit.

Fig. 2

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the orbit showing a hyperintense left extraconal meningioma of the lateral wall involving the orbital apex; (c) Endoscopic intraoperative photograph obtained during tumor excision. OR: orbital roof; M: meningioma; LW: lateral orbital wall; (d) Patient photograph obtained 6 months after surgery and showing a good cosmetic result in the affected eye; (e) Post-op T1-weighted gadolinium contrast.enhanced MRI of the orbit.

Fig. 3

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the right spheno-orbital region showing a spheno-orbital meningioma with a clear dural tail involving the orbital apex; Axial (c) and coronal (d) non-enhanced bone-window CT showing massive hyperostosis of the lateral wall of the right orbit and greater sphenoid wing; (e) Intraoperative image showing the patient placed in a supine position with the head fixed by a three-point head clamp; (f) Intraoperative image showing the subperiosteal dissection of the periorbita after skin incision; (g) Extensive drilling of the sphenoid ridge allowed exposure of the middle fossa dura; (h) the opening of the spheno-orbital dura was made just above the orbital apex, and the meningioma was fully exposed, debulked and dissected (i); (j) Intraoperative photograph at the end of surgery showing the sphenoidal compartment of the Sylvian fissure, the Sylvian cistern, the M1 segment of middle cerebral artery, along the origin of the lateral lenticulostriate arteries; (k) onlay reconstruction of the spheno-orbital dural defect with collagen dura substitute and fibrin glue; (l) image of the patient obtained 6 months after surgery revealing a good cosmetic outcome; (m) Post-op T1-weighted gadolinium contrast.enhanced MRI of the spheno-orbital region OR: orbital roof; P: periorbita; MFD: middle cranial fossa dura; LW: lateral orbital wall; GSW: greater sphenoid wing; TP: Temporal pole; M: meningioma; SF: Sylvian fissure; M1: M1 segment of the middle cerebral artery; LSA: lateral lenticulostriate arteries; DS: dural substitute.

Fig. 3

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the right spheno-orbital region showing a spheno-orbital meningioma with a clear dural tail involving the orbital apex; Axial (c) and coronal (d) non-enhanced bone-window CT showing massive hyperostosis of the lateral wall of the right orbit and greater sphenoid wing; (e) Intraoperative image showing the patient placed in a supine position with the head fixed by a three-point head clamp; (f) Intraoperative image showing the subperiosteal dissection of the periorbita after skin incision; (g) Extensive drilling of the sphenoid ridge allowed exposure of the middle fossa dura; (h) the opening of the spheno-orbital dura was made just above the orbital apex, and the meningioma was fully exposed, debulked and dissected (i); (j) Intraoperative photograph at the end of surgery showing the sphenoidal compartment of the Sylvian fissure, the Sylvian cistern, the M1 segment of middle cerebral artery, along the origin of the lateral lenticulostriate arteries; (k) onlay reconstruction of the spheno-orbital dural defect with collagen dura substitute and fibrin glue; (l) image of the patient obtained 6 months after surgery revealing a good cosmetic outcome; (m) Post-op T1-weighted gadolinium contrast.enhanced MRI of the spheno-orbital region OR: orbital roof; P: periorbita; MFD: middle cranial fossa dura; LW: lateral orbital wall; GSW: greater sphenoid wing; TP: Temporal pole; M: meningioma; SF: Sylvian fissure; M1: M1 segment of the middle cerebral artery; LSA: lateral lenticulostriate arteries; DS: dural substitute.

