{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,16]],"date-time":"2026-01-16T10:38:14Z","timestamp":1768559894035,"version":"3.49.0"},"reference-count":75,"publisher":"Public Library of Science (PLoS)","issue":"7","license":[{"start":{"date-parts":[[2022,7,28]],"date-time":"2022-07-28T00:00:00Z","timestamp":1658966400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Meningioma surgery has evolved over the last 20 years with increased use of minimally invasive approaches including the endoscopic endonasal route and endoscope-assisted and gravity-assisted transcranial approaches. As the \u201ckeyhole\u201d concept remains controversial, we present detailed outcomes in a cohort series.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>Retrospective analysis was done for all patients undergoing meningioma removal at a tertiary brain tumor referral center from 2008\u20132021. Keyhole approaches were defined as: use of a minimally invasive \u201cretractorless\u201d approach for a given meningioma in which a traditional larger approach is often used instead. The surgical goal was maximal safe removal including conservative (subtotal) removal for some invasive locations. <jats:italic>Primary outcomes<\/jats:italic> were resection rates, complications, length of stay and Karnofsky Performance Scale (KPS). <jats:italic>Secondary outcomes<\/jats:italic> were endoscopy use, perioperative treatments, tumor control and acute MRI FLAIR\/T2 changes to assess for brain manipulation and retraction injury.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>Of 329 patients, keyhole approaches were utilized in 193(59%) patients (mean age 59\u00b113; 30 (15.5%) had prior surgery) who underwent 213 operations; 205(96%) were skull base location. Approaches included: endoscopic endonasal (n = 74,35%), supraorbital (n = 73,34%), retromastoid (n = 38,18%), mini-pterional (n = 20,9%), suboccipital (n = 4,2%), and contralateral transfalcine (n = 4,2%). <jats:italic>Primary outcomes<\/jats:italic>: Gross total\/near total (&gt;90%) resection was achieved in 125(59%) (5% for petroclival, cavernous sinus\/Meckel\u2019s cave, spheno-cavernous locations vs 77% for all other locations). Major complications included: permanent neurological worsening 12(6%), CSF leak 2(1%) meningitis 2(1%). There were no DVTs, PEs, MIs or 30-day mortality. Median LOS decreased from 3 to 2 days in the last 2 years; 94% were discharged to home with favorable 90-day KPS in 176(96%) patients. <jats:italic>Secondary outcomes<\/jats:italic>: Increased FLAIR\/T2 changes were noted on POD#1\/2 MRI in 36\/213(17%) cases, resolving in all but 11 (5.2%). Endoscopy was used in 87\/139(63%) craniotomies, facilitating additional tumor removal in 55%. Tumor progression occurred in 26(13%) patients, mean follow-up 42\u00b136 months.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions &amp; relevance<\/jats:title>\n<jats:p>Our experience suggests minimally invasive keyhole transcranial and endoscopic endonasal meningioma removal is associated with comparable resection rates and low complication rates, short hospitalizations and high 90-day performance scores in comparison to prior reports using traditional skull base approaches. Subtotal removal may be appropriate for invasive\/adherent meningiomas to avoid neurological deficits and other post-operative complications, although longer follow-up is needed. With careful patient selection and requisite experience, these approaches may be considered reasonable alternatives to traditional transcranial approaches.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0264053","type":"journal-article","created":{"date-parts":[[2022,7,28]],"date-time":"2022-07-28T17:52:30Z","timestamp":1659030750000},"page":"e0264053","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":9,"title":["Critical appraisal of minimally invasive keyhole surgery for intracranial meningioma in a large case series"],"prefix":"10.1371","volume":"17","author":[{"given":"Jai Deep","family":"Thakur","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Regin Jay","family":"Mallari","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alex","family":"Corlin","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Samantha","family":"Yawitz","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Amalia","family":"Eisenberg","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"John","family":"Rhee","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Walavan","family":"Sivakumar","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Howard","family":"Krauss","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Neil","family":"Martin","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Chester","family":"Griffiths","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Garni","family":"Barkhoudarian","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8358-056X","authenticated-orcid":true,"given":"Daniel