Meningiomas Involving the Anterior Visual Pathway: Neuroimaging Findings, Visual Prognosis, and Neurosurgical Decision-Making

Optic pathway-related meningiomas represent a significant diagnostic and therapeutic challenge because of their proximity to critical neurovascular structures and their potential to cause progressive and irreversible visual impairment. This narrative review aimed to analyze the radiological characteristics, mechanisms of visual deterioration, and criteria guiding therapeutic selection in meningiomas involving the optic nerve sheath, tuberculum sellae, anterior clinoid process, and adjacent skull base structures. Twenty scientific publications, including international clinical studies, systematic reviews, meta-analyses, and Latin American contributions, were examined through a structured qualitative synthesis. The analysis focused on magnetic resonance imaging and computed tomography findings, optic canal involvement, preoperative visual function, surgical approaches, and postoperative outcomes. Published evidence demonstrated frequent optic canal involvement in tuberculum sellae meningiomas, highlighting the importance of anatomical localization beyond tumor dimensions. In a large international surgical cohort, postoperative visual improvement occurred in 73.0% of patients undergoing endoscopic endonasal surgery and 57.1% undergoing transcranial surgery among those with preoperative visual impairment and available follow-up assessments. However, endonasal procedures were associated with higher cerebrospinal fluid leakage rates (17.3% versus 2.2%). A separate meta-analysis reported an overall visual improvement estimate of 80.3% following optic canal unroofing. Differences in patient selection, tumor characteristics, and study methodologies limit direct comparisons between therapeutic strategies. The findings support individualized, multidisciplinary management integrating advanced neuroimaging, neuro-ophthalmological evaluation, and anatomical considerations. Preservation of visual function, neurological safety, and long-term quality of life should remain fundamental therapeutic priorities.