Month: September 2026

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Comparative Outcomes of Frontal, Bifrontal, and Pterional Craniotomies for Resection of Large Anterior Skull Base Meningiomas

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.

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Evaluating Conscious Sedation Versus General Anesthesia for Venous Sinus Stenting for Idiopathic Intracranial Hypertension and Implications for Outpatient Management

Neurosurgery 99:700–709, 2026

Venous sinus stenting for idiopathic intracranial hypertension is commonly separated into diagnostic manometry under conscious sedation and later stenting under general anesthesia. This cohort asks whether conscious sedation and a more streamlined pathway can deliver comparable safety and efficacy. After propensity matching, outcomes did not differ significantly between conscious sedation and general anesthesia. Same-admission diagnosis and treatment were associated with more repeat stenting, although this group included every fulminant presentation. The work supports outpatient feasibility but not indiscriminate conversion to a single-session pathway.

Objective

To compare venous sinus stenting under conscious sedation and general anesthesia and to evaluate single-session diagnostic venography plus stenting versus staged procedures, with particular attention to outpatient management.

Methods

The retrospective cohort included 114 adults treated for idiopathic intracranial hypertension at one comprehensive cerebrovascular center from January 2017 through December 2024. Clinical presentation, procedural characteristics, symptom resolution and restenosis were compared between general anesthesia and conscious sedation and between same-admission and staged pathways. Propensity-score matching was used for both comparisons.

Main results

Thirty-six patients underwent general anesthesia and 78 conscious sedation. After matching, 36 patients remained in each group, with no significant difference in the measured safety or clinical outcomes. One major complication—acute visual loss caused by cerebral venous thrombosis—occurred in the conscious-sedation cohort.

Thirty-seven patients underwent same-admission venography and stenting, compared with 77 staged procedures. All 17 fulminant cases belonged to the same-admission group. Apparent differences in time to recurrent headache and visual symptoms were no longer significant after matching, but restenosis requiring repeat stenting remained more frequent after the same-admission strategy.

Interpretation

Conscious sedation appears technically feasible for venous sinus stenting in selected patients and could remove a barrier to outpatient care. The increased repeat-stenting signal after same-admission treatment may reflect the biological and clinical severity of fulminant disease, residual confounding or differences in pressure measurement and selection; it should not be attributed automatically to workflow.

Limitations

This was a retrospective single-center study with only 114 patients and one major complication, limiting safety comparisons. Anesthetic and admission strategies were chosen clinically rather than randomly. Propensity matching cannot correct unmeasured confounding, especially because every fulminant case entered the same-session group.

Clinical takeaway

Conscious sedation and staged outpatient venography followed by outpatient stenting may be reasonable in carefully selected, stable adults. Fulminant presentations still require expedited individualized treatment, and same-session stenting should not become routine until predictors of restenosis and the effect of anesthetic conditions on manometry are better defined.

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