F.","family":"Kelly","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2022,7,28]]},"reference":[{"issue":"Supplement_1","key":"pone.0264053.ref001","doi-asserted-by":"crossref","first-page":"iv1","DOI":"10.1093\/neuonc\/noaa200","article-title":"\"CBTRUS statistical report: Primary brain and other central nervous system tumors diagnosed in the United States in 2013\u20132017,\"","volume":"22","author":"Q. T. Ostrom","year":"2020","journal-title":"Neuro-oncology"},{"issue":"5","key":"pone.0264053.ref002","doi-asserted-by":"crossref","first-page":"1268","DOI":"10.3171\/2010.11.JNS10326","article-title":"\"Petroclival meningiomas: study on outcomes, complications and recurrence rates,\"","volume":"114","author":"A. Nanda","year":"2011","journal-title":"Journal of neurosurgery"},{"issue":"1","key":"pone.0264053.ref003","doi-asserted-by":"crossref","first-page":"20","DOI":"10.3171\/jns.1996.84.1.0020","article-title":"\"Petroclival meningiomas: surgical experience in 109 cases,\"","volume":"84","author":"W. T. Couldwell","year":"1996","journal-title":"Journal of neurosurgery"},{"issue":"3","key":"pone.0264053.ref004","first-page":"546","article-title":", \"Surgical management of petroclival meningiomas: defining resection goals based on risk of neurological morbidity and tumor recurrence rates in 137 patients,\"","volume":"56","author":"K. M. Little","year":"2005","journal-title":"Neurosurgery"},{"issue":"4","key":"pone.0264053.ref005","doi-asserted-by":"crossref","first-page":"367","DOI":"10.1055\/s-0037-1608654","article-title":"\"Petroclival meningiomas: factors determining the choice of approach,","volume":"79","author":"G. R. Isolan","year":"2018","journal-title":"Journal of neurological surgery. Part B, Skull base"},{"key":"pone.0264053.ref006","doi-asserted-by":"crossref","first-page":"e221","DOI":"10.1016\/j.wneu.2019.03.052","article-title":"\"Tumor control and cranial nerve outcomes after adjuvant radiosurgery for low-grade skull base meningiomas,\"","volume":"127","author":"A. Faramand","year":"2019","journal-title":"World neurosurgery"},{"issue":"3","key":"pone.0264053.ref007","doi-asserted-by":"crossref","first-page":"675","DOI":"10.3171\/2013.5.JNS13206","article-title":"\"Single-fraction radiosurgery of benign cavernous sinus meningiomas,\"","volume":"119","author":"B. E. Pollock","year":"2013","journal-title":"Journal of neurosurgery"},{"issue":"2","key":"pone.0264053.ref008","doi-asserted-by":"crossref","first-page":"380","DOI":"10.3171\/2018.10.JNS181480","article-title":"\"Outcomes of decompressive surgery for cavernous sinus meningiomas: long-term follow-up in 50 patients,\"","volume":"132","author":"Y. M. Gozal","year":"2019","journal-title":"Journal of neurosurgery"},{"key":"pone.0264053.ref009","doi-asserted-by":"crossref","DOI":"10.3389\/fneur.2020.00652","article-title":"\"Improving Function in Cavernous Sinus Meningiomas: A Modern Treatment Algorithm,\"","volume":"11","author":"A. Beer-Furlan","year":"2020","journal-title":"Frontiers in Neurology"},{"issue":"3","key":"pone.0264053.ref010","doi-asserted-by":"crossref","first-page":"551","DOI":"10.3171\/2015.9.JNS15754","article-title":"\"The Simpson grading revisited: aggressive surgery and its place in modern meningioma management,\"","volume":"125","author":"K. Gousias","year":"2016","journal-title":"Journal of neurosurgery"},{"issue":"5","key":"pone.0264053.ref011","doi-asserted-by":"crossref","first-page":"1029","DOI":"10.3171\/2010.3.JNS091971","article-title":"\"The relevance of Simpson Grade I and II resection in modern neurosurgical treatment of World Health Organization Grade I meningiomas,\"","volume":"113","author":"M. E. Sughrue","year":"2010","journal-title":"Journal of neurosurgery"},{"issue":"7","key":"pone.0264053.ref012","doi-asserted-by":"crossref","first-page":"2253","DOI":"10.1007\/s00464-013-2973-9","article-title":"\"Minimally invasive surgery: national trends in adoption and future directions for hospital strategy,\"","volume":"27","author":"C. 