{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,26]],"date-time":"2026-09-26T00:18:34Z","timestamp":1790381914913,"version":"4.1.0"},"reference-count":41,"publisher":"MDPI AG","issue":"21","license":[{"start":{"date-parts":[[2023,10,30]],"date-time":"2023-10-30T00:00:00Z","timestamp":1698624000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Meckel\u2019s cave is a challenging surgical target due to its deep location and proximity to vital neurovascular structures. Surgeons have developed various microsurgical transcranial approaches (MTAs) to access it, but there is no consensus on the best method. Newer endoscopic approaches have also emerged. This study seeks to quantitatively compare these surgical approaches to Meckel\u2019s cave, offering insights into surgical volumes and exposure areas. Methods: Fifteen surgical approaches were performed bilaterally in six specimens, including the pterional approach (PTA), fronto-temporal-orbito-zygomatic approach (FTOZA), subtemporal approach (STA), Kawase approach (KWA), retrosigmoid approach (RSA), retrosigmoid approach with suprameatal extension (RSAS), endoscopic endonasal transpterygoid approach (EETPA), inferolateral transorbital approach (ILTEA) and superior eyelid approach (SEYA). All the MTAs were performed both with 10 mm and 15 mm of brain retraction, to consider different percentages of surface exposure. A dedicated navigation system was used to quantify the surgical working volumes and exposure of different areas of Meckel\u2019s cave (ApproachViewer, part of GTx-Eyes II, University Health Network, Toronto, Canada). Microsurgical transcranial approaches were quantified with two different degrees of brain retraction (10 mm and 15 mm). Statistical analysis was performed using a mixed linear model with bootstrap resampling. Results: The RSAS with 15 mm of retraction offered the maximum exposure of the trigeminal stem (TS). If compared to the KWA, the RSA exposed more of the TS (69% vs. 46%; p = 0.01). The EETPA and ILTEA exposed the Gasserian ganglion (GG) mainly in the anteromedial portion, but with a significant 20% gain in exposure provided by the EETPA compared to ILTEA (42% vs. 22%; p = 0.06). The STA with 15 mm of retraction offered the maximum exposure of the GG, with a significant gain in exposure compared to the STA with 10 mm of retraction (50% vs. 35%; p = 0.03). The medial part of the three trigeminal branches was mainly exposed by the EETPA, particularly for the ophthalmic (66%) and maxillary (83%) nerves. The EETPA offered the maximum exposure of the medial part of the mandibular nerve, with a significant gain in exposure compared to the ILTEA (42% vs. 11%; p = 0.01) and the SEY (42% vs. 2%; p = 0.01). The FTOZA offered the maximum exposure of the lateral part of the ophthalmic nerve, with a significant gain of 67% (p = 0.03) and 48% (p = 0.04) in exposure compared to the PTA and STA, respectively. The STA with 15 mm of retraction offered the maximum exposure of the lateral part of the maxillary nerve, with a significant gain in exposure compared to the STA with 10 mm of retraction (58% vs. 45%; p = 0.04). The STA with 15 mm of retraction provided a significant exposure gain of 23% for the lateral part of the mandibular nerve compared to FTOZA with 15 mm of retraction (p = 0.03). Conclusions: The endoscopic approaches, through the endonasal and transorbital routes, can provide adequate exposure of Meckel\u2019s cave, especially for its more medial portions, bypassing the impediment of major neurovascular structures and significant brain retraction. As far as the most lateral portion of Meckel\u2019s cave, MTA approaches still seem to be the gold standard in obtaining optimal exposure and adequate surgical volumes.<\/jats:p>","DOI":"10.3390\/jcm12216847","type":"journal-article","created":{"date-parts":[[2023,10,30]],"date-time":"2023-10-30T13:20:07Z","timestamp":1698672007000},"page":"6847","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["Quantitative Anatomical Comparison of Surgical Approaches to Meckel\u2019s Cave"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1761-7202","authenticated-orcid":false,"given":"Luca","family":"Zanin","sequence":"first","affiliation":[{"name":"Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6463-5000","authenticated-orcid":false,"given":"Edoardo","family":"Agosti","sequence":"additional","affiliation":[{"name":"Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Florian","family":"Ebner","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Eberhard-Karls University, T\u00fcbingen University Hospital, D-72076 T\u00fcbingen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4062-5665","authenticated-orcid":false,"given":"Lucio","family":"de