Name:
10.3171/2025.10.FOCVID25171_vid
Description:
10.3171/2025.10.FOCVID25171_vid
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/f9c5a617-6dee-4914-b354-0590c60f75c7/videoscrubberimages/Scrubber_82.jpg
Duration:
T00H05M39S
Embed URL:
https://thejns.org/video/
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/f9c5a617-6dee-4914-b354-0590c60f75c7/17. 25-171.mp4?sv=2019-02-02&sr=c&sig=Vg6%2BQ1vH3Gm8%2FlOul73o6lDr7bxCCR%2BueLy1SpGPa9c%3D&st=2026-04-05T05%3A29%3A07Z&se=2026-04-05T07%3A34%3A07Z&sp=r
Upload Date:
2026-04-05T05:34:07.6765807Z
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This video shows an endoscopic transorbital approach for resection of a recurrent atypical clinoid meningioma. A 66-year-old female with a history of recurrent intracranial meningioma, previously treated in 2016 with transcranial microsurgical resection of a WHO grade II sphenoidal ridge meningioma via a left pterional approach, followed by adjuvant intensity-modulated radiation therapy. MRI demonstrated tumor progression involving the left anterior clinoid process.
SPEAKER: Clinical evaluation showed mild left-sided proptosis, right homonymous hemianopia, and decreased left visual acuity. MRI showed a left clinoid meningioma compressing the ipsilateral optic nerve. Due to the proximity to the second cranial nerve, radiotherapy was not indicated. Preoperative cranial CT confirmed a regular morphology of the left clinoid without pneumatization or anatomical variants, such as a caroticoclinoid foramen.
SPEAKER: To achieve a Simpson grade 1 resection, an endoscopic transorbital approach was selected. This minimally invasive route, increasingly adopted for the management of complex skull base tumors, provides a direct trajectory to the anterior clinoid process while avoiding brain retraction. Moreover, it minimizes the cosmetic and functional morbidity often associated with frontotemporal craniotomy, such as temporary muscle atrophy and masticatory pain.
SPEAKER: The procedure was performed under general anesthesia, with the patient in a supine neutral position and the head secured in a Mayfield skull clamp. Magnetic neuronavigation with navigated suction was used. The initial phase was conducted using an exoscope, followed by an endoscope. Through a subbrow incision, subperiosteal dissection of the periorbita was performed up to the superior orbital fissure.
SPEAKER: The orbital rim was flattened with a coarse diamond burr under periorbital protection, exposing the temporal fascia. Drilling was then redirected to the greater sphenoid wing until the temporal dura was reached. The sagittal crest, a nonnative anatomical landmark, was exposed and progressively removed. The meningo-orbital band was dissected with endoscopic scissors. A zero degree endoscope was introduced to complete crest removal, expose the anterior cranial fossa dura, and finalize the meningo-orbital band incision.
SPEAKER: Using a 2-mm Kerrison rongeur, superior orbital fissure is opened and, as shown in this anatomical picture, using an eggshell technique, anterior clinoid process is progressively entered using a 2-mm pure diamond drill, alternating drilling and suction. Magnetic neuronavigation provides to confirm the correct trajectory.
SPEAKER: Finally, using a rongeur, the tip of the anterior clinoid process is gently dissected and removed, taking care to avoid injury of the adjacent neurovascular structures. Hemostatic agents are used to stop venous bleeding after anterior clinoidectomy. Anterior cranial fossa dura is progressively exposed and dura mater cutting is started in a lateromedial direction.
SPEAKER: Using the arachnoid plane and alternating gentle traction and cutting of the arachnoid bridge, the almost completely devascularized meningioma is removed en bloc avoiding brain manipulation. After inspection of the surgical field, the pieces of the tumor adherent to the brain are removed and hemostasis is completed using Surgicel. In order to achieve a Simpson grade 1 resection, the dura mater is cut and removed.
SPEAKER: The small dura defect is repaired in a multilayered fashion. Reconstruction begins with an inlay of dura patch reinforced by fibrin glue. Another dura patch is used to isolate the surgical field. Valsalva maneuver is performed in order to confirm the absence of cerebrospinal fluid leak. The patient tolerated the procedure well with no new neurological deficits and was discharged on postoperative day 2.
SPEAKER: Postoperative CT showed no complications, and 1-year follow-up MRI confirmed absence of recurrences. The main limitations of the transorbital approach include tumor exceeding 6 cm in diameter, predominant invasion of the frontal lobe, and/or extension to the supraclinoid segment of the internal carotid artery.
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