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Video of an endoscopic skull base surgery in action under an endoscope

Skull base surgery is a surgical procedure that treats lesions at the skull base. It is used for tumours, congenital defects at the skull, cerebrospinal (CSF) fluid leaks and blood vessel lesions while protecting critical neurovascular structures. This multidisciplinary surgery integrates both neurosurgery and otorhinolaryngology, employing two major approaches: open transcranial and endoscopic endonasal approach (EEA). EEA is often preferred, yet open transcranial techniques are still being employed to treat complex or laterally extended lesions. This field has evolved from early open procedures in the late 19th century to modern endoscopic techniques, leading to widened indications and improvements in surgical outcomes. The field continues to focus on the advancement of surgical visualisation and reconstruction techniques, complication management, and addressing global challenges in its accessibility.

Uses

[edit]

Skull base surgery focuses on treating lesions (damaged tissues) in the intricate anatomical region of the skull base.[1] Surgeons select between the minimally invasive endoscopic endonasal approach (EEA) and the traditional open transcranial approach.[2]

Neoplastic lesions (tumours)

[edit]

A major indication for skull base surgery is tumours. They can be classified by their benign (non-cancerous) or malignant (cancerous) nature[3] and their anatomical location (at the anterior, middle, or posterior cranial fossa).[4]

For craniopharyngiomas, the tumour is removed to achieve a higher gross total resection (GTR) rate, improvements in visuals, lower recurrence[5] and lower permanent diabetes insipidus rates when EEA is used compared with the transcranial approach.[6] For chordomas, both approaches have similar survival outcomes after tumour removal, but EEA reduces worsening cranial nerve function better.[7] For pituitary adenomas, both approaches have similar GTR rates, with EEA associated with better recovery of vision.[8]

EEA is generally favoured for tumours due to its advantages.[9] However, surgeons still need to retain open approaches in their toolkit as it is reserved for skull base tumours that have invaded structures like orbit and intradural compartments (i.e. sphenoorbital meningioma[10]) or further disease developments that result in the inability of a second endoscopic approach.[11] Other cases of favouring an open approach over EEA include considerations like the tumour extending over the orbital roof[12] or prioritising olfaction (smelling) preservation.[9]

Congenital lesions

[edit]

Congenital (present from birth) skull base lesions (e.g. encephaloceles, fibrous dysplasia or other developmental defects) are rarer indications. Intervention is required when they cause complications such as mass effect (a growing mass that pushes its surrounding tissue), cerebrospinal fluid leakage or recurrent infections leading to meningitis or forming brain abscess.[13] For anterior congenital cephaloceles (a subtype of encephaloces), EEA removes the protruding tissue with lower complications and mortality post-operation than open surgery.[14]

Cerebrospinal fluid (CSF) leaks

[edit]

CSF leaks are classified as traumatic (resulting from accidental or iatrogenic injury: healer-caused harm) or non-traumatic (birth defects, infections, inflammation).[15][16] For CSF rhinorrhea (CSF leakage into the nose), EEA seals the leak site and is established as the gold-standard treatment, with meta-analyses reporting the pooled primary repair success rate and overall success after surgery redo being 93.7% and 99.7% respectively.[16]

Vascular abnormalities

[edit]

In rare selected cases, EEA provides access to treat vascular abnormalities such as paraclinoid aneurysms (bulges in the wall of the internal carotid artery) or cavernous malformation that lie next to the brainstem.[17] However, EEA currently plays a limited role and is continuously evolving, although it may already offer improvements in visualisation and vascular control.[17]

Contraindications

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Absolute contraindications of endoscopic endonasal surgery (EEA), where the approach should never be used, include the presence of active bacterial sinusitis, as no surgery should be performed until the infection is cleared.[18] If the tumour has extended laterally beyond boundaries set by critical neurovascular structures,[18] EEA should not be used as the only approach, as a microscopic, open transcranial or combined approach may be required instead.[9] Other absolute contraindications include total maxillectomy (removal of upper jawbone), orbital exenteration (removal of eye socket), resection of fascial skin or anterior wall of frontal sinus and aggressive tumour wrapping around the internal carotid artery.[18]

