Commentary

The authors discovered one of the central tenets of contemporary cranial base surgery in a difficult way. One reason underlying current management strategies is to avoid such excessive blood loss in basal meningioma surgery. The concept is to make these lesions akin to convexity meningiomas, where the blood supply is exposed as an initial step in the operation. The blood supply then can be handled effectively and safely early in the procedure to make tumor resection less hazardous. In large olfactory meningiomas, the important point is to attack the tumor at the base;mdwhether intradurally or extradurally is not so important. I have performed both, and the result is the same. The blood supply is interrupted, and tumor resection is much easier. Blood loss is minimal, even without preoperative embolization. In my experience, preoperative embolization is unnecessary and only increases the patient's risk of morbidity. The goal in such cases is a Simpson grade 1 removal of the tumor. Resection is possible through either a unilateral or bilateral approach. The old-fashioned technique of exposing a tumor and diving in to debulk it with no thought to the blood supply should now be of only historical significance. In this era of more sophisticated cranial base surgery, no patients should be subjected to that type of approach.