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Smith","year":"2012","journal-title":"Nature Reviews Neurology"},{"issue":"1","key":"pone.0264053.ref016","doi-asserted-by":"crossref","first-page":"102","DOI":"10.3171\/jns.1971.34.1.0102","article-title":"\"Limited exposure in cerebral surgery,\"","volume":"34","author":"D. H. Wilson","year":"1971","journal-title":"Journal of neurosurgery"},{"issue":"2","key":"pone.0264053.ref017","doi-asserted-by":"crossref","first-page":"291","DOI":"10.3171\/2011.8.JNS101896","article-title":"\"The quiet revolution: retractorless surgery for complex vascular and skull base lesions,\"","volume":"116","author":"R. F. Spetzler","year":"2012","journal-title":"Journal of neurosurgery"},{"key":"pone.0264053.ref018","doi-asserted-by":"crossref","first-page":"e61","DOI":"10.1016\/j.wneu.2020.03.095","article-title":"\"Prospective Evaluation of the Need for Fixed Brain Retractors During Complex Cranial Surgery,\"","volume":"139","author":"M. Y. S. 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Cavallo","year":"2005","journal-title":"Neurosurgical focus"},{"issue":"5","key":"pone.0264053.ref025","doi-asserted-by":"crossref","first-page":"832","DOI":"10.3171\/jns.2005.102.5.0832","article-title":"\"The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors,\"","volume":"102","author":"J. R. Dusick","year":"2005","journal-title":"Journal of neurosurgery"},{"issue":"5","key":"pone.0264053.ref026","doi-asserted-by":"crossref","first-page":"825","DOI":"10.3171\/jns.2005.102.5.0825","article-title":"\"Extended transsphenoidal approach,\"","volume":"102","author":"E. R. Laws","year":"2005","journal-title":"Journal of neurosurgery"},{"key":"pone.0264053.ref027","article-title":"\"Endoscopic Endonasal and Supraorbital Removal of Tuberculum Sellae Meningiomas: Anatomic Guides and Operative Nuances for Keyhole Approach Selection,\"","author":"R. J. Mallari","year":"2021","journal-title":"Operative Neurosurgery"},{"key":"pone.0264053.ref028","doi-asserted-by":"crossref","first-page":"268","DOI":"10.1016\/j.wneu.2020.07.198","article-title":"\"Tuberculum Sellae Meningiomas in Pregnancy: 3 Cases Treated in the Second Trimester and Literature Review,\"","volume":"143","author":"R. J. Mallari","year":"2020","journal-title":"World Neurosurgery"},{"issue":"6","key":"pone.0264053.ref029","doi-asserted-by":"crossref","first-page":"724","DOI":"10.1093\/ons\/opx067","article-title":"\"Microsurgical endoscope-assisted gravity-aided transfalcine approach for contralateral metastatic deep medial cortical tumors,\"","volume":"13","author":"G. Barkhoudarian","year":"2017","journal-title":"Operative Neurosurgery"},{"issue":"4","key":"pone.0264053.ref030","doi-asserted-by":"crossref","first-page":"475","DOI":"10.1227\/NEU.0000000000000970","article-title":"\"Endoscopic and gravity-assisted resection of medial temporo-occipital lesions through a supracerebellar transtentorial approach: technical notes with case illustrations,\"","volume":"11","author":"P. Villanueva","year":"2015","journal-title":"Operative Neurosurgery"},{"issue":"suppl_5","key":"pone.0264053.ref031","first-page":"ons269-ons287","article-title":"\"Endonasal versus supraorbital keyhole removal of craniopharyngiomas and tuberculum sellae meningiomas,\"","volume":"64","author":"N. Fatemi","year":"2009","journal-title":"Operative Neurosurgery"},{"key":"pone.0264053.ref032","doi-asserted-by":"crossref","first-page":"e12","DOI":"10.1016\/j.wneu.2019.06.073","article-title":"\"Strategy and Technique of Endonasal Endoscopic Bony Decompression and Selective Tumor Removal in Symptomatic Skull Base Meningiomas of the Cavernous Sinus and Meckel\u2019s Cave,\"","volume":"131","author":"W. Sivakumar","year":"2019","journal-title":"World neurosurgery"},{"issue":"3","key":"pone.0264053.ref033","doi-asserted-by":"crossref","first-page":"861","DOI":"10.3171\/2017.11.JNS172141","article-title":"\"Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients,\"","volume":"130","author":"A. Conger","year":"2018","journal-title":"Journal of neurosurgery"},{"key":"pone.0264053.ref034","first-page":"2021","article-title":", \"Supraorbital and mini-pterional keyhole craniotomies for brain tumors: a clinical and anatomical comparison of indications and outcomes in 204 cases,\"","author":"M. B. Avery","year":"2021","journal-title":"Journal of neurosurgery"},{"issue":"7","key":"pone.0264053.ref035","doi-asserted-by":"crossref","first-page":"e0254958","DOI":"10.1371\/journal.pone.0254958","article-title":"\"Streamlining brain tumor surgery care during the COVID-19 pandemic: A case-control study,\"","volume":"16","author":"R. J. Mallari","year":"2021","journal-title":"Plos one"},{"issue":"6","key":"pone.0264053.ref036","doi-asserted-by":"crossref","first-page":"667","DOI":"10.1093\/ons\/opaa217","article-title":"\"The supraorbital eyebrow craniotomy for intra-and extra-axial brain tumors: a single-center series and technique modification,\"","volume":"19","author":"S. F. Ansari","year":"2020","journal-title":"Operative