Relative contraindications to EEA, which make the procedure risky but not completely forbidden, include medical comorbidities (co-occurrence of chronic diseases), such as severe sleep apnea or granulomatosis with polyangiitis.[18] Others include decreased sinus pneumatization (presence of air spaces between bones), narrow piriform aperture(significant for patients less than 2 years old).[18] Furthermore, the surgeon's insufficient experience, as this surgery requires extensive familiarity with vital neurovascular structures,[9] and lack of advanced hospital equipment, are considered relative contraindications.[9]

Stereotactic radiosurgery as a non-surgical alternative

Preference for non-surgical alternatives

[edit]

Stereotactic radiosurgery can be applied to benign tumours such as meningioma that are asymptomatic or mildly symptomatic,[19] and is even used as a standard treatment for those that are especially small or incidentally discovered.[20] This alternative is suitable for elderly patients with serious comorbidities and poor health status,[20] with the consequences of surgical risks outweighing tumour control.[21]

Risk and complications

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Cerebrospinal fluid leak and meningitis

[edit]

Cerebrospinal fluid (CSF) leak is the most common risk of skull base surgery. The incidence rate is around 2.5-3%.[22] The risk is significantly higher when tumours develop in the functional areas of the brain.[22] CSF leakage can cause severe morbidity, including meningitis.[22] Treatment includes a lumbar drain, ventriculoperitoneal shunt (a medical device to drain CSF) and surgical repair.[22] It was found that the introduction of injectable hydroxyapatite and nasoseptal flap (a patient's own tissue from the nose) during the surgery would be an effective way to minimise CSF leakage, when compared with using nasoseptal flap alone.[23]

Cranial nerve deficits

[edit]

Two commonly affected cranial nerves are the oculomotor nerve and the abducens nerve.[9][24] The oculomotor nerve is particularly susceptible to damage in the surgery of medial sphenoid wing meningioma and spheno-orbital meningiomas (specific brain tumours).[24] On the other hand, the abducens nerve is often subject to risk of palsy in transclival approaches (procedure to access the clivus and posterior cranial fossa) due to its unique location.[25] Damage to the nerve leads to impaired lateral rectus muscle function and double vision (diplopia).[25][26]Intraoperative neurophysiological monitoring helps reduce the risk of cranial nerve deficits by immediate identification.[9] The endoscopic approach, when compared to open transcranial resection, can significantly reduce potential damage to the nerves.[25]

Vascular injury

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The internal carotid artery (ICA) suffers from a specifically high risk of injury, and its damage is potentially fatal.[9][25][26] Apart from direct damage, ICA injury may result from infection or pseudoaneurysm, with sentinel bleeding (a small amount of blood leaks from a weakened blood vessel) happening as an alert.[25] In some cases, ICA injury may be followed by an embolic stroke.[26] ICA injury is a universal risk for both open approaches (much higher risk) and endoscopic approaches.[25] Unlike open approaches, endoscopic approaches would have a higher risk of cerebral infarction due to blood vessel damage or vasospasm.[25] Risk factors of ICA injury include prior surgery and certain types of adenoma (growth hormone-secreting pituitary adenomas).[9]

Techniques

[edit]

Skull base surgery is performed via two routes: the open transcranial and endoscopic endonasal approach (EEA).[27]

Example of a craniotomy removing an arachnoid cyst using the open transcranial approach

The open transcranial approach requires the creation of a bone flap by performing craniotomy with high-speed drills and burr holes, followed by microsurgery with brain retraction and nerve manipulation to expose lesions.[27]

EEA uses corridors in the nasal cavity with the two-surgeon, four-hand technique (one surgeon holding surgical instruments, while the other controls the endoscope) and removes bone to create a wider surgical corridor for visualisation.[28] With this, EEA can avoid brain retraction by directly reaching skull base lesions,[6] accessing both the anterior and middle cranial fossa.[29]

Multilayered skull-base reconstruction is required to prevent cerebrospinal fluid leakage, utilising nasoseptal flaps along with techniques such as bilayer fascia lata graft (specialised technique to fix skull base holes) and gasket seal closure (tight seal to prevent cerebrospinal fluid leakage).[30]

Recovery and rehabilitation

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Immediate postoperative care

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Common postoperative care includes nasal packing (procedure to stop nose bleeding),[31] bed rest and lumbar drain (in case of serious cerebrospinal fluid leakage).[32][33] On top of that, patients usually receive hospital monitoring for infection and stroke for days to weeks.[32]

