Background: The transorbital approaches (TOAs) have acquired growing notoriety, thanks to their ability to offer alternative corridors to the skull base. However, the limited access and the unfamiliarity with this surgical perspective make recognition of key landmarks difficult, especially for less experienced surgeons. The study wants to offer a detailed description of the anatomy to comprehend the potential and limitations of TOAs. Methods: Measurements of the orbit region and the surrounding areas were performed on two hundred high-resolution CT scans and thirty-nine dry skulls. Five specimens were dissected to illustrate the TOA, and one was used to perform the extradural clinoidectomy. Three clinical cases highlighted the surgical applications. Results: A step-by-step description of the key steps of the TOA was proposed and a comparison with the transcranial anterior clinoidectomy was discussed. The mean work distance was 6.1 ± 0.4 cm, and the lateral working angle increased 20 ± 5.4° after removing the lateral orbital rim. Conclusions: TOAs are indicated in selected cases when tumor involves the lateral portion of the cavernous sinus or the middle skull base, obtaining a direct decompression of the optic nerve and avoiding excessive manipulation of the neurovascular structures. Comprehension of surgical anatomy of the orbit and its surrounding structures is essential to safely perform these approaches.

The anterior cranial fossa (ACF) is a complex anatomical region that can be affected by a broad spectrum of pathology. For the surgical treatment of these lesions, many approaches have been described, each of them with different scope and potential surgical complications, often associated with significant morbidity. Traditionally, tumors involving the ACF have been operated by transcranial approaches; however, in the last two decades, endoscopic endonasal approaches (EEAs) have been gaining popularity. In this work, the authors review and describe the anatomical aspects of the ACF and the technical nuances of transcranial and endoscopic approaches for tumors located in this region. Four approaches were performed in embalmed cadaveric specimens and the key steps were documented. Four illustrative cases of ACF tumors were selected to demonstrate the clinical application of anatomical and technical knowledge, which are essential in the preoperative decision-making process.

Los macroadenomas hipofisarios tienen una elevada incidencia de pérdida visual como consecuencia de la compresión de la vía óptica. La tomografía de coherencia óptica (TCO) ha sido descripta como un factor pronóstico de recuperación. Nuestro objetivo es evaluar si la TCO puede predecir los resultados de recuperación visual. Se realizó un trabajo prospectivo de macroadenomas hipofisarios con compresión de la vía visual e indicación quirúrgica entre febrero del 2015 y noviembre del 2016. Se evaluaron los estudios de agudeza visual, perimetría computarizada y TCO. Se compararon los resultados tras 6-12 semanas y 6-9 meses de la intervención. Las variables cuantitativas continuas dependientes e independientes se relacionaron mediante una prueba T de Student, regresión lineal y correlación de Pearson considerando como estadísticamente significativo una P < 0,05. La alteración en la agudeza visual y la perimetría computarizada preoperatorios, fue mayor en aquellos pacientes con TCO alterada. Tanto los pacientes con CFNR normal como adelgazada se constató una mejoría significativa del campo visual a las 6-12 semanas. Los valores de TCO se correlacionaron en forma inversa con los valores de campo visual, lo que significa que a mayor grosor menor es el déficit campimétrico. Los pacientes con TCO normal tuvieron una mejor recuperación ya que el defecto campimétrico preoperatorio fue más leve. La correlación entre los valores de TCO y la mejoría del campo visual no fue significativa, lo que sugiere independientemente del grosor del nervio los pacientes mejoran el campo visual tras la cirugía. El campo visual computarizado continúa siendo el estudio de elección en la evaluación de pacientes con macroadenomas. La TCO no se considera un predictor de outcome visual.

Meningiomas are slow-growing neoplasms, accounting for 20% of all primary intracranial neoplasms and 25% of all intraspinal tumors. Atypical and anaplastic meningiomas are infrequent, representing fewer than 5% of all meningiomas. Unusually, they can show aggressive behavior, and extracranial metastases are extremely rare, representing approximately 0.1% of all reported cases. Fifty-six-year-old male patient diagnosed with atypical basal frontal meningioma with multiple resections, both endoscopic endonasal and transcranial. After hypofractionated radiosurgery, the patient showed new tumor recurrence associated to right cervical level II ganglionic metastasis. We opted for complete resection of the meningioma and reconstruction with anterior rectus abdominis muscle flap, as well as selective cervical ganglionectomy. Anatomical pathology showed neoplastic proliferation of meningothelial cells in syncytial cytoplasm, oval or spherical nuclei with slight anisocariosis and hyperchromasia, and intranuclear vacuoles, all compatible with anaplastic meningioma. Due to a lack of consensus on how to treat a metastatic malignant meningioma, this pathology requires a multidisciplinary approach, and treatment needs to be adapted to each particular case. Complete resection of the lesion is the primary goal, and this requires complex procedures involving endocranial as well as extracranial surgeries, which result in composite defects difficult to resolve. Microvascular free flaps are considered the gold standard in reconstructions of large skull base defects, with high success rates and few complications.