Operative Neurosurgery 31:484–494, 2026
Large anterior skull-base meningiomas can be approached through unilateral frontal, bifrontal or pterional craniotomies, but anatomy and case complexity strongly influence that choice. This retrospective series compares the three exposures and uses propensity matching to reduce baseline imbalance. Bifrontal procedures had more medical and surgical complications and poorer cosmetic results after matching. Frontal procedures showed shorter progression-free survival, with subtotal resection emerging as an adverse predictor. The findings help frame approach selection but do not establish that one craniotomy is intrinsically superior for every tumor.
Objective
To compare outcomes after frontal, bifrontal and pterional craniotomy for large anterior skull-base meningiomas and identify approach-specific predictors of complications and tumor control.
Methods
The study retrospectively included 337 adults operated at one institution between 2010 and 2024, each with at least 1 year of follow-up. Eighty patients underwent bifrontal, 189 frontal and 68 pterional craniotomy. Propensity-score matching balanced groups for tumor size, grade and preoperative Karnofsky Performance Status. Complications, cosmetic outcomes and progression-free survival were then compared.
Main results
Before matching, patients selected for bifrontal surgery had larger tumors and lower functional status, whereas the frontal group had higher-grade tumors. After matching, medical complications occurred in 25.0% and surgical complications in 22.5% of the bifrontal group, both significantly more often than in the other groups. Unsatisfactory cosmetic outcomes were also more frequent after bifrontal surgery (6.25%).
Kaplan-Meier analysis showed more minor complications after bifrontal craniotomy and shorter progression-free survival in the frontal group. Olfactory-groove location predicted poorer outcomes in the pterional cohort, while subtotal resection predicted poorer outcome in the frontal cohort.
Interpretation
The bilateral exposure carries a morbidity cost even after adjustment for several markers of complexity. However, approach is inseparable from anatomy: midline extension, vascular encasement, optic involvement, surgeon experience and the probability of safe complete resection must shape the decision. A unilateral route should not be selected merely to avoid the statistical risk associated with bifrontal surgery.
Limitations
The retrospective single-center design is vulnerable to selection bias and changing surgical practice over 14 years. Matching addressed only measured variables and could not balance all anatomical features. The abstract does not provide adjusted effect sizes for every comparison, and the broad category of anterior skull-base meningioma combines distinct origins and operative challenges.
Clinical takeaway
Use the least disruptive exposure that still provides safe control of the tumor, neurovascular structures and dural attachment. Reserve a bifrontal route for anatomy that genuinely requires bilateral access, and counsel those patients about its higher observed medical, surgical and cosmetic complication burden.