Fig. 3

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the right spheno-orbital region showing a spheno-orbital meningioma with a clear dural tail involving the orbital apex; Axial (c) and coronal (d) non-enhanced bone-window CT showing massive hyperostosis of the lateral wall of the right orbit and greater sphenoid wing; (e) Intraoperative image showing the patient placed in a supine position with the head fixed by a three-point head clamp; (f) Intraoperative image showing the subperiosteal dissection of the periorbita after skin incision; (g) Extensive drilling of the sphenoid ridge allowed exposure of the middle fossa dura; (h) the opening of the spheno-orbital dura was made just above the orbital apex, and the meningioma was fully exposed, debulked and dissected (i); (j) Intraoperative photograph at the end of surgery showing the sphenoidal compartment of the Sylvian fissure, the Sylvian cistern, the M1 segment of middle cerebral artery, along the origin of the lateral lenticulostriate arteries; (k) onlay reconstruction of the spheno-orbital dural defect with collagen dura substitute and fibrin glue; (l) image of the patient obtained 6 months after surgery revealing a good cosmetic outcome; (m) Post-op T1-weighted gadolinium contrast.enhanced MRI of the spheno-orbital region OR: orbital roof; P: periorbita; MFD: middle cranial fossa dura; LW: lateral orbital wall; GSW: greater sphenoid wing; TP: Temporal pole; M: meningioma; SF: Sylvian fissure; M1: M1 segment of the middle cerebral artery; LSA: lateral lenticulostriate arteries; DS: dural substitute.

Fig. 3

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the right spheno-orbital region showing a spheno-orbital meningioma with a clear dural tail involving the orbital apex; Axial (c) and coronal (d) non-enhanced bone-window CT showing massive hyperostosis of the lateral wall of the right orbit and greater sphenoid wing; (e) Intraoperative image showing the patient placed in a supine position with the head fixed by a three-point head clamp; (f) Intraoperative image showing the subperiosteal dissection of the periorbita after skin incision; (g) Extensive drilling of the sphenoid ridge allowed exposure of the middle fossa dura; (h) the opening of the spheno-orbital dura was made just above the orbital apex, and the meningioma was fully exposed, debulked and dissected (i); (j) Intraoperative photograph at the end of surgery showing the sphenoidal compartment of the Sylvian fissure, the Sylvian cistern, the M1 segment of middle cerebral artery, along the origin of the lateral lenticulostriate arteries; (k) onlay reconstruction of the spheno-orbital dural defect with collagen dura substitute and fibrin glue; (l) image of the patient obtained 6 months after surgery revealing a good cosmetic outcome; (m) Post-op T1-weighted gadolinium contrast.enhanced MRI of the spheno-orbital region OR: orbital roof; P: periorbita; MFD: middle cranial fossa dura; LW: lateral orbital wall; GSW: greater sphenoid wing; TP: Temporal pole; M: meningioma; SF: Sylvian fissure; M1: M1 segment of the middle cerebral artery; LSA: lateral lenticulostriate arteries; DS: dural substitute.

Fig. 3

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the right spheno-orbital region showing a spheno-orbital meningioma with a clear dural tail involving the orbital apex; Axial (c) and coronal (d) non-enhanced bone-window CT showing massive hyperostosis of the lateral wall of the right orbit and greater sphenoid wing; (e) Intraoperative image showing the patient placed in a supine position with the head fixed by a three-point head clamp; (f) Intraoperative image showing the subperiosteal dissection of the periorbita after skin incision; (g) Extensive drilling of the sphenoid ridge allowed exposure of the middle fossa dura; (h) the opening of the spheno-orbital dura was made just above the orbital apex, and the meningioma was fully exposed, debulked and dissected (i); (j) Intraoperative photograph at the end of surgery showing the sphenoidal compartment of the Sylvian fissure, the Sylvian cistern, the M1 segment of middle cerebral artery, along the origin of the lateral lenticulostriate arteries; (k) onlay reconstruction of the spheno-orbital dural defect with collagen dura substitute and fibrin glue; (l) image of the patient obtained 6 months after surgery revealing a good cosmetic outcome; (m) Post-op T1-weighted gadolinium contrast.enhanced MRI of the spheno-orbital region OR: orbital roof; P: periorbita; MFD: middle cranial fossa dura; LW: lateral orbital wall; GSW: greater sphenoid wing; TP: Temporal pole; M: meningioma; SF: Sylvian fissure; M1: M1 segment of the middle cerebral artery; LSA: lateral lenticulostriate arteries; DS: dural substitute.

