Endoscopic Endonasal Approach Versus Transcranial Microsurgery in the Management of Skull Base Tumors With Optic Chiasm Compression: A Systematic Review and Meta-Analysis.

Skull base tumors, which compress the optic chiasm, include meningiomas, craniopharyngiomas, and pituitary macroadenomas and pose a serious neurosurgical problem. The best surgical route, that is, endoscopic endonasal (EEA) versus microsurgical transcranial (MTA), is still subject to debate. This systematic review and meta-analysis compares the clinical outcomes, visual function, and complications between these approaches. This research followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020. A comprehensive search of PubMed, EMBASE, and Scopus was performed until May 17, 2025, for comparative studies providing data on EEA vs. MTA for skull base tumors with documented optic apparatus involvement. The primary outcomes were the rate of gross total resection (GTR) and the rate of post-operative visual improvement. Secondary outcomes included the rates of cerebrospinal fluid (CSF) leak, new cranial nerve deficit, endocrine worsening, and other medical complications. Data were combined with a random-effects model, and heterogeneity was evaluated with the use of I² statistics. Seven studies met the inclusion criteria with a total of 582 patients (EEA: 287; MTA: 295). No significant difference could be found for GTR rates between EEA and MTA (RR = 1.09; 95% CI: 0.95-1.26; p = 0.22). EEA was associated with a significantly greater rate of post-operative visual improvement (RR = 1.32; 95% confidence interval: 1.08-1.61; p = 0.007). There was a significantly higher rate of CSF leak in the EEA cohort (RR = 3.45; 95% CI: 1.68-7.09; p = 0.0007). Rates of new cranial nerve deficits (RR = 0.65; 95% CI: 0.39-1.08; p = 0.10), endocrine worsening (RR = 0.87; 95% CI: 0.64-1.18; p = 0.37) did not differ significantly. For tumors at the skull base that compress the optic chiasm, EEA and MTA are associated with similar rates of gross total resection. EEA was associated with superior rates of visual function restoration, but with a greater risk for CSF leakage. The decision on which approach to take should be made on an individualized basis, weighing the importance of visual recovery versus the risk of developing certain complications.