Short-term recovery

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Patients after skull base surgery often suffer from significant morbidity, including pain, nasal secretions, hyposmia (loss of smell) and blocked nose.[31][33][34] Some may also develop endocrine issues,[32] severely worsening quality of life. Symptoms will improve after a few months as nasal crusting clears up.[31] In this stage, patients are usually subject to weekly clinical follow-up after being discharged,[31][34] including videoendoscopic debridement (wound treatment), nasal irrigation, antibiotic treatment, and lumbar drain.[31]

Long-term rehabilitation

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Generally, patients' condition returns to normal by 12 months.[33] Individuals may receive monthly follow-up during this period, after which most people would feel normal.[31]

History

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Early open approaches (1900-1970s)

[edit]

Francesco Durante performed the first recorded skull base surgery in 1884.[35] It was a removal of an olfactory groove meningioma (a kind of brain tumour) using the transbasal approach (removing the skull bones right above the sinuses).[35] In 1907, Hermann Schloffer completed a pituitary adenoma (pituitary tumour) resection by transsphenoidal surgery via a lateral rhinotomy (cutting along the side of the nose).[36] Following Schloffer, Oskar Hirsch introduced the endonasal transseptal transsphenoidal approach in 1910, aimed at avoiding lateral rhinotomy.[37] In the same year, Albert E. Halstead suggested the sublabial, gingival incision (cutting from the inner side of the lips) to reach the sphenoid sinus.[37] Besides the surgical aspect, technological advancements have also enhanced transsphenoidal surgery. Improved illumination by Norman Dott, fluoroscopy by Gerard Guiot, and the introduction of the operating microscope together improved the quality of transsphenoidal surgeries.[37]

Multidisciplinary skull base era (1980s–1990s)

[edit]

Operating microscope

[edit]

The first use of an operating microscope in surgery was by Carl Nylen in 1921.[1] Counterbalanced and floating stands for the operating microscope were introduced by M. Gazi Yaşargil in 1969.[1] This facilitated the systematic use of operating microscopes in surgical processes.

High-speed drills

[edit]

The drill was first used by Arthur Mathewson in 1876 to remove external auditory canal hyperostosis (excess bone growth).[1] A milestone was in 1969, when M.Gazi Yaşargil performed extradural (outside the tough membrane covering the brain) drilling of the sphenoid wing during the standard pterional craniotomy (removing the bones over the pterion).[1]

Popularising extradural skull base neurosurgery (SBNS) approaches

[edit]

Extradural SBNS approaches were rarely conducted in neurosurgery before the 1990s.[1] These techniques have been popularised since William House's "translabyrinthine approach".[1] A classic case of collaboration was an operation carried out by neurosurgeon Madjid Samii and otolaryngologist Wolfgang Draf. They developed techniques to preserve the facial nerve during vestibular schwannoma (a tumour on the nerve from the inner ear to the brain) surgery.[1]

Endoscopic endonasal revolution (1990s–present)

[edit]

The first endoscopic skull base surgery was carried out by Roger Jankowski, an otolaryngologist, in the 1990s.[1] In 2006, Gustavo Haddad introduced a surgical technique that utilised a nasoseptal flap, a patient's own tissue from the nose, to limit cerebrospinal fluid (CSF) leaks.[38] On top of that, a technique called Gasket Seal Closure is introduced to reduce CSF leak risk further.[39] Subsequently, it gives rise to the multilayered closure algorithm, a stepwise protocol for skull base reconstruction.[39] Currently, techniques including the bilayer button (using connective tissue to patch skull base holes),[40] in-situ bone flap (reusing the same skull bone removed for patching holes),[41] and 3 F (fat, flap and flash) technique are commonly used.[42]

Society and culture

[edit]

Cultural connotations of skull base surgery are shaped by public perceptions, as they believe brain surgery to be high risk and invasive, linking to patient-reported fear and frustration, loss of self-identity, and social isolation due to physical appearance changes.[43] In low- and middle-income countries, this surgery imposes significant financial burdens as well as limited neurosurgical care.[44] In Eastern African countries, neurosurgical treatments take up 132% of their annual income while neurosurgeon density is extremely low, with 1 out of 687740 people.[45] Awareness remains limited globally, with Ethiopians and Nigerians believing brain diseases to be outworldly, preferring traditional medicine or spiritual healing.[46]

