Types of Skull Base Surgery

Skull base surgery is generally performed in two ways. Although endoscopic surgery is the preferred method, open surgery may also be an option depending on the type and location of the growth:

Endoscopic Skull Base Surgery

This type of surgery usually does not require a large incision. It is typically performed using an endoscopic procedure, where the surgeon inserts instruments through the natural openings of the skull—such as the nose, mouth, or eye socket. This approach requires a specialized team, including neurosurgeons, ENT surgeons, maxillofacial surgeons, and radiologists.

Using the endoscope, surgeons can reach the growth through the nasal cavity and create a small opening in the meninges if necessary. Specialists often use imaging techniques like magnetic resonance imaging (MRI) or navigation technology (mapping) during the procedure to ensure complete removal of the growth.

Microsurgical Skull Base Surgery

This is the traditional approach to skull base surgery. It often involves incisions in the face or skull and removal of bone segments of varying sizes. A microscope is primarily used during the procedure. The surgical team usually includes neurosurgeons, ENT surgeons, maxillofacial surgeons, and plastic surgeons.

If needed, interventional neuroradiologists are also involved. The main goal is maximal tumor removal. Advanced technological devices such as CUSA (ultrasonic aspirator),lasers, navigation systems, and bipolar instruments are used for tumor excision. Various surgical approaches have been described to reach the tumor while minimizing damage to healthy tissue.

Neuronavigation-Guided Surgical Approach: Using scalp markers, surface landmarks, or laser indicators, the topographic anatomy of the patient’s head and face is mapped. The data is combined with the patient’s CT or MRI scans to plan the procedure with computer assistance. In the virtual environment, the planned images are translated to the real surgical field, determining the scalp incision, bone window removal, and most importantly, the three-dimensional target within the brain.

This planning and virtual guidance significantly aid in reaching the skull base region. The shortest, most accurate, and safest route to the lesion is selected. Surgeries performed using this technology offer numerous benefits to patients: reduced hospital stay, decreased risk of bleeding, shorter operation times, faster recovery to daily activities, and complete removal of the lesion without damaging critical tissues or the brain.

Intraoperative MRI

With the advancement of minimally invasive techniques, interest in intraoperative magnetic resonance imaging (ioMRI) has increased in interventional approaches and skull base surgery practice. It offers significant advantages due to multiplanar and real-time imaging capabilities as well as excellent soft tissue resolution. The procedure requires the use of MRI-compatible devices during surgery. As MRI technology has advanced, surgical technology has also evolved.

The magnetic field strength of ioMRI can range from 0.12T to 3T. Higher magnetic field strength improves image quality and functional capability. During surgery, ioMRI allows monitoring of the extent of tumor removal, increasing surgical confidence. It enables maximum tumor resection while preserving the functions of critical tissues. Professional centers performing skull base surgery routinely incorporate intraoperative MRI in their procedures.

Neuromonitoring

One of the advanced healthcare technologies used in skull base surgeries is neuromonitoring. Employed in head, neck, and spine-spinal cord surgeries, this technology prevents damage to nerve tissues during operations.

Neuromonitoring involves recording the patient’s motor, sensory, and reflex responses before surgery and continuously monitoring them throughout the procedure. The system indicates how close the surgery is to nerve tissue based on the signals it receives. It stimulates the patient’s nervous system and, most importantly, continuously records its activity. Skull base surgery involves working near very critical nerves and blood vessels, making this system essential to reduce the risk of complications.

Other Treatment Options

Besides surgical approaches, treatment for skull base diseases may include chemotherapy, radiotherapy, Gamma Knife, CyberKnife, and proton therapy.

Radiosurgery

Radiosurgery is a treatment method used for functional and lesion-related disorders. Although it contains the word “surgery,” it is not a traditional surgical method. It involves targeting diseased tissues with focused radiation without making an incision, achieving effects similar to surgical intervention.

Diseased tissues are identified using imaging techniques, and radioactive beams—such as gamma rays, protons, or X-rays—are directed to these areas. Outcomes can be as effective as conventional surgery. Radiosurgery can be delivered in a single session or fractionated over several days depending on the case. It maximizes the preservation of surrounding healthy tissue. During treatment, some methods require the patient to wear a head frame. High-resolution imaging with thin slices is used for treatment planning, which is completed with computer assistance.

Today, radiosurgery is routinely applied for benign and malignant tumors, pain, movement disorders, psychiatric conditions, epilepsy, and residual lesions after skull base surgery. Advanced devices such as Proton Beam, Gamma Knife, and CyberKnife have been developed over the past fifty years and are widely used.

Neuroendovascular Treatment

This refers to endovascular interventions for brain and neck vessels. The primary technique involves high-technology angiography and should be performed by specially trained physicians. Thin, specialized catheters are typically inserted through the femoral artery to reach the target area.

The diagnostic and treatment steps are monitored live on screens. One of the main advantages in skull base surgery is the ability to reduce tumor vascularization before surgery, minimizing intraoperative bleeding. This technique also maintains stable vital signs postoperatively and can be applied directly or as an adjunct for vascular lesions.

Postoperative Care and Neurorehabilitation

After skull base surgery, physicians and care teams support patients in quickly returning to daily activities. Neurorehabilitation aims to restore functions such as walking, speaking, and movement affected by nervous system disorders, reduce symptoms, and improve quality of life, helping patients achieve maximum independence.

It also addresses potential complications from skull base surgery, such as muscle weakness or abnormal tone, pain, difficulty walking, swallowing or speaking, and visual or balance coordination issues. Follow-up care includes clinical evaluations and periodic MRI and CT scans to monitor recovery.