Clinical characteristics of patients with asymptomatic intracranial meningiomas and results of their surgical management

Postoperative Vision-Related Quality of Life After Sphenoid Wing Meningioma Surgery: Impact of Radiomic Shape Features and Age

Background: Sphenoid wing meningiomas (SWM) frequently compress structures of the optic pathway, resulting in significant visual dysfunction characterized by vision loss and visual field deficits, which profoundly impact patients' quality of life (QoL), daily activities, and independence. The objective of this study was to assess the impact of SWM surgery on patient-reported outcome measures (PROMs) regarding postoperative visual function. Methods: The Visual Function Score Questionnaire (VFQ-25) is a validated tool designed to assess the impact of visual impairment on quality of life. The questionnaire was distributed to a previously published study population in which shape radiomics were correlated with new cranial nerve deficits after SWM surgery. Results: A total of 42 patients (42/74; 56.8%) responded to the questionnaire. Of the 42 patients, 30 were female (71%) and 12 were male (29%). The multivariable analysis demonstrated that lower sphericity reflecting irregular SWM shape was associated with poorer VFQ-25 (OR: 6.8, 95% CI: 1.141.8, p = 0.039), while age was associated with lower VFQ-25 (OR: 27, 95% CI: 2.7-272.93, p = 0.005), too. Analysis of the subcategories of the VFQ-25 revealed significantly reduced general vision (p = 0.045), social functioning (p = 0.045), and peripheral vision (p = 0.017) in those with SWM with low sphericity. Conclusions: The study highlights that SWM surgery impacts postoperative visual function, with age and irregular SWM shape being associated with poorer postoperative VFQ-25 scores. VFQ-25 is a feasible tool to assess vision outcome in SWM surgery and has clinical potential for longitudinal follow-up evaluations. Irregular SWM shape should be considered during preoperative treatment planning and patient consultation regarding functional outcome.

Incidence and Risk Factors of Surgical Site Infection After Cranial Surgery for Patients with Brain Tumors: A Systematic Review and Meta-analysis

BACKGROUND

Surgical site infections after craniotomy (SSI-CRANs) are a serious adverse event given the proximity of the wound to the central nervous system. SSI-CRANs are associated with substantial patient morbidity and mortality. Despite the importance and recognition of this event in other surgical fields, there is a paucity of evidence in the neurosurgical literature devoted to SSI-CRAN specifically in patients after brain tumor surgery.

METHODS

Systematic searches of Medline, Embase, and Cochrane Central were undertaken. The primary outcome was the incidence of SSI-CRAN at 30 and 90 days. Secondary outcomes were risk factors for SSI-CRAN.

RESULTS

Thirty-seven studies reporting 91,907 patients with brain tumors who underwent cranial surgery were included in the meta-analysis. Pooled incidence of SSI-CRAN at 30 and 90 days was 4.03% (95% CI: 2.94%-5.28%, I2 = 97.3) and 6.17% (95% CI: 3.16%-10.07%, I2 = 97.3), respectively. Specifically, incidence of SSI-CRAN following surgery for posterior fossa tumors was the highest at 9.67% (95% CI: 5.98%-14.09%, I2 = 75.5). Overall pooled incidence of readmission within 30 days and reoperation due to SSI-CRAN were 13.9% (95% CI: 12.5%-15.5%, I2 = 0.0) and 16.3% (95% CI: 5.4%-31.3%, I2 = 72.9), respectively. Risk factors for SSI-CRAN included reintervention (risk ratio [RR] 1.58, 95% CI: 1.22-2.04, I2 = 0.0), previous radiotherapy (RR 1.69, 95% CI: 1.20-2.38, I2 = 0.0), longer duration of operation (mean difference 64.18, 95% CI: 3.96-124.40 minutes, I2 = 90.3) and cerebrospinal fluid (CSF) leaks (RR 14.26, 95% CI: 2.14-94.90, I2 = 73.2).