References

[edit]
  1. 1 2 3 4 5 6 7 8 9 Pamir, M. Necmettin; Mathiesen, Tiit Illimar; Hüseyinoğlu, Zeynep; Bozkurt, Baran; Özduman, Koray (2026-01-17). "A concise history of skull base surgery: what is its contribution to neurosurgery?". Acta Neurochirurgica. 168 (1) 15. doi:10.1007/s00701-025-06765-4. ISSN 0942-0940. PMC 12816123. PMID 41546744.
  2. ↑ Graffeo, Christopher S.; Dietrich, August R.; Grobelny, Bartosz; Zhang, Meng; Goldberg, Judith D.; Golfinos, John G.; Lebowitz, Richard; Kleinberg, David; Placantonakis, Dimitris G. (2014-08-13). "A panoramic view of the skull base: systematic review of open and endoscopic endonasal approaches to four tumors". Pituitary. 17 (4): 349–356. doi:10.1007/s11102-013-0508-y. ISSN 1386-341X. PMC 4214071. PMID 24014055.
  3. ↑ Marszałek, Andrzej; Szylberg, Łukasz; Wiśniewski, Sławomir (2016-04-03). "Pathologic aspects of skull base tumors". Reports of Practical Oncology & Radiotherapy. 21 (4): 288–303. doi:10.1016/j.rpor.2016.02.006. PMC 4899430. PMID 27330415.
  4. ↑ Rangel-Castilla, Leonardo; Russin, Jonathan J.; Spetzler, Robert F. (2014-10-14). "Surgical management of skull base tumors". Reports of Practical Oncology & Radiotherapy. 21 (4): 325–335. doi:10.1016/j.rpor.2014.09.002. PMC 4899518. PMID 27330418.
  5. ↑ Wisnawa, I Wayan Weda; Immadoel Haq, Irwan Barlian (2024-10-04). "Comparative efficacy of transcranial and endoscopic surgery for craniopharyngioma: A systematic review and meta-analysis of contemporary literature". Surgical Neurology International. 15 356. doi:10.25259/SNI_399_2024. ISSN 2152-7806. PMC 11544467. PMID 39524598.
  6. 1 2 Figueredo, Luisa F.; Martínez, Andrea L.; Suarez-Meade, Paola; Marenco-Hillembrand, Lina; Salazar, Andrés Felipe; Pabon, Daniela; Guzmán, Juan; Murguiondo-Perez, Renata; Hallak, Hana; Godo, Alex; Sandoval-Garcia, Carolina; Ordoñez-Rubiano, Edgar G.; Donaldson, Angela; Chaichana, Kaisorn L.; Peris-Celda, María (2023-05-23). "Current Role of Endoscopic Endonasal Approach for Craniopharyngiomas: A 10-Year Systematic Review and Meta-Analysis Comparison with the Open Transcranial Approach". Brain Sciences. 13 (6): 842. doi:10.3390/brainsci13060842. ISSN 2076-3425. PMC 10296530. PMID 37371322.
  7. ↑ Pahlavi, Iqbal Reza; Usman, Herdyansyah; Azhari, Nidya Tyaz Putri (2025-12-02). "Endoscopic endonasal approach vs microsurgical transcranial approach in intracranial chordoma surgery: a systematic review and meta-analysis". Neurosurgical Review. 49 (1) 38. doi:10.1007/s10143-025-03970-8. ISSN 1437-2320. PMID 41326884.
  8. ↑ Jiménez-Sánchez, Jesús; Fiallos Baldeón, Rashell Danae; Zamora-Amezcua, Karim N; Buitrago Navarro, Juan Felipe; Miranda De La Paz, Hugo David; García, Andrés Pérez; Ceja, Montserrat; Chávez Fuenmayor, Santiago Alejandro (2026-02-26). "Endoscopic Endonasal Approach Versus Transcranial Microsurgery in the Management of Skull Base Tumors With Optic Chiasm Compression: A Systematic Review and Meta-Analysis". Cureus. 18 (2) e104297. doi:10.7759/cureus.104297. ISSN 2168-8184. PMC 13032787. PMID 41909374.
  9. 1 2 3 4 5 6 7 8 9 Porras, Jose L.; Rowan, Nicholas R.; Mukherjee, Debraj (2022-12-08). "Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review". Brain Sciences. 12 (12): 1685. doi:10.3390/brainsci12121685. ISSN 2076-3425. PMC 9776068. PMID 36552145.
