Practical Indications and Intraoperative Contribution of Neuroendoscopic Assistance During Exoscopic Skull Base Surgery: A Single-Center Experience.

BACKGROUND

Neuroendoscopy complements exoscopic visualization by providing angled views of anatomical structures hidden from the direct surgical line of sight. However, its practical indications and intraoperative contribution during exoscope-assisted skull base surgery have not been systematically evaluated. This study aimed to characterize the patterns of neuroendoscopic use and its observed intraoperative contribution during exoscope-assisted skull base surgery.

METHODS

We retrospectively reviewed 164 consecutive skull base procedures performed between March 2024 and June 2026. After excluding 58 pure endoscopic endonasal procedures, 106 exoscope-assisted procedures were analyzed. Neuroendoscopic assistance was used in 42 procedures, each performed in a different patient. Complete operative video recordings from these 42 procedures were retrospectively reviewed by two neurosurgeons, and the observed contribution of neuroendoscopy was classified as visualization-only, confirmatory, or decision-changing.

RESULTS

Neuroendoscopic assistance was used in 42 of 106 exoscope-assisted procedures (39.6%), including 30 aneurysms and 12 tumors. The most common indication was clip and perforator confirmation during aneurysm surgery (30/42, 71.4%). The observed contribution was classified as visualization-only in 8 procedures (19.0%), confirmatory in 20 (47.6%), and decision-changing in 14 (33.3%). Among the 14 decision-changing procedures, neuroendoscopic findings led to clip repositioning in 5 aneurysm procedures and additional tumor removal in 9 tumor procedures. No complications judged attributable to neuroendoscope insertion or manipulation were identified in the 42 procedures.

CONCLUSIONS

Neuroendoscopic assistance provided additional intraoperative information during exoscope-assisted skull base surgery, with decision-changing findings identified in 14 of 42 assisted procedures. These findings characterize the observed contribution and practical indications of neuroendoscopic assistance; however, the retrospective design, selective use of neuroendoscopy, and limited sample size preclude conclusions regarding comparative efficacy or safety.