Endoscopic Endonasal Approaches to Anterior Cranial Base Meningiomas: Indications, Limitations, and Surgical Decision-Making

Endoscopic endonasal surgery (EES) has fundamentally changed the management of anterior skull base meningiomas by enabling access to many lesions through a direct minimally invasive corridor that avoids traditional transcranial exposure. Improvements in endoscopic optical technology, surgical instrumentation, and skull base reconstruction have steadily expanded the range of tumors that can be treated through an endonasal approach. Even so, EES is not appropriate for every lesion, making thoughtful patient selection and surgical team experience the most important determinants of surgical success. This review explores where EES fits in the contemporary management of anterior skull base meningiomas, including olfactory groove, tuberculum sellae, and planum sphenoidale meningiomas, with particular attention to its indications, limitations, and situations in which EES may not be appropriate. Evidence comparing endoscopic endonasal and transcranial approaches for anterior skull base meningiomas is reviewed, with attention to how tumor anatomy, oncologic objectives, and individual patient characteristics influence the choice of approach. A major consideration is how surgical morbidity can be minimized without compromising oncologic and safety outcomes. Current strategies to protect critical neurovascular structures, reduce the risk of cerebrospinal fluid leakage, and improve skull base durability, including advances in vascularized reconstruction techniques, are discussed. Emerging outcome data and the evolving learning curve associated with EES are also reviewed. Rather than presenting EES as a universal solution, the evidence points toward a patient-centered approach in which operative strategy and clinical decision making is guided by tumor characteristics, anatomy, and surgical goals.