  10. ↑ Costanzo, Roberta; D'Andrea, Marcello; Manfrellotti, Roberto; Nielsen, Jon Kristinn; Tafuto, Roberto; Tomassini, Alessia; Iacopino, Domenico Gerardo; Maugeri, Rosario; Tosatto, Luigino; Prats-Galino, Alberto; Di Somma, Alberto; Enseñat, Joaquim (2025-09-24). "Endoscopic Transorbital Approach and Transcranial Approach in Spheno-Orbital Meningiomas: A Comparative Qualitative and Preliminary Quantitative Anatomical Study". Journal of Clinical Medicine. 14 (19): 6744. doi:10.3390/jcm14196744. ISSN 2077-0383. PMC 12524937. PMID 41095823.
  11. ↑ Lund, Valerie J.; Wei, William I. (2015-09-01). "Endoscopic surgery for malignant sinonasal tumours: an eighteen year experience". Rhinology Journal. 53 (3): 204–211. doi:10.4193/Rhino14.318. PMID 26363161.
  12. ↑ Wu, Liping; Qian, Guohong; Gu, Ye (2026-02-02). "Endoscopic endonasal approach with extended orbital roof removal for a giant esthesioneuroblastoma: illustrative case". Journal of Neurosurgery: Case Lessons. 11 (5). doi:10.3171/CASE25914. ISSN 2694-1902. PMC 12863157. PMID 41628435.
  13. ↑ Valencia-Sanchez, Bastien A.; Kim, Jeeho D.; Zhou, Sheng; Chen, Sonja; Levy, Michael L.; Roxbury, Christopher; Patel, Vijay A.; Polster, Sean P. (2024-03-26). "Special Considerations in Pediatric Endoscopic Skull Base Surgery". Journal of Clinical Medicine. 13 (7): 1924. doi:10.3390/jcm13071924. ISSN 2077-0383. PMC 11013018. PMID 38610689.
  14. ↑ Thompson, Harrison M.; Cho, Do-Yeon; Riley, Kristen O.; Grayson, Jessica W.; Woodworth, Bradford A. (2020-09-27). "Systematic review of anterior congenital cephaloceles: open vs endoscopic repair". International Forum of Allergy & Rhinology. 10 (12): 1334–1336. doi:10.1002/alr.22701. ISSN 2042-6976. PMID 32981221.
  15. ↑ Mughal, Zahir; Martinez-Devesa, Pablo; Boukas, Alexandros; Jeyaretna, Sanjeeva; Qureishi, Ali (2025-02-04). "Contemporary Management of Cerebrospinal Fluid Rhinorrhoea: A Review of the Literature". Journal of Clinical Medicine. 14 (3): 995. doi:10.3390/jcm14030995. ISSN 2077-0383. PMC 11818516. PMID 39941665.
  16. 1 2 Mughal, Zahir; Osuji, Judith; Jonah, Syntyche; Rajdev, Kishan; Silva, Priyamal; Mathew, Rajeev; Mackeith, Samuel; Boukas, Alexandros; Jeyaretna, Sanjeeva; Martinez-Devesa, Pablo; Qureishi, Ali (2025-07-12). "Outcomes of Endoscopic Management of Spontaneous Cerebrospinal Fluid Rhinorrhea: A Meta-Analysis". The Laryngoscope. 136 (1): 36–49. doi:10.1002/lary.32428. ISSN 0023-852X. PMID 40650638.
  17. 1 2 Patel, Aneek; Abou-Al-Shaar, Hussam; Mallela, Arka N.; Algattas, Hanna; McDowell, Michael M.; Zenonos, Georgios A.; Wang, Eric W.; Snyderman, Carl H.; Gardner, Paul A. (2022-10-01). "Endoscopic Techniques in Vascular Neurosurgery". Neurosurgery Clinics of North America. Update on Open Vascular Surgery. 33 (4): 491–503. doi:10.1016/j.nec.2022.06.005. ISSN 1042-3680. PMID 36229136.
  18. 1 2 3 4 5 Kasemsiri, Pornthep; Carrau, Ricardo L.; Ditzel Filho, Leo F. S.; Prevedello, Daniel M.; Otto, Bradley A.; Old, Matthew; de Lara, Danielle; Kassam, Amin B. (2014-12-01). "Advantages and Limitations of Endoscopic Endonasal Approaches to the Skull Base". World Neurosurgery. Neuroendoscopy Refinements & Innovation in Endoscopic Skull Base Surgery. 82 (6, Supplement): S12–S21. doi:10.1016/j.wneu.2014.07.022. ISSN 1878-8750. PMID 25496622.
