Vascular-based compartmental resection of anterior clinoidal meningiomas: an inter-perforator microdebulking strategy

BACKGROUND: Anterior clinoidal meningiomas (ACMs) frequently encase critical perforating arteries, making safe resection technically challenging and placing patients at risk for ischemic complications. This study aimed to evaluate the feasibility and surgical outcomes of a perforator-oriented inter-perforator microdebulking approach designed to preserve perforating arteries during ACM resection. METHODS: We retrospectively reviewed 11 patients with ACMs who underwent surgical resection using an inter-perforator microdebulking technique between 2019 and 2024. The surgical strategy consisted of systematic tumor compartmentalization along major arterial trunks followed by further subdivision at the perforator level, enabling controlled microdebulking within inter-perforator spaces. Surgical outcomes, ischemic complications, visual outcomes, cranial nerve deficits, and tumor recurrence were analyzed. RESULTS: Simpson Grade II resection was achieved in 10 of 11 patients (91%), and one patient underwent Simpson Grade III resection to avoid vascular injury. No patient developed a symptomatic ischemic stroke. Asymptomatic infarctions were observed in 5 patients (45%), predominantly involving the basal ganglia, all of whom had large tumors (≥ 45 mm). Visual improvement occurred in 2 of 4 symptomatic patients (50%), and no visual deterioration was observed. Transient oculomotor nerve palsy occurred in 2 patients, with complete resolution during follow-up; no permanent cranial nerve deficits were noted. No tumor recurrence was observed during a median follow-up of 19 months. CONCLUSIONS: The present findings suggest that perforator-oriented inter-perforator microdebulking may provide a useful anatomical framework for ACM surgery and may facilitate favorable tumor resection while preserving neurological function in selected patients.