Neurosurg Focus 36 (4):E14, 2014

©AANS, 2014

Craniotomy for anterior cranial fossa meningiomas:

historical overview
Saul F. Morales-Valero, M.D., Jamie J. Van Gompel, M.D., Ioannis Loumiotis, M.D.,
and Giuseppe Lanzino, M.D.

Department of Neurologic Surgery, Mayo Clinic, Mayo Medical School, Rochester, Minnesota

The surgical treatment of meningiomas located at the base of the anterior cranial fossa is often challenging, and
the evolution of the surgical strategy to resect these tumors parallels the development of craniotomy, and neurosur-
gery in general, over the past century. Early successful operations to treat these tumors were pioneered by prominent
figures such as Sir William Macewen and Francesco Durante. Following these early reports, Harvey Cushing made
significant contributions, allowing a better understanding and treatment of meningiomas in general, but particularly
those involving the anterior cranial base. Initially, large-sized unilateral or bilateral craniotomies were necessary
to approach these deep-seated lesions. Technical advances such as the introduction of electrosurgery, the operating
microscope, and refined microsurgical instruments allowed neurosurgeons to perform less invasive surgical proce-
dures with better results. Today, a wide variety of surgical strategies, including endoscopic surgery and radiosurgery,
are used to treat these tumors. In this review, the authors trace the evolution of craniotomy for anterior cranial fossa
meningiomas.
(http://thejns.org/doi/abs/10.3171/2014.1.FOCUS13569)

Key Words    •    intracranial meningiomas    •    craniotomy    •    history    •   
anterior cranial fossa

M
eningiomas of the anterior cranial fossa represent
12%–20% of all intracranial meningiomas.5,30
The large size of these lesions at the time of di-
agnosis, as well as their close relation with important neu-
rovascular structures (Fig. 1), often makes their resection
challenging. This group of tumors represents an exemplar
of the evolution of craniotomy for surgical approaches to
the skull base. The first surgical procedures to treat these
tumors were performed in the late 19th century and were
carried out by prominent and pioneering neurosurgeons.
Subsequent technical advances have allowed better surgi-
cal outcomes, and presently these tumors can be treated
safely using a plethora of surgical approaches. Further-
more, adjuvant therapies not available at the outset of
surgical treatment of anterior fossa meningiomas, such as
stereotactic radiation and intensity modulated radiation
therapies, have provided options for treating surgeons. In
this review, we trace the evolution of neurosurgery for
anterior cranial fossa meningiomas.
Classification
According to the site of attachment, the most com-
mon meningiomas of the anterior cranial fossa are clas-
sified into olfactory groove, planum sphenoidale, and
tuberculum sellae meningiomas.21 Each of these tumors
Abbreviation used in this paper: ICA = internal carotid artery.
has a few distinct clinical features. However, in practice,
this group of tumors often represents a continuum. Their
original site of attachment may differ, but given the high
compliance of the brain at this location, they can attain
large sizes and at the time of diagnosis the more anterior
types (olfactory groove and planum sphenoidale group)
occupy a significant portion of the anterior cranial fossa.
Clinical Presentation
At a time when imaging modalities were not widely
available, the diagnosis of diseases relied upon accurate
observations of clinicians. The identification of intracrani-
al lesions was particularly difficult because the functional
division of the brain was not completely understood. Dr.
Robert Foster Kennedy made a significant contribution,
recognizing a common clinical presentation of space-oc-
cupying lesions located in the frontal lobe. These observa-
tions, which led him to describe what is now called “Foster
Kennedy syndrome,” came from the time he spent at the
National Hospital in Queen’s Square in London, working
with prominent figures such as Sir William Gowers and Sir
Victor Horsley. Foster Kennedy defined the syndrome in
191111 and described it further in later publications:11
One syndrome when present is diagnostically decisive: a
speedy reduction in ipsilateral acuity of vision due to ipsilateral
compression neuritis of the optic nerve lying below the frontal
lobe, coincident with papilledema and normal vision of the

