Endoscopic Endonasal Midline versus Lateral Transcranial and Combined Approaches for Surgical Resection of Olfactory Groove Meningiomas: Systematic Review and Meta-analysis

Introduction: With advances in surgical endoscopy, the management of olfactory groove meningiomas (OGMs) has shifted to include the endoscopic endonasal transcribiform approach (EEA). This minimally invasive technique has improved outcomes, such as the extent of resection, while complementing the array of open microsurgical techniques available for OGMs. It is an excellent choice for patients with anosmia at baseline, enabling excellent operative margins, early devascularization, and minimization of frontal lobe retraction. On the other hand, open craniotomy and other transcranial approaches enable olfactory preservation in patients with serviceable olfactory function.

Objective: Herein, we delineate the safety and efficacy of the EEA (midline approach), open craniotomy and other non-midline transcranial approaches, and combined (staged midline EEA and lateral) approaches for surgical resection of OGMs.

Methods: We queried three databases according to PRISMA guidelines to identify studies comparing EEA versus alternative craniotomy/transcranial (versus combined) approaches to surgical resection of OGMs.

Results: Following the systematic search and screen, 6 comparative studies (Levels of Evidence: II–III) met eligibility criteria and were included in the present meta-analysis. The studies featured 1,136 patients (740 F, 65.1%) whose mean age was 54.3 years. A total of 153 (13.4%) patients underwent surgical resection of OGM via EEA, while most patients (86.6%) underwent surgery via an open craniotomy, transcranial endoscopic, or combined approach (involving EEA + additional transcranial approach). Mixed-effects meta-analysis demonstrates that EEA provides greater odds for obtaining GTR and Simpson Grade I resection relative to lateral transcranial approaches (OR: 0.30, 95% CI [0.19, 0.46], I ² = 37%, p < 0.0001). However, there was no appreciable difference in rates of GTR associated with EEA compared to combined [staged] approaches. Furthermore, there is a statistically significant association between non-EEA (open craniotomy/transcranial) approaches and the odds that STR will be obtained (OR: 4.03, 95% CI [2.60, 6.24], I ² = 31%, p < 0.0001). There was no statistically significant difference in risk for recurrence between EEA and alternative one (p = 0.31) or two-stage (combined) [p = 0.20] approaches. Furthermore, there was no significant difference in risk for postoperative anosmia even though the EEA is classically associated with loss of olfaction resulting from the endoscopic endonasal transcribiform approach to the midline anterior fossa. While there was negligible difference in risk for CSF leak following EEA versus combined approaches, non-midline (open or endoscopic transcranial) approaches demonstrated a higher risk for CSF leak than EEA when used for surgical resection of olfactory groove meningiomas.

Conclusion: The present meta-analysis—which consists of the latest evidentiary base—indicates that the EEA transcribiform approach provides superior rates of GTR with negligible differences in complication rates or risk for postoperative anosmia. These findings likely reflect advances in extended EEA techniques, which enable early devascularization of the ethmoidal arteries and minimize frontal lobe retraction. Furthermore, these findings likely reflect improved patient-specific approach selection and incorporation of two-stage EEA craniotomy approaches for lesions that extend outside the reach of purely EEA or open craniotomy approaches.

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Artikel online veröffentlicht:
07. Februar 2025