Fig. 3

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the right spheno-orbital region showing a spheno-orbital meningioma with a clear dural tail involving the orbital apex; Axial (c) and coronal (d) non-enhanced bone-window CT showing massive hyperostosis of the lateral wall of the right orbit and greater sphenoid wing; (e) Intraoperative image showing the patient placed in a supine position with the head fixed by a three-point head clamp; (f) Intraoperative image showing the subperiosteal dissection of the periorbita after skin incision; (g) Extensive drilling of the sphenoid ridge allowed exposure of the middle fossa dura; (h) the opening of the spheno-orbital dura was made just above the orbital apex, and the meningioma was fully exposed, debulked and dissected (i); (j) Intraoperative photograph at the end of surgery showing the sphenoidal compartment of the Sylvian fissure, the Sylvian cistern, the M1 segment of middle cerebral artery, along the origin of the lateral lenticulostriate arteries; (k) onlay reconstruction of the spheno-orbital dural defect with collagen dura substitute and fibrin glue; (l) image of the patient obtained 6 months after surgery revealing a good cosmetic outcome; (m) Post-op T1-weighted gadolinium contrast.enhanced MRI of the spheno-orbital region OR: orbital roof; P: periorbita; MFD: middle cranial fossa dura; LW: lateral orbital wall; GSW: greater sphenoid wing; TP: Temporal pole; M: meningioma; SF: Sylvian fissure; M1: M1 segment of the middle cerebral artery; LSA: lateral lenticulostriate arteries; DS: dural substitute.

Fig. 3

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the right spheno-orbital region showing a spheno-orbital meningioma with a clear dural tail involving the orbital apex; Axial (c) and coronal (d) non-enhanced bone-window CT showing massive hyperostosis of the lateral wall of the right orbit and greater sphenoid wing; (e) Intraoperative image showing the patient placed in a supine position with the head fixed by a three-point head clamp; (f) Intraoperative image showing the subperiosteal dissection of the periorbita after skin incision; (g) Extensive drilling of the sphenoid ridge allowed exposure of the middle fossa dura; (h) the opening of the spheno-orbital dura was made just above the orbital apex, and the meningioma was fully exposed, debulked and dissected (i); (j) Intraoperative photograph at the end of surgery showing the sphenoidal compartment of the Sylvian fissure, the Sylvian cistern, the M1 segment of middle cerebral artery, along the origin of the lateral lenticulostriate arteries; (k) onlay reconstruction of the spheno-orbital dural defect with collagen dura substitute and fibrin glue; (l) image of the patient obtained 6 months after surgery revealing a good cosmetic outcome; (m) Post-op T1-weighted gadolinium contrast.enhanced MRI of the spheno-orbital region OR: orbital roof; P: periorbita; MFD: middle cranial fossa dura; LW: lateral orbital wall; GSW: greater sphenoid wing; TP: Temporal pole; M: meningioma; SF: Sylvian fissure; M1: M1 segment of the middle cerebral artery; LSA: lateral lenticulostriate arteries; DS: dural substitute.

Fig. 3

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the right spheno-orbital region showing a spheno-orbital meningioma with a clear dural tail involving the orbital apex; Axial (c) and coronal (d) non-enhanced bone-window CT showing massive hyperostosis of the lateral wall of the right orbit and greater sphenoid wing; (e) Intraoperative image showing the patient placed in a supine position with the head fixed by a three-point head clamp; (f) Intraoperative image showing the subperiosteal dissection of the periorbita after skin incision; (g) Extensive drilling of the sphenoid ridge allowed exposure of the middle fossa dura; (h) the opening of the spheno-orbital dura was made just above the orbital apex, and the meningioma was fully exposed, debulked and dissected (i); (j) Intraoperative photograph at the end of surgery showing the sphenoidal compartment of the Sylvian fissure, the Sylvian cistern, the M1 segment of middle cerebral artery, along the origin of the lateral lenticulostriate arteries; (k) onlay reconstruction of the spheno-orbital dural defect with collagen dura substitute and fibrin glue; (l) image of the patient obtained 6 months after surgery revealing a good cosmetic outcome; (m) Post-op T1-weighted gadolinium contrast.enhanced MRI of the spheno-orbital region OR: orbital roof; P: periorbita; MFD: middle cranial fossa dura; LW: lateral orbital wall; GSW: greater sphenoid wing; TP: Temporal pole; M: meningioma; SF: Sylvian fissure; M1: M1 segment of the middle cerebral artery; LSA: lateral lenticulostriate arteries; DS: dural substitute.