Maria","sequence":"additional","affiliation":[{"name":"Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francesco","family":"Belotti","sequence":"additional","affiliation":[{"name":"Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8531-7730","authenticated-orcid":false,"given":"Barbara","family":"Buffoli","sequence":"additional","affiliation":[{"name":"Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7515-5846","authenticated-orcid":false,"given":"Rita","family":"Rezzani","sequence":"additional","affiliation":[{"name":"Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bernard","family":"Hirt","sequence":"additional","affiliation":[{"name":"Department of Clinical Anatomy, Eberhard-Karls-University, T\u00fcbingen University Hospital, D-72076 T\u00fcbingen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marco","family":"Ravanelli","sequence":"additional","affiliation":[{"name":"Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3741-0639","authenticated-orcid":false,"given":"Tamara","family":"Ius","sequence":"additional","affiliation":[{"name":"Neurosurgery Unit, Head-Neck and NeuroScience Department, University Hospital of Udine, p.le S. Maria della Misericordia 15, 33100 Udine, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0999-5545","authenticated-orcid":false,"given":"Marco","family":"Zeppieri","sequence":"additional","affiliation":[{"name":"Department of Ophthalmology, University Hospital of Udine, p.le S. Maria della Misericordia 15, 33100 Udine, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcos Soares","family":"Tatagiba","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Eberhard-Karls University, T\u00fcbingen University Hospital, D-72076 T\u00fcbingen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4023-1909","authenticated-orcid":false,"given":"Marco Maria","family":"Fontanella","sequence":"additional","affiliation":[{"name":"Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7438-0734","authenticated-orcid":false,"given":"Francesco","family":"Doglietto","sequence":"additional","affiliation":[{"name":"Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy"},{"name":"Neurosurgery, Universit\u00e0 Cattolica del Sacro Cuore, 20123 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,10,30]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1016\/j.wneu.2011.03.037","article-title":"Meckel\u2019s Cave","volume":"76","author":"Batay","year":"2011","journal-title":"World Neurosurg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"178","DOI":"10.1016\/j.wneu.2021.01.081","article-title":"Meckel\u2019s Cave and Somatotopy of the Trigeminal Ganglion","volume":"148","author":"Bond","year":"2021","journal-title":"World Neurosurg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"787","DOI":"10.1007\/s00405-013-2581-2","article-title":"Meckel\u2019s Cave Access: Anatomic Study Comparing the Endoscopic Transantral and Endonasal Approaches","volume":"271","author":"Suruliraj","year":"2014","journal-title":"Eur. Arch. Otorhinolaryngol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1055\/s-0033-1342989","article-title":"What Is the Best Route to the Meckel Cave? Anatomical Comparison between the Endoscopic Endonasal Approach and a Lateral Approach","volume":"74","author":"Bush","year":"2013","journal-title":"J. Neurol. Surg. B Skull Base"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"e256","DOI":"10.1227\/ons.0000000000000312","article-title":"Quantitative Anatomic Comparison of Endoscopic Transnasal and Microsurgical Transcranial Approaches to the Anterior Cranial Fossa","volume":"23","author":"Agosti","year":"2022","journal-title":"Oper. Neurosurg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e128","DOI":"10.1016\/j.wneu.2021.05.055","article-title":"Endoscopic Subtemporal Epidural Key-Hole Approach: Quantitative Anatomic Analysis of Three Surgical Corridors","volume":"152","author":"Rampinelli","year":"2021","journal-title":"World Neurosurg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"E494","DOI":"10.1093\/ons\/opab310","article-title":"Quantitative Anatomic Comparison of Microsurgical Transcranial, Endoscopic Endonasal, and Transorbital Approaches to the Spheno-Orbital Region","volume":"21","author":"Agosti","year":"2021","journal-title":"Oper. Neurosurg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"649","DOI":"10.1007\/s00701-019-04152-4","article-title":"Quantitative Anatomical Comparison of Transnasal and Transcranial Approaches to the Clivus","volume":"162","author":"Agosti","year":"2020","journal-title":"Acta Neurochir."},{"key":"ref_9","first-page":"83","article-title":"Microsurgical Pterional Approach to Aneurysms of the Basilar Bifurcation","volume":"6","author":"Yasargil","year":"1976","journal-title":"Surg. Neurol."