  19. ↑ Marchetti, Marcello; Sahgal, Arjun; De Salles, Antonio A F; Levivier, Marc; Ma, Lijun; Paddick, Ian; Pollock, Bruce E; Regis, Jean; Sheehan, Jason; Suh, John H; Yomo, Shoji; Fariselli, Laura (2020-10-15). "Stereotactic Radiosurgery for Intracranial Noncavernous Sinus Benign Meningioma: International Stereotactic Radiosurgery Society Systematic Review, Meta-Analysis and Practice Guideline". Neurosurgery. 87 (5): 879–890. doi:10.1093/neuros/nyaa169. ISSN 0148-396X. PMC 7566438. PMID 32463867.
  20. 1 2 Goldman, Matthew J.; Teh, Bin S.; Lo, Simon S.; Butler, E. Brian; Baskin, David S. (2024-12-27). "Radiosurgery for Intracranial Meningiomas: A Review of Anatomical Challenges and an Update on the Evidence". Cancers. 17 (1): 45. doi:10.3390/cancers17010045. ISSN 2072-6694. PMC 11718812. PMID 39796674.
  21. ↑ Rueß, Daniel; Weyer, Vera; Tutunji, Juman; Grau, Stefan; Kocher, Martin; Hoevels, Mauritius; Treuer, Harald; Baues, Christian; Ruge, Maximilian I. (2020-12-09). "Stereotactic radiosurgery of benign brain tumors in elderly patients: evaluation of outcome and toxicity". Radiation Oncology. 15 (1) 274. doi:10.1186/s13014-020-01714-0. ISSN 1748-717X. PMC 7724716. PMID 33298109.
  22. 1 2 3 4 Corvino, Sergio; Berardinelli, Jacopo; Corazzelli, Giuseppe; Altieri, Roberto; Dallan, Iacopo; Corrivetti, Francesco; de Notaris, Matteo (2025-03-06). "Surgical risk of CSF leakage following endoscopic transorbital approach for anterior and middle skull base pathologies: a systematic review and meta-analysis". Neurosurgical Review. 48 (1) 282. doi:10.1007/s10143-025-03426-z. ISSN 1437-2320. PMC 11882707. PMID 40044979.
  23. ↑ Shin, Dong-Won; Yee, Gi-Taek (2024-11-18). "Skull base reconstruction using hydroxyapatite and nasoseptal flap versus nasoseptal flap alone: meta-analysis and systematic review". Scientific Reports. 14 (1) 28433. Bibcode:2024NatSR..1428433S. doi:10.1038/s41598-024-79956-1. ISSN 2045-2322. PMC 11574179. PMID 39558022.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  24. 1 2 Schneider, Matthias; Schuss, Patrick; Güresir, Ági; Wach, Johannes; Hamed, Motaz; Vatter, Hartmut; Güresir, Erdem (2019-05-01). "Cranial Nerve Outcomes After Surgery for Frontal Skull Base Meningiomas: The Eternal Quest of the Maximum-Safe Resection with the Lowest Morbidity". World Neurosurgery. 125: e790–e796. doi:10.1016/j.wneu.2019.01.171. ISSN 1878-8750. PMID 30738945.
  25. 1 2 3 4 5 6 7 Mian, Ubaid Ullah; Hameed, Alishba; Azeem, Touba; Ullah, Sajjad; Khan, Muhammad Idris; Iftikhar, Hammad; Farooq, Umar; Wais, Meer; Ikram, Jibran (2025-11-14). Khatra, Harleen (ed.). "The Endoscopic Versus Open Approach for Anterior Skull Base Tumors: A Systematic Review of Comparative Outcomes and a Framework for Surgical Selection". Neurology Research International. 2025 (1) 7730393. doi:10.1155/nri/7730393. ISSN 2090-1852. PMC 12638158. PMID 41281588.
  26. 1 2 3 Wang, Weitao; Shokri, Tom; Manolidis, Spiros; Ducic, Yadranko (2020-12-24). "Complications in Skull Base Surgery and Subsequent Repair". Seminars in Plastic Surgery. 34 (4): 286–292. doi:10.1055/s-0040-1721765. ISSN 1535-2188. PMC 7759428. PMID 33380915.