Fig. 3

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the right spheno-orbital region showing a spheno-orbital meningioma with a clear dural tail involving the orbital apex; Axial (c) and coronal (d) non-enhanced bone-window CT showing massive hyperostosis of the lateral wall of the right orbit and greater sphenoid wing; (e) Intraoperative image showing the patient placed in a supine position with the head fixed by a three-point head clamp; (f) Intraoperative image showing the subperiosteal dissection of the periorbita after skin incision; (g) Extensive drilling of the sphenoid ridge allowed exposure of the middle fossa dura; (h) the opening of the spheno-orbital dura was made just above the orbital apex, and the meningioma was fully exposed, debulked and dissected (i); (j) Intraoperative photograph at the end of surgery showing the sphenoidal compartment of the Sylvian fissure, the Sylvian cistern, the M1 segment of middle cerebral artery, along the origin of the lateral lenticulostriate arteries; (k) onlay reconstruction of the spheno-orbital dural defect with collagen dura substitute and fibrin glue; (l) image of the patient obtained 6 months after surgery revealing a good cosmetic outcome; (m) Post-op T1-weighted gadolinium contrast.enhanced MRI of the spheno-orbital region OR: orbital roof; P: periorbita; MFD: middle cranial fossa dura; LW: lateral orbital wall; GSW: greater sphenoid wing; TP: Temporal pole; M: meningioma; SF: Sylvian fissure; M1: M1 segment of the middle cerebral artery; LSA: lateral lenticulostriate arteries; DS: dural substitute.

Fig. 3

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the right spheno-orbital region showing a spheno-orbital meningioma with a clear dural tail involving the orbital apex; Axial (c) and coronal (d) non-enhanced bone-window CT showing massive hyperostosis of the lateral wall of the right orbit and greater sphenoid wing; (e) Intraoperative image showing the patient placed in a supine position with the head fixed by a three-point head clamp; (f) Intraoperative image showing the subperiosteal dissection of the periorbita after skin incision; (g) Extensive drilling of the sphenoid ridge allowed exposure of the middle fossa dura; (h) the opening of the spheno-orbital dura was made just above the orbital apex, and the meningioma was fully exposed, debulked and dissected (i); (j) Intraoperative photograph at the end of surgery showing the sphenoidal compartment of the Sylvian fissure, the Sylvian cistern, the M1 segment of middle cerebral artery, along the origin of the lateral lenticulostriate arteries; (k) onlay reconstruction of the spheno-orbital dural defect with collagen dura substitute and fibrin glue; (l) image of the patient obtained 6 months after surgery revealing a good cosmetic outcome; (m) Post-op T1-weighted gadolinium contrast.enhanced MRI of the spheno-orbital region OR: orbital roof; P: periorbita; MFD: middle cranial fossa dura; LW: lateral orbital wall; GSW: greater sphenoid wing; TP: Temporal pole; M: meningioma; SF: Sylvian fissure; M1: M1 segment of the middle cerebral artery; LSA: lateral lenticulostriate arteries; DS: dural substitute.