Neurosurg Focus / Volume 36 / April 2014 1


Fig. 1.  Harvey Cushing’s illustration showing the large size attained
by certain olfactory groove meningiomas and their relation to the ante-
rior cerebral artery (A. Cer. Anterior). A. com. ant. = anterior communi-
cating artery. Reproduced from Cushing H: Meningiomas, Their Clas-
sification, Regional Behavior, Life History and Surgical End Results,
Charles C. Thomas, 1938.
opposite eye. From compression of the olfactory tract there is
usually under these circumstances anosmia on the same side on
which retrobulbar neuritis and the primary optic atrophy have
occurred.
He also described some changes in mental function
that could be caused by these tumors:11 “First, is seen
a lessening in power of attention; irrelevant replies are
made. There develops a trivial and meaningless jocosity.
Short periods of excitement occur, with foolish, inept and
causeless laughter.”
With modern imaging and earlier diagnosis, the
Foster Kennedy syndrome is only seen in a minority of
patients and in some series it has been found in approxi-
mately 5% of cases.10 A change in mental function (such
as loss of inhibition, memory deterioration, and person-
ality changes) is reported as the primary symptom in
20%–70% of patients harboring olfactory groove menin-
giomas.1 These symptoms, which are often attributed to
aging and depression, are occasionally overlooked by the
patients and are mainly noticed by family members.10
Visual impairment is among the primary symptoms
of patients with meningiomas of the anterior cranial
fossa, especially those located in the tuberculum sellae15
(Fig. 2). In patients harboring olfactory groove meningio-
mas, the incidence of preoperative visual deficits ranges
between 15% and 60%.1 Compression of the ipsilateral
optic apparatus in a posteroinferior direction results in
painless visual blurring and defects in the inferior visual
field. When the tumor arises from the tuberculum sellae,
bitemporal visual field deficits are common.15,25
Early Surgical Experience
Sir William Macewen and Francesco Durante
There is some controversy regarding the first suc-
cessful operation for a tumor of the anterior cranial fos-
2 Neurosurg Focus / Volume 36 / April 2014
S. F. Morales-Valero et al.
Fig. 2.  Cushing’s depiction of the stages of optic chiasm compres-
sion by tuberculum sellae meningiomas.  I and II: Presymptomatic
stages.  III: Early stage of visual symptoms, surgically favorable.  IV:
Twenty-gram tumor, surgically unfavorable. A.C. = anterior commis-
sure; C. = chiasm; Hy. = hypohysis; I. = infundibulum; O.R. = optic re-
cess. Reproduced from Cushing H: Meningiomas, Their Classification,
Regional Behavior, Life History and Surgical End Results, Charles C.
Thomas, 1938.
sa. In 1879, Sir William Macewen (Fig. 3) evaluated a
14-year-old girl with a swelling at the upper and inner
portion of the left orbital cavity; she complained of oc-
casional frontal headache and was found to have a miotic
left pupil with no response to light.14 Macewen suspected
an intracranial lesion and admitted her for observation.
During this period she developed seizures, initially local-
ized to the right side of her body but later generalized
and associated with loss of consciousness. The presence
of seizures and their prolonged duration prompted Mace-
wen to proceed with resection.14 He described the surgical
procedure in an article published in 1881:14
A trephine having a disc an inch in diameter was chosen
and a portion of bone was elevated. The skull was thicker
than normal, and attached to the undersurface of the disc was
a tumour of a gummatous aspect. A portion of the tumour
adhered to the disc which was removed. The remainder was
attached to the dura mater and spread over that membrane in
a downward direction towards the base of the frontal lobes...
The tumor was removed from the dura mater as far down as the
orbital portion of the frontal bone.