  27. 1 2 Raper, Daniel M.S.; Komotar, Ricardo J.; Starke, Robert M.; Anand, Vijay K.; Schwartz, Theodore H. (2011-12-01). "Endoscopic versus open approaches to the skull base: A comprehensive literature review". Operative Techniques in Otolaryngology-Head and Neck Surgery. 22 (4): 302–307. doi:10.1016/j.otot.2011.08.003. ISSN 1043-1810.
  28. ↑ Kasemsiri, Pornthep; Prevedello, Daniel Monte Serrat; Otto, Bradley Alan; Old, Matthew; Filho, Leo Ditzel; Kassam, Amin Bardai; Carrau, Ricardo Luis (2015-10-08). "Endoscopic endonasal technique: treatment of paranasal and anterior skull base malignancies". Brazilian Journal of Otorhinolaryngology. 79 (6): 760–779. doi:10.5935/1808-8694.20130138. PMC 9442400. PMID 24474490.
  29. ↑ Lobo, Bjorn; Heng, Annie; Barkhoudarian, Garni; Griffiths, ChesterF; Kelly, DanielF (2015). "The expanding role of the endonasal endoscopic approach in pituitary and skull base surgery: A 2014 perspective". Surgical Neurology International. 6 (1): 82. doi:10.4103/2152-7806.157442. ISSN 2152-7806. PMC 4443401. PMID 26015870.
  30. ↑ Hannan, Cathal John; Kelleher, Eoin; Javadpour, Mohsen (2020-08-11). "Methods of Skull Base Repair Following Endoscopic Endonasal Tumor Resection: A Review". Frontiers in Oncology. 10 1614. doi:10.3389/fonc.2020.01614. ISSN 2234-943X. PMC 7431707. PMID 32850466.
  31. 1 2 3 4 5 6 Rezende, Gustavo Lara; Neto, Oswaldo Ribeiro Marquez; Kückelhaus, Selma Aparecida Souza (2021-11-03). "Morbidity in the postoperative follow-up of endoscopic anterior skull base surgery". Brazilian Journal of Otorhinolaryngology. 87 (6): 689–694. doi:10.1016/j.bjorl.2020.02.006. PMC 9422415. PMID 32327364.
  32. 1 2 3 Pang, Jonathan C.; Liu, Derek H.; Hong, Ellen M.; Frank, Madelyn; Roman, Kelsey M.; Jung, Jinho; Abiri, Arash; Nguyen, Theodore V.; Bitner, Benjamin F.; Hsu, Frank P. K.; Kuan, Edward C. (2025-02-01). "Predictors of length of postoperative stay following endoscopic skull base surgery with intraoperative CSF leak". Journal of Neurosurgery. 142 (2): 498–506. doi:10.3171/2024.6.JNS232409. ISSN 0022-3085. PMID 39332030.
  33. 1 2 3 Sperl, Veronika; Rhomberg, Thomas; Kretschmer, Thomas (2024-12-20). "Determinants of quality of life following resection of skull base tumors: a systematic review". Frontiers in Oncology. 14 1473261. doi:10.3389/fonc.2024.1473261. ISSN 2234-943X. PMC 11696366. PMID 39759154.
  34. 1 2 Shipman, Paige; Arnold, Erica; Beswick, Daniel M.; Rowan, Nicholas R.; Karsy, Michael; Alt, Jeremiah A.; Gill, Amarbir S. (2024-03-23). "Site-Specific Quality of Life Outcomes Following Anterior Skull Base Surgery: A Systematic Review and Meta-Analysis". World Neurosurgery. 185: 254–260. doi:10.1016/j.wneu.2024.02.129. PMID 38431213.
  35. 1 2 Durante, F. (1887-10-01). "Contribution to Endocranial Surgery.1". The Lancet. 130 (3344): 654–655. doi:10.1016/S0140-6736(02)10289-3. ISSN 0140-6736.
  36. ↑ Schmidt, Richard F.; Choudhry, Osamah J.; Takkellapati, Ramya; Eloy, Jean Anderson; Couldwell, William T.; Liu, James K. (2012-08-23). "Hermann Schloffer and the origin of transsphenoidal pituitary surgery". Neurosurgical Focus. 33 (2): E5. doi:10.3171/2012.5.FOCUS12129. ISSN 1092-0684. PMID 22853836.