},{"key":"ref_10","first-page":"ONS103","article-title":"The Orbitozygomatic Approach","volume":"58","author":"Agur","year":"2006","journal-title":"Neurosurgery"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"857","DOI":"10.3171\/jns.1985.63.6.0857","article-title":"Transpetrosal Approach for Aneurysms of the Lower Basilar Artery","volume":"63","author":"Kawase","year":"1985","journal-title":"J. Neurosurg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"824","DOI":"10.3171\/jns.1983.58.6.0824","article-title":"Direct Microsurgical Repair of Intracavernous Vascular Lesions","volume":"58","author":"Dolenc","year":"1983","journal-title":"J. Neurosurg."},{"key":"ref_13","first-page":"ons53","article-title":"Retrosigmoid Intradural Inframeatal Approach: Indications and Technique","volume":"73","author":"Samii","year":"2013","journal-title":"Neurosurgery"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1055\/s-0040-1718914","article-title":"The Role of the Transorbital Superior Eyelid Approach in the Management of Selected Spheno-Orbital Meningiomas: In-Depth Analysis of Indications, Technique, and Outcomes from the Study of a Cohort of 35 Patients","volume":"83","author":"Locatelli","year":"2022","journal-title":"J. Neurol. Surg. B Skull Base"},{"key":"ref_15","first-page":"ons44","article-title":"Quantitative Comparison of Kawase\u2019s Approach versus the Retrosigmoid Approach: Implications for Tumors Involving Both Middle and Posterior Fossae","volume":"64","author":"Chang","year":"2009","journal-title":"Neurosurgery"},{"key":"ref_16","first-page":"171","article-title":"A Comparison between the Kawase and Extended Retrosigmoid Approaches (Retrosigmoid Transtentorial and Retrosigmoid Intradural Suprameatal Approaches) for Accessing the Petroclival Tumors","volume":"75","author":"Sharma","year":"2014","journal-title":"A Cadaveric Study. Skull Base Surg."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2191","DOI":"10.1007\/s00701-021-04800-8","article-title":"Letter: How I Do It: Retrosigmoid Intradural Inframeatal Petrosectomy","volume":"163","author":"Meling","year":"2021","journal-title":"Acta Neurochir."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1097\/MAO.0000000000001602","article-title":"Surgical Management of Tumors Involving Meckel\u2019s Cave and Cavernous Sinus: Role of an Extended Middle Fossa and Lateral Sphenoidectomy Approach","volume":"39","author":"Sun","year":"2018","journal-title":"Otol. Neurotol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1080\/02688697.2020.1754334","article-title":"Trigeminal Schwannoma: A Single-Center Experience with 43 Cases and Review of Literature","volume":"35","author":"Li","year":"2021","journal-title":"Br. J. Neurosurg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"862","DOI":"10.1016\/j.jocn.2011.09.023","article-title":"Endoscopic Endonasal Management of Trigeminal Schwannomas Extending into the Infratemporal Fossa","volume":"19","author":"Zhang","year":"2012","journal-title":"J. Clin. Neurosci."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1027","DOI":"10.1007\/BF01412304","article-title":"Trigeminal Neurinomas a Series of 111 Surgical Cases from a Single Institution","volume":"138","author":"An","year":"1996","journal-title":"Acta Neurochir."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1007\/s12070-022-03405-6","article-title":"Trigeminal Schwannoma\u2014Case Report of a Rare Tumour","volume":"75","author":"Dabas","year":"2023","journal-title":"Indian J. Otolaryngol. Head Neck Surg."},{"key":"ref_23","first-page":"449","article-title":"A Trigeminal Schwannoma Masked by Solely Vestibulocochlear Symptoms","volume":"31","author":"Evans","year":"2019","journal-title":"J. Am. Acad. Audiol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1080\/02688697.2020.1763257","article-title":"Successful Endoscopic Endonasal Surgery for Very Huge Trigeminal Schwannomas in Nasopharynx","volume":"35","author":"Nguyen","year":"2021","journal-title":"Br. J. Neurosurg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"627736","DOI":"10.3389\/fneur.2021.627736","article-title":"Analysis of Approaches in the Microsurgical Treatment of 102 Cases of Petroclival Meningioma in a Single Center","volume":"12","author":"Lin","year":"2021","journal-title":"Front. Neurol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"499","DOI":"10.1007\/s13244-018-0604-7","article-title":"Neuroimaging of Meckel\u2019s Cave in Normal and Disease Conditions","volume":"9","author":"Malhotra","year":"2018","journal-title":"Insights Imaging"},{"key":"ref_27","first-page":"ons291","article-title":"Meckel\u2019s Cave Tumors: Relation to the Meninges and Minimally Invasive Approaches for Surgery: Anatomic and Clinical Studies","volume":"67","author":"Muto","year":"2010","journal-title":"Neurosurgery"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"S155","DOI":"10.1016\/j.wneu.2014.08.003","article-title":"The Endoscopic Endonasal Approach to the Meckel\u2019s Cave Tumors: Surgical Technique and Indications","volume":"82","author":"Jouanneau","year":"2014","journal-title":"World Neurosurg."