However, this is not a typical case in presentation and
demographics and the exact pathology is not known.
More celebrated and definitely typical in presenta-
tion is the case described by Francesco Durante (Fig. 4)
in 1887, but operated on in 1884.6 Durante’s patient on
inspection:6
…showed no abnormality, except as to her left eye, which
appeared somewhat low and drawn outwardly, otherwise the
movements as well as the functions of the globe were normal.
For a year or more, however, she had entirely lost her sense
of smell; her memory had become impaired, particularly as to
remembering names… From her husband I learnt that she had
History of craniotomy for anterior cranial fossa meningiomas
Fig. 3.  Photograph of Sir William Macewen at about 30 years of age.
Reprinted with permission from the Royal College of Physicians and
Surgeons of Glasgow.
somewhat changed in disposition; that from being generally
happy and bright, she had become sad, melancholic, and taci-
turn, although she did not seem to brood over the state of her
health.
Finally he concluded:
The course of the disease, the loss of memory and of the
sense of smell, and the objective and subjective state of the
patient led me to believe in the presence of a tumour within the
cranium, the pressure of which affected the anterior lobes of the
brain and paralysed or destroyed the olfactory nerve. Moreover,
the displacement of the globe of the left eye led me to believe
also that the tumour had penetrated the superior arch of the
orbital cavity.
Durante reported that: “Such being my diagnosis, I
now proposed to the patient an operation that would re-
move the offending object, explaining to her the gravity
of the operation without reserve. She was brave, and she
consented.”
The tumor was approached through a left frontal cra-
niectomy: “It occupied the anterior fossa at the base of
the left cranium, extending to the right and upon the crib-
riform lamina, which it destroyed. Posteriorly it extended
to the glenoid tubercles before the sella turcica. The left
anterior cerebral lobe was greatly atrophied; the orbital
arch was much depressed, but not perforated by the tumor
as I had anticipated.”
Chloroform was used for anesthesia and surprisingly,
the entire procedure lasted only an hour; the patient was
discharged home on the 15th day and Durante concluded,
Neurosurg Focus / Volume 36 / April 2014
Fig. 4.  Francesco Durante at the age of 28 (photograph circa 1898,
in the public domain).
“My diagnosis and the operation, apparently so hazard-
ous at the time, are therefore justified by the result.”6 Dr.
Durante presented the patient 3 months after the surgery
at a local meeting in Perugia, where she narrated her ex-
perience. The case was later published in the Lancet6 and
presented in the International Medical Congress held in
Washington, D.C., in 1887. The patient is known to have
suffered a recurrence and underwent another operation
in 1896 with good results;7 she was last known to be in
good condition in 1905, more than 20 years after the first
surgery.
Contributions by Harvey Cushing
Although the tumors described by Macewen and
Durante were most likely meningiomas, the term “me-
ningioma” to describe this type of neoplasms was later
introduced by Harvey Cushing. In 1927, he dedicated the
Macewen Memorial Lecture to illustrate two cases of ol-
factory groove meningiomas.4 In the lecture, titled “Me-
ningiomas arising from the olfactory groove and their
removal by the aid of electro-surgery,” Cushing demon-
strated the utility of the recently introduced electrocau-
tery, comparing the treatment of two tumors before and
after this tool was available.4 Cushing stated: “…with Dr.
Bovie’s co-operation, during the past few months I have
gained sufficient familiarity with the instrument to real-
ize that it holds out untold possibilities for the future of
neurosurgery”4 (Fig. 5).
The first patient was a 62-year-old woman who pre-
3