Neurosurgery"},{"key":"pone.0264053.ref037","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3171\/2020.6.JNS201904","article-title":"\"The Simpson grade: abandon the scale but preserve the message,\"","volume":"1","author":"T. H. Schwartz","year":"2020","journal-title":"Journal of Neurosurgery"},{"issue":"6","key":"pone.0264053.ref038","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1016\/j.jacc.2010.03.053","article-title":"\"Minimally-invasive valve surgery,\"","volume":"56","author":"J. D. Schmitto","year":"2010","journal-title":"Journal of the American College of Cardiology"},{"issue":"6","key":"pone.0264053.ref039","doi-asserted-by":"crossref","first-page":"535","DOI":"10.1097\/DCR.0000000000000580","article-title":"\"Comparison of open, laparoscopic, and robotic colectomies using a large national database: outcomes and trends related to surgery center volume,\"","volume":"59","author":"H. L. 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Koutourousiou","year":"2014","journal-title":"Journal of neurosurgery"},{"issue":"4","key":"pone.0264053.ref043","doi-asserted-by":"crossref","first-page":"608","DOI":"10.3171\/jns.1985.63.4.0608","article-title":"\"The risk of cerebral damage during graded brain retractor pressure in the rat,\"","volume":"63","author":"J. Rosen\u00f8rn","year":"1985","journal-title":"Journal of neurosurgery"},{"issue":"4","key":"pone.0264053.ref044","doi-asserted-by":"crossref","first-page":"1191","DOI":"10.3171\/2016.3.JNS152307","article-title":"\"Craniotomy for perisellar meningiomas: comparison of simple (appropriate for endoscopic approach) versus complex anatomy and surgical outcomes,\"","volume":"126","author":"S. 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Taha","year":"2011","journal-title":"World neurosurgery"},{"issue":"1","key":"pone.0264053.ref050","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1007\/s11060-016-2262-2","article-title":"\"Impact of operative length on post-operative complications in meningioma surgery: a NSQIP analysis,\"","volume":"131","author":"A. V. Karhade","year":"2017","journal-title":"Journal of neuro-oncology"},{"key":"pone.0264053.ref051","doi-asserted-by":"crossref","first-page":"106460","DOI":"10.1016\/j.clineuro.2020.106460","article-title":"\"The incidence of venous thromboembolism following surgical resection of intracranial and intraspinal meningioma. A systematic review and retrospective study,\"","author":"R. 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Ehresman","year":"2019","journal-title":"Part B, Skull base"},{"issue":"2","key":"pone.0264053.ref057","doi-asserted-by":"crossref","first-page":"195","DOI":"10.3171\/jns.1994.80.2.0195","article-title":"\"Postoperative irradiation for subtotally resected meningiomas: A retrospective analysis of 140 patients treated from 1967 to 1990,\"","volume":"80","author":"B. J. Goldsmith","year":"1994","journal-title":"Journal of neurosurgery"},{"issue":"5","key":"pone.0264053.ref058","doi-asserted-by":"crossref","first-page":"915","DOI":"10.1097\/00006123-199611000-00005","article-title":"\"Long-term follow-up of patients with meningiomas involving the cavernous sinus: recurrence, progression, and quality of life,\"","volume":"39","author":"O. 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Savardekar","year":"2018","journal-title":"World neurosurgery"},{"issue":"2","key":"pone.0264053.ref061","doi-asserted-by":"crossref","first-page":"351","DOI":"10.1007\/s11060-021-03775-x","article-title":"\"Effect of adjuvant radiotherapy after subtotal resection for WHO grade I meningioma: a propensity score matching analysis of the Brain Tumor Registry of Japan,\"","volume":"153","author":"S. Oya","year":"2021","journal-title":"Journal of Neuro-Oncology"},{"key":"pone.0264053.ref062","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1016\/j.wneu.2016.11.021","article-title":"\"Adjuvant radiosurgery versus serial surveillance following subtotal resection of atypical meningioma: a systematic analysis,\"","volume":"98","author":"C. Lagman","year":"2017","journal-title":"World neurosurgery"},{"issue":"1","key":"pone.0264053.ref063","first-page":"1","article-title":"\"transsphenoidal versus transcranial Approach for treatment of tuberculum sellae Meningiomas: A systematic Review and Meta-analysis of Comparative studies,\"","volume":"9","author":"C. Yang","year":"2019","journal-title":"Scientific reports"},{"issue":"5\u20136","key":"pone.0264053.ref064","doi-asserted-by":"crossref","first-page":"713","DOI":"10.1016\/j.wneu.2011.08.025","article-title":"\"Endoscopic endonasal versus open transcranial resection of anterior midline skull base meningiomas,\"","volume":"77","author":"R. J. 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