  37. 1 2 3 Liu, James K.; Das, Kaushik; Weiss, Martin H.; Laws, Edward R.; Couldwell, William T. (2001-12-01). "The history and evolution of transsphenoidal surgery". Journal of Neurosurgery. 95 (6): 1083–1096. doi:10.3171/jns.2001.95.6.1083. ISSN 0022-3085. PMID 11765830.
  38. ↑ Hadad, Gustavo; Bassagasteguy, Luis; Carrau, Ricardo L.; Mataza, Juan C.; Kassam, Amin; Snyderman, Carl H.; Mintz, Arlan (2009-01-02). "A Novel Reconstructive Technique After Endoscopic Expanded Endonasal Approaches: Vascular Pedicle Nasoseptal Flap". The Laryngoscope. 116 (10): 1882–1886. doi:10.1097/01.mlg.0000234933.37779.e4. ISSN 0023-852X. PMID 17003708.
  39. 1 2 Garcia-Navarro, Victor; Anand, Vijay K.; Schwartz, Theodore H. (2011-05-16). "Gasket Seal Closure for Extended Endonasal Endoscopic Skull Base Surgery: Efficacy in a Large Case Series". World Neurosurgery. 80 (5): 563–568. doi:10.1016/j.wneu.2011.08.034. PMID 22120292.
  40. ↑ Luginbuhl, Adam J.; Campbell, Peter G.; Evans, James; Rosen, Marc (2010-04-21). "Endoscopic repair of high-flow cranial base defects using a bilayer button". The Laryngoscope. 120 (5): 876–880. doi:10.1002/lary.20861. ISSN 0023-852X. PMID 20422679.
  41. ↑ Jin, Biao; Wang, Xiao-shu; Huo, Gang; Mou, Jia-min; Yang, Gang (2020-03-16). "Reconstruction of skull base bone defects using an in situ bone flap after endoscopic endonasal transplanum-transtuberculum approaches". European Archives of Oto-Rhino-Laryngology. 277 (7): 2071–2080. doi:10.1007/s00405-020-05911-1. ISSN 0937-4477. PMID 32180016.
  42. ↑ Cavallo, Luigi M.; Solari, Domenico; Somma, Teresa; Cappabianca, Paolo (2019-04-14). "The 3F (Fat, Flap, and Flash) Technique For Skull Base Reconstruction After Endoscopic Endonasal Suprasellar Approach". World Neurosurgery. 126: 439–446. doi:10.1016/j.wneu.2019.03.125. PMID 30904811.
  43. ↑ de Almeida, John; Vescan, Allan; Witterick, Ian; Gullane, Patrick; Gentili, Fred; Ringash, Jolie; Thoma, Achilles; Lohfeld, Lynne (2014-11-06). "Changes Experienced in Quality of Life for Skull Base Surgical Patients: A Qualitative Case Study". Journal of Neurological Surgery Part B: Skull Base. 76 (2): 129–144. doi:10.1055/s-0034-1371520. ISSN 2193-6331. PMC 5566088. PMID 28856080.
  44. ↑ Weiss, Hannah K.; Garcia, Roxanna M.; Omiye, Jesutofunmi A.; Vervoort, Dominique; Riestenberg, Robert; Yerneni, Ketan; Murthy, Nikhil; Wescott, Annie B.; Hutchinson, Peter; Rosseau, Gail (2019-12-09). "A Systematic Review of Neurosurgical Care in Low-Income Countries". World Neurosurgery: X. 5 100068. doi:10.1016/j.wnsx.2019.100068. PMC 6957821. PMID 31956859.
  45. ↑ Kihunyu, Alex Mwangi; Pouwels, Sjaak; Adeyeye, Ademola; Abbas, Ghulam Husain; Oldenbeuving, Annemarie W.; Ramnarain, Dharmanand (2025-09-02). "Navigating neurosurgical care in low- and middle-income countries from Africa: a narrative review of barriers and facilitators". Annals of Medicine & Surgery. 87 (11): 7261–7268. doi:10.1097/MS9.0000000000003844. ISSN 2049-0801. PMC 12577848. PMID 41180625.
  46. ↑ Kanmounye, Ulrick S.; Nguembu, Stéphane; Djiofack, Dylan; Zolo, Yvan; Tétinou, Franklin; Ghomsi, Nathalie; Figuim, Bello; Esene, Ignatius (2021-01-21). "Patient Attitudes toward Neurosurgery in Low- and Middle-Income Countries: A Systematic Review". Neurology India. 69 (1): 12–20. doi:10.4103/0028-3886.310098. ISSN 0028-3886. PMID 33642264.
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