Fig. 5.  Cushing’s piecemeal removal (Steps I–IV) of a meningioma
using electrosurgery. Reproduced from Cushing H: Meningiomas, Their
Classification, Regional Behavior, Life History and Surgical End Re-
sults, Charles C. Thomas, 1938.
sented with impaired vision for 1 year, frontal headaches,
loss of sense of smell, and mental deterioration. Skull ra-
diographs revealed an enlarged sella and erosion of the
left wing of the sphenoid. A left frontal tumor was di-
agnosed and she underwent surgical treatment. However,
the resection was not simple; in fact, 3 different opera-
tions were required to remove the entire tumor due to dif-
ficulty achieving hemostasis.4 Cushing described:4
…the intra-capsular method of enucleation, long put in use
in the surgical treatment of acoustic tumors, was called upon
to get us out of difficulties. Accordingly, with a sharp spoon,
cup-shaped fragments were scooped out of the anterior pole of
the tumor until a large cavity was produced. This was a tedious
procedure since it was necessary, after the removal of each
fragment, to delay until bleeding from the raw surface could be
checked.
The second case, in contrast, involved a relatively
straightforward treatment. A 45-year-old man present-
ing with progressive loss of vision and altered personality
was found to have complete loss of smell and bilateral op-
tic atrophy on examination. Radiographs showed a small
area of calcification lying above the left olfactory groove.
The tumor was approached by a frontal craniotomy, and
in Cushing’s words:4
…to make a long story short, it was finally possible so far to
excavate the chief mass of the tumor lying to the left of the falx
that the outer border of the growth could be drawn forward and
freed from its dense site of attachment along the deepened and
widened olfactory groove underlying the ethmoidal plate. Only
in this area was any troublesome bleeding encountered, and
it was easily controlled by using a desiccating current which
charred the dura and, at the same time, it is to be expected,
destroyed any remaining nests of tumor cells which remained
adherent to it.
Cushing finally concludes: “As can be appreciated, this
was not a procedure to be done hurriedly, nor could it pos-
sibly have been carried through in a single session by any
other method I can conceive of… from the time when the
scalp was novocainized to the final closure and dressing,
seven hours were consumed.” The postoperative course of
4 Neurosurg Focus / Volume 36 / April 2014
S. F. Morales-Valero et al.
this patient was unremarkable and there was immediate
improvement in both visual and mental symptoms.3
These cases were later included in his renowned
book Meningiomas, Their Classification, Regional Be-
havior, Life History and Surgical End Results, which was
published in 1938 and summarized data on patients with
intracranial meningiomas in different locations.5 Among
the 313 cases presented in this publication, 28 were su-
prasellar and 29 olfactory groove meningiomas. Cushing
provided details about the clinical history and diagnostic
approach as well as the surgical procedures to treat these
tumors. In most cases, the tumor was approached via a
unilateral frontal craniotomy with resection of part of the
frontal lobe (Fig. 6).5 However, he considered some me-
ningiomas to be inoperable due to their size, and in those
cases a subtemporal decompression was performed.5 He
provided follow-up data of the surviving patients up to 10
years and demonstrated good functional outcomes.
Evolution of Modern Approaches to Anterior
Cranial Fossa Meningiomas
Since the initial experience of these pioneering neu-
rosurgeons, multiple advances have taken place allowing
a safer and more effective treatment of this group of tu-
mors. The unilateral frontal craniotomy used by Cush-
ing evolved to a bifrontal craniotomy and a transbasal
approach described by Dandy, but a continued necessity
of frontal lobe resection. Subsequently, Tonnis reported
his successful experience with the bifrontal approach pre-
serving the brain tissue, which was followed by multiple
surgeons. The introduction of the operating microscope