},{"key":"ref_29","first-page":"ons71","article-title":"The Front Door to Meckel\u2019s Cave: An Anteromedial Corridor via Expanded Endoscopic Endonasal Approach- Technical Considerations and Clinical Series","volume":"64","author":"Kassam","year":"2009","journal-title":"Neurosurgery"},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Mastantuoni, C., Cavallo, L.M., Esposito, F., d\u2019Avella, E., de Divitiis, O., Somma, T., Bocchino, A., Fabozzi, G.L., Cappabianca, P., and Solari, D. (2022). Midline Skull Base Meningiomas: Transcranial and Endonasal Perspectives. Cancers, 14.","DOI":"10.3390\/cancers14122878"},{"key":"ref_31","first-page":"1836","article-title":"Combined and Simultaneous Endoscopic Endonasal and Transorbital Surgery for a Meckel\u2019s Cave Schwannoma: Technical Nuances of a Mini-Invasive, Multiportal Approach","volume":"134","author":"Langdon","year":"2020","journal-title":"J. Neurosurg."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"e1491","DOI":"10.1016\/j.wneu.2018.11.090","article-title":"Endoscopic Endonasal Versus Transorbital Surgery for Middle Cranial Fossa Tumors: Comparison of Clinical Outcomes Based on Surgical Corridors","volume":"122","author":"Lee","year":"2019","journal-title":"World Neurosurg."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"403","DOI":"10.1016\/j.wneu.2016.03.017","article-title":"The Inferolateral Transorbital Endoscopic Approach: A Preclinical Anatomic Study","volume":"90","author":"Ferrari","year":"2016","journal-title":"World Neurosurg."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1007\/s10143-023-01980-y","article-title":"Endoscopic Transorbital Approach for Skull Base Lesions: A Report of 16 Clinical Cases","volume":"46","author":"Han","year":"2023","journal-title":"Neurosurg. Rev."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"e667","DOI":"10.1097\/SCS.0000000000004754","article-title":"Cavernous Sinus and Parasellar Region: An Endoscopic Endonasal Anatomic Cadaver Dissection","volume":"29","author":"Erdogan","year":"2018","journal-title":"J. Craniofacial Surg."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"553","DOI":"10.1055\/s-0039-1692639","article-title":"Endoscopic Endonasal Transpterygoid Approach to Sphenoid Sinus Lateral Recess Defects","volume":"81","author":"Bozkurt","year":"2020","journal-title":"J. Neurol. Surg. B Skull Base"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"967","DOI":"10.3171\/2009.10.JNS09157","article-title":"The endoscopic, endonasal, transmaxillary transpterygoid approach to the pterygopalatine fossa, infratemporal fossa, petrous apex, and the Meckel cave","volume":"113","author":"Hofstetter","year":"2010","journal-title":"J. Neurosurg."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"S121","DOI":"10.1016\/j.wneu.2014.07.036","article-title":"Endonasal endoscopic approaches to the paramedian skull base","volume":"82","author":"Prevedello","year":"2014","journal-title":"World Neurosurg."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"534","DOI":"10.2176\/nmc.ra.2017-0039","article-title":"Surgical Anatomy for the Endoscopic Endonasal Approach to the Ventrolateral Skull Base","volume":"57","author":"Oyama","year":"2017","journal-title":"Neurol. Med. Chir."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"332","DOI":"10.23736\/S0390-5616.18.04330-8","article-title":"Limits of endoscopic endonasal transpterygoid approach to cavernous sinus and Meckel\u2019s cave","volume":"62","author":"Hardesty","year":"2018","journal-title":"J. Neurosurg. Sci."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"V15","DOI":"10.3171\/2020.4.FocusVid.19904","article-title":"Expanded endoscopic endonasal transpterygoid transmaxillary approach for a giant trigeminal schwannoma","volume":"2","author":"Zachariah","year":"2020","journal-title":"Neurosurg. Focus. Video"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/21\/6847\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T21:14:02Z","timestamp":1760130842000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/21\/6847"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,10,30]]},"references-count":41,"journal-issue":{"issue":"21","published-online":{"date-parts":[[2023,11]]}},"alternative-id":["jcm12216847"],"URL":"https:\/\/doi.org\/10.3390\/jcm12216847","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,10,30]]}}}