Fig. 3

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the right spheno-orbital region showing a spheno-orbital meningioma with a clear dural tail involving the orbital apex; Axial (c) and coronal (d) non-enhanced bone-window CT showing massive hyperostosis of the lateral wall of the right orbit and greater sphenoid wing; (e) Intraoperative image showing the patient placed in a supine position with the head fixed by a three-point head clamp; (f) Intraoperative image showing the subperiosteal dissection of the periorbita after skin incision; (g) Extensive drilling of the sphenoid ridge allowed exposure of the middle fossa dura; (h) the opening of the spheno-orbital dura was made just above the orbital apex, and the meningioma was fully exposed, debulked and dissected (i); (j) Intraoperative photograph at the end of surgery showing the sphenoidal compartment of the Sylvian fissure, the Sylvian cistern, the M1 segment of middle cerebral artery, along the origin of the lateral lenticulostriate arteries; (k) onlay reconstruction of the spheno-orbital dural defect with collagen dura substitute and fibrin glue; (l) image of the patient obtained 6 months after surgery revealing a good cosmetic outcome; (m) Post-op T1-weighted gadolinium contrast.enhanced MRI of the spheno-orbital region OR: orbital roof; P: periorbita; MFD: middle cranial fossa dura; LW: lateral orbital wall; GSW: greater sphenoid wing; TP: Temporal pole; M: meningioma; SF: Sylvian fissure; M1: M1 segment of the middle cerebral artery; LSA: lateral lenticulostriate arteries; DS: dural substitute.

Fig. 3

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the right spheno-orbital region showing a spheno-orbital meningioma with a clear dural tail involving the orbital apex; Axial (c) and coronal (d) non-enhanced bone-window CT showing massive hyperostosis of the lateral wall of the right orbit and greater sphenoid wing; (e) Intraoperative image showing the patient placed in a supine position with the head fixed by a three-point head clamp; (f) Intraoperative image showing the subperiosteal dissection of the periorbita after skin incision; (g) Extensive drilling of the sphenoid ridge allowed exposure of the middle fossa dura; (h) the opening of the spheno-orbital dura was made just above the orbital apex, and the meningioma was fully exposed, debulked and dissected (i); (j) Intraoperative photograph at the end of surgery showing the sphenoidal compartment of the Sylvian fissure, the Sylvian cistern, the M1 segment of middle cerebral artery, along the origin of the lateral lenticulostriate arteries; (k) onlay reconstruction of the spheno-orbital dural defect with collagen dura substitute and fibrin glue; (l) image of the patient obtained 6 months after surgery revealing a good cosmetic outcome; (m) Post-op T1-weighted gadolinium contrast.enhanced MRI of the spheno-orbital region OR: orbital roof; P: periorbita; MFD: middle cranial fossa dura; LW: lateral orbital wall; GSW: greater sphenoid wing; TP: Temporal pole; M: meningioma; SF: Sylvian fissure; M1: M1 segment of the middle cerebral artery; LSA: lateral lenticulostriate arteries; DS: dural substitute.

Fig. 3

Axial (a) and coronal (b) T1-weighted gadolinium contrast-enhanced MRI of the right spheno-orbital region showing a spheno-orbital meningioma with a clear dural tail involving the orbital apex; Axial (c) and coronal (d) non-enhanced bone-window CT showing massive hyperostosis of the lateral wall of the right orbit and greater sphenoid wing; (e) Intraoperative image showing the patient placed in a supine position with the head fixed by a three-point head clamp; (f) Intraoperative image showing the subperiosteal dissection of the periorbita after skin incision; (g) Extensive drilling of the sphenoid ridge allowed exposure of the middle fossa dura; (h) the opening of the spheno-orbital dura was made just above the orbital apex, and the meningioma was fully exposed, debulked and dissected (i); (j) Intraoperative photograph at the end of surgery showing the sphenoidal compartment of the Sylvian fissure, the Sylvian cistern, the M1 segment of middle cerebral artery, along the origin of the lateral lenticulostriate arteries; (k) onlay reconstruction of the spheno-orbital dural defect with collagen dura substitute and fibrin glue; (l) image of the patient obtained 6 months after surgery revealing a good cosmetic outcome; (m) Post-op T1-weighted gadolinium contrast.enhanced MRI of the spheno-orbital region OR: orbital roof; P: periorbita; MFD: middle cranial fossa dura; LW: lateral orbital wall; GSW: greater sphenoid wing; TP: Temporal pole; M: meningioma; SF: Sylvian fissure; M1: M1 segment of the middle cerebral artery; LSA: lateral lenticulostriate arteries; DS: dural substitute.

Fig. 4

Overview of the main approaches to the orbital and spheno-orbital region based on the “round-the-clock” scheme TONE: transorbital neuroendoscopic (approach); ON: optic nerve.