in the 1970s and the refinement of surgical instruments
improved the ability of neurosurgeons to carefully dissect
these neoplasms.20,26 The unilateral and bifrontal crani-
otomies have been further modified and currently some
craniofacial approaches are used to treat tumors invading
the nasal cavity and/or paranasal sinuses. The endoscope,
which has been available for a long time for the treatment
of other neurosurgical entities, was introduced recently in
the treatment of anterior cranial fossa meningiomas and
is acquiring more advocates as supporting evidence be-
comes available.
The ideal surgical approach should provide enough
exposure of the tumor and the surrounding structures, in-
cluding its dural attachment, to interrupt its blood supply
early in the procedure. In addition, brain retraction and
manipulation of critical neurovascular structures should
be minimized as much as possible to avoid procedure-re-
lated morbidity. Sufficient access to the skull base is also
desirable in cases in which bone resection and subsequent
cranial base reconstruction are necessary. The selection
of the most appropriate approach depends on multiple
factors, including surgeon’s preference and experience,
tumor size and location, extent of dural attachment, and
relation with the surrounding neurovascular structures.
Subfrontal Approaches
Anterior cranial fossa meningiomas can be ap­
proached by a subfrontal route using either bifrontal or
History of craniotomy for anterior cranial fossa meningiomas
Fig. 6.  Preferred approach by Cushing for lesions of the anterior cranial fossa. Reproduced from Cushing H: Meningiomas,
Their Classification, Regional Behavior, Life History and Surgical End Results, Charles C. Thomas, 1938.
unilateral craniotomies. Bifrontal craniotomy is frequent-
ly used for large tumors and offers advantages such as
wide symmetrical exposure that is useful when cranial
base reconstruction has to be performed. However, this
strategy requires ligation of part of the superior sagittal
sinus and exposes both frontal lobes to the risk of postop-
erative edema from retraction.16,21,28 Other disadvantages
include the opening of the frontal sinuses and, more im-
portantly, late visualization of important structures such
as the optic apparatus, the internal carotid arteries (ICAs),
and the anterior cerebral–anterior communicating artery
complex.
Compared with the bifrontal approach, a unilateral
frontal craniotomy allows sparing of the superior sagit-
tal sinus and minimizes manipulation of the contralateral
frontal lobe. The optic chiasm and ipsilateral carotid ar-
tery can be identified early during the surgical procedure
and the more lateral view of the tumor/optic nerve and
tumor/neurovascular complex favors precise microsurgi-
cal dissection. However, the view is limited, which can
be problematic when treating large tumors and dealing
with their superior portion. Nevertheless, high rates of
Neurosurg Focus / Volume 36 / April 2014
complete resection have been reported even for large tu-
mors (> 6 cm) with minimal morbidity and no mortal-
ity.23,24 Nakamura et al. directly compared the bifrontal
and frontolateral approaches in a series of patients with
olfactory groove meningiomas and found comparable
rates of complete tumor removal but higher morbidity in
the group treated with the bifrontal approach as there was
a greater incidence of cerebral edema in this group.16
To provide a wider exposure and to avoid excessive
brain retraction, some modifications to these approaches
have been proposed.2,19 Persing and colleagues described
an approach through the frontal sinus that provides ad-
equate exposure of the anterior cranial base and is es-
pecially useful to resect tumors with extension to the
facial region.19 This approach can be extended by using
a larger frontal craniotomy or including orbital osteoto-
mies. More recently, Chi et al. reported their successful
experience treating midline anterior fossa meningiomas
with an extended bifrontal approach that included or-
bital osteotomies.2 Simpson Grade 1 or 2 resection was
achieved in 80% of patients, and postoperative cerebral
edema was observed in only 7% of patients. Disadvan-
5

