Management of vascular injury during endoscopic surgery for anterior and middle cranial fossa meningiomas

Objective Skull base meningiomas, comprising ~25% of intracranial meningiomas, present therapeutic challenges due to their proximity to critical neurovascular structures. This review focuses on managing vascular injuries during endoscopic endonasal approaches (EEA) for anterior and middle cranial fossa meningiomas. Key anatomical landmarks, risk factors, and intraoperative strategies are synthesized, and a management algorithm is proposed. Methods A narrative literature review was conducted using PubMed and Embase, focusing on relevant studies addressing skull base meningiomas and EEA. Articles in English and Spanish were selected based on their relevance to the topic. Key data on patient demographics, tumor location, surgical techniques, and vascular injury management were extracted and synthesized. Results The review addresses anterior and middle cranial fossa meningiomas, including olfactory groove, tuberculum sellae, and cavernous sinus tumors. Risk factors for vascular injury include internal carotid artery displacement, tumor size, and surgeon experience. Preoperative imaging is essential to identify anatomical variations. Intraoperative vascular injuries require immediate control via muscle graft packing, microsuturing, or endovascular interventions such as embolization. Two illustrative cases highlight the complexity of managing vascular complications during EEA. Conclusions Successful management of vascular injuries during EEA for skull base meningiomas depends on meticulous preoperative planning, anatomical familiarity, and rapid intraoperative response. The proposed algorithm emphasizes preparedness for vascular events to minimize morbidity. Further studies are needed to validate these strategies and develop standardized clinical guidelines, improving safety and outcomes in endoscopic skull base surgery.