Commentary

Mendenhall et al provide a concise, comprehensive review of the changing trends that have occurred in the past 2 decades in the management strategies for skull base meningiomas. The morbidity rate associated with surgical resection of various skull base meningiomas has decreased significantly with improved neuroimaging, better understanding of the anatomy, and the introduction of intraoperative neuronavigational techniques.

However, as we move into the third decade of modern skull base surgery, the emphasis has shifted from designing new approaches to establishing approaches that aim to preserve neural function. Skull base surgery in particular has evolved through certain phases of development: early skepticism, enthusiastic application, reconciliation with reports of morbidity and recurrences, and maturation in which goals and expectations translate into reasonable application. The authors succeed in making this point by citing large series from specialized skull base surgery centers and quoting their control, mortality, and morbidity rates.

In the past few years, radiosurgery has rapidly gained popularity as a treatment option for benign skull base tumors. Many series have described both early and long-term outcomes associated with the treatment of various benign intracranial neoplasms, including meningiomas. Again, however, as the authors note, the definition of tumor control for radiation and radiosurgery is much more accommodating compared with the definition of control after resection (which mandates complete resection of the tumor and its dural attachment). This controversy will continue to be a topic of debate between microsurgeons and radiosurgeons in the near future.