tages of approaches combining craniotomy with orbital
osteotomies include a higher risk of CSF fistula caused by
wide opening of the frontal sinus and their complex and
time-consuming nature. Furthermore, infection of this
large free bone flap is difficult to reconstruct if needed.
The Pterional Approach and its Variations
The use of the pterional approach was popularized
by Yaşargil and first described specifically for the resec-
tion of anterior skull base meningiomas by Hassler and
Zentner.9 This approach constitutes a short route to the
parasellar region and allows early visualization of impor-
tant structures such as the optic apparatus and the ICA
and its branches.9,29 The patient’s nondominant side is
usually approached, unless the tumor extends predomi-
nantly to the left side with significant encasement of the
left ICA.23,24 The basal cisterns are opened early to allow
CSF release and brain relaxation and thus an adequate
exposure is possible before the tumor is dissected. The
main disadvantage of this approach is the difficulty in
removing tumor located underneath the ipsilateral optic
nerve without considerable manipulation. Tomasello and
colleagues described the pterional route to treat giant ol-
factory groove meningiomas with high rates of complete
macroscopic removal, minimal morbidity, and a low re-
currence rate at long-term follow-up.29
There are multiple variations of the pterional ap-
proach; for instance, the frontoorbitozygomatic21 ap-
proach that involves a more extensive craniotomy and
includes osteotomies of the roof and lateral wall of the
orbit as well as a part of the zygoma and supraorbital rim.
This variant combines the advantages of the subfron-
tal approaches allowing a more basal exposure, and the
pterional approach providing early neurovascular control
and a better inferior to superior view than other anterolat-
eral approaches.
Supraorbital Approach
Modern neuroimaging techniques allow proper char-
acterization of brain tumors and their relation to sur-
rounding structures. This characterization is helpful in
presurgical planning and in the intraoperative setting
and makes it possible to approach deep-seated lesions
through very small openings. Perneczky and colleagues
introduced the concept of a supraorbital “keyhole” crani-
otomy to approach a variety of skull base lesions, includ-
ing meningiomas of the anterior cranial fossa.18,22 This ap-
proach represents the frontobasal portion of the pterional
approach with the advantage of greatly reducing the size
of the skin incision (made typically within the eyebrow
or palpebral fissure) and the craniotomy.22 With adequate
patient positioning and brain relaxation there is minimal
need of brain retraction to obtain adequate visualization.
In the series of 1125 lesions treated by Reisch and Per-
neczky during a 10-year period using this approach, 93
represented anterior cranial base meningiomas.22 The
majority of tumors (80.2%) were completely resected in a
piecemeal fashion regardless of their size.
Extended Endonasal Transsphenoidal Approach
Most tumors arising in the midline of the anterior
6 Neurosurg Focus / Volume 36 / April 2014
S. F. Morales-Valero et al.
cranial base expand, displacing the critical neurovascular
structures superiorly and laterally. This anatomical relation
makes a ventral approach appropriate for small “midline”
tumors without significant lateral extension. In relation to
endoscopic approaches, lateral extension is defined as lat-
eral to the supraclinoid carotid, or lateral to the midpor-
tion of the superior orbit. The transsphenoidal approach,
initially used to treat intrasellar lesions, was modified to
gain access to lesions located beyond the boundaries of the
sella turcica. For instance, this approach may be extended
anteriorly to reach tumors of the anterior cranial base by
removing the anterior part of the sella turcica, and part of
the planum sphenoidale. In circumstances in which olfac-
tory groove meningiomas are approached in this manner,
anterior extension to the posterior table of the frontal sinus
can be managed with this technique.
Couldwell et al. pioneered the extended endonasal
transsphenoidal approach and emphasized its utility to
treat lesions such as tuberculum sellae and planum sphe-
noidale meningiomas.3 The advantages of this approach
include the avoidance of brain exposure and retraction,
early devascularization of the tumor at its base, and re-
moval of the tumor beneath the chiasm and optic nerves
with minimal manipulation of these delicate structures.
Thus, this ventral approach constitutes a valid alternative
to transcranial approaches and is particularly useful in
elderly patients or properly selected patients.
Endoscopic Approaches
The introduction of the endoscope to the realm of
neurosurgery led to successful treatment of deep-seated
lesions with minimal brain retraction. To gain access to
the anterior skull base, the endoscope can be used mainly
through two of the previously described approaches: via a
ventral, midline approach through the skull base, such as
the extended endonasal approach, or using a small supra-
orbital craniotomy. The endoscopic endonasal approach
for the treatment of anterior cranial fossa meningiomas is
relatively new and has been increasingly reported during
the last decade, with significant contributions from differ-
ent study groups.8,27,31,32
The advantages of the endoscopic endonasal removal
include its minimally invasive nature and the early medi-
al optic canal decompression, when necessary. However,
an important disadvantage of this approach is the high
incidence of postoperative CSF leakage, which has been
reported in as many as 40% of cases.8 A recent systematic
review compared transcranial approaches with the endo-
nasal endoscopic approach for the treatment of olfactory
groove, tuberculum sellae, and planum sphenoidale me-
ningiomas with more favorable results in the transcra-
nial approaches. The endonasal endoscopic approach was
found to be associated with a lower percentage of gross-
total resection and a higher rate of postoperative CSF
leakage.12 Increased experience, better instrumentation,
and the use of multilayer closure and nasoseptal flaps may
minimize and reduce the risk of this complication.13,17
Conclusions
Diagnosis and surgical treatment of anterior cranial
History of craniotomy for anterior cranial fossa meningiomas
base meningiomas has paralleled the dramatic advances
in neurosurgery over the past century. Pioneering neuro-
surgeons such as Sir William McEwen, Francesco Du-
rante, and Harvey Cushing made significant contributions
to this area. Since then, approaches to these tumors have
evolved, and the recent explosion of interest for minimal-
ly invasive techniques has opened a new chapter in the
treatment of these formidable lesions.
Disclosure
Dr. Lanzino serves as a consultant to Covidien/ev3, Edge
Therapeutics, and Codman/Johnson and Johnson.
Author contributions to the study and manuscript preparation
include the following. Conception and design: Lanzino, Morales-
Valero. Acquisition of data: Lanzino, Morales-Valero. Analysis and
interpretation of data: Lanzino, Morales-Valero. Drafting the article:
all authors. Critically revising the article: all authors. Reviewed
submitted version of manuscript: all authors. Approved the final
version of the manuscript on behalf of all authors: Lanzino. Study
supervision: Lanzino.
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Manuscript submitted December 15, 2013.
Accepted January 24, 2014.
Please include this information when citing this paper: DOI:
10.3171/2014.1.FOCUS13569.
Address correspondence to: Giuseppe Lanzino, M.D., Mayo
Clinic, Department of Neurologic Surgery, 200 1st St. NW, Roches-
ter, MN 55905. email: lanzino.giuseppe@mayo.edu.
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