State of the art and future perspectives on the management of spheno-orbital meningiomas: a meta-analysis comparing transorbital and transcranial approaches

Background: Spheno-orbital meningiomas (SOMs) are challenging skull base tumors requiring a balance between oncologic control and functional-aesthetic outcomes. Endoscopic transorbital approaches (ETOA) have recently gained popularity as minimally invasive alternatives to standard transcranial techniques, but comparative evidence is lacking. Methods: A systematic review and meta-analysis were conducted following PRISMA guidelines. PubMed/MEDLINE, Embase, and Scopus were searched from inception to the final search date. Studies reporting outcomes after ETOA or standard transcranial approaches were included. Primary outcomes included improvement in proptosis and visual function, extent of resection, and complications. Secondary outcomes included tumor progression and recurrence. Random-effects generalized linear mixed models were used to pool proportions. Mixed-effects meta-regression evaluated the association between approach and outcomes. Results: Fifty-three studies encompassing 2016 patients were included. A total of 155 (7.7%) ETOA and 1864 (92.3%) transcranial approaches were performed. Proptosis improvement was greater with ETOA (96% vs 72%) while visual improvement was similar (ETOA 31% vs standard 33%; p=0.857). Gross total resection (GTR) was lower with ETOA (21.1% vs 48.0%) and favored transcranial approaches after sensitivity analysis excluding influential studies (OR 5.00, p=0.047). Complication rates did not differ significantly between approaches, with a numerically lower rate observed after ETOA compared with standard transcranial surgery (18% vs 26%; p = 0.165). Median follow-up was shorter in the ETOA series (18 vs 52 months); recurrence and progression were lower after ETOA but likely influenced by follow-up duration. Conclusions: ETOA demonstrates superior proptosis improvement compared with standard transcranial approaches, comparable visual outcomes, and lower rates of GTR. Complication rates did not differ significantly. In appropriately selected SOMs, ETOA represents a valid surgical strategy within a tailored, goal-oriented approach, while standard transcranial techniques remain a workhorse for cases requiring extensive intracranial or dural control. Longer follow-up is required to clarify long-term tumor control.