CONCLUSIONS

SSI-CRAN affects up to 1 in 14 patients with brain tumors. High-risk groups include those with reintervention, previous radiotherapy, longer duration of operation, and CSF leaks. Further prospective studies should focus on bundles of care that will reduce SSI-CRAN.

A nomogram for predicting the risk of major postoperative complications for patients with meningioma

PURPOSE

To identify risk factors for major postoperative complications in meningioma patients and to construct and validate a nomogram that identify patients at high risk of these complications.

METHODS

The medical records of meningioma patients who underwent surgical resection in our hospital from January 2018 to December 2020 were collected. The patients were divided into a training set (815 cases from the main campus in 2018 and 2019) and a validation set (300 cases from two other campuses in 2020). Major postoperative complications were defined as any new neurological deficits and complications classified as Clavien-Dindo Grading (CDG) II or higher. Univariate and multivariate analyses were conducted using the training set to identify independent risk factors. A nomogram was constructed based on these results. And then validated the nomogram through bootstrap re-sampling in both the training and validation sets. The concordance index (C-index) and the area under the curve (AUC) were used to assess the discriminative ability of the nomogram. The Hosmer-Lemeshow test was performed to evaluate the goodness-of-fit. The optimal cutoff point for the nomogram was calculated using Youden's index.

RESULTS

In the training set, 135 cases (16.56%) experienced major postoperative complications. The independent risk factors identified were male sex, recurrent tumors, American Society of Anesthesiologists (ASA) class III-IV, preoperative Karnofsky Performance Scale (KPS) score < 80, preoperative serum albumin < 35 g/L, tumor in the skull base or central sulcus area, subtotal tumor resection (STR), allogeneic blood transfusion, and larger tumor size. A nomogram was constructed based on these risk factors. It demonstrated good predictive performance, with a C-index of 0.919 for the training set and 0.872 for the validation set. The area under the curve (AUC) > 0.7 indicated satisfactory discriminative ability. The Hosmer-Lemeshow test showed no significant deviation from the predicted probabilities. And the cutoff for nomogram total points was about 200 (specificity 0.881 and sensitivity 0.834).

CONCLUSIONS

The constructed nomogram demonstrated robust predictive performance for major postoperative complications in meningioma patients. This model can be used by surgeons as a reference in clinical decision-making.

Incidental Meningiomas: Potential Predictors of Growth and Current State of Management

The rise in availability of neuroimaging has led to an increase in incidentally discovered meningiomas. These tumors are typically asymptomatic and tend to display slow growth. Treatment options include observation with serial monitoring, radiation, and surgery. Although optimal management is unclear, clinicians recommend a conservative approach, which preserves quality of life and limits unnecessary intervention. Several risk factors have been investigated for their potential utility in the development of prognostic models for risk assessment. Herein, the authors review the current literature on incidental meningiomas, focusing their discussion on potential predictive factors for tumor growth and appropriate management practices.

Role of risk factors, scoring systems, and prognostic models in predicting the functional outcome in meningioma surgery: multicentric study of 552 skull base meningiomas

Despite the importance of functional outcome, only a few scoring systems exist to predict neurologic outcome in meningioma surgery. Therefore, our study aims to identify preoperative risk factors and develop the receiver operating characteristics (ROC) models estimating the risk of a new postoperative neurologic deficit and a decrease in Karnofsky performance status (KPS). A multicentric study was conducted in a cohort of 552 consecutive patients with skull base meningiomas who underwent surgical resection from 2014 to 2019. Data were gathered from clinical, surgical, and pathology records as well as radiological diagnostics. The preoperative predictive factors of functional outcome (neurologic deficit, decrease in KPS) were analyzed in univariate and multivariate stepwise selection analyses. Permanent neurologic deficits were present in 73 (13.2%) patients and a postoperative decrease in KPS in 84 (15.2%). Surgery-related mortality was 1.3%. A ROC model was developed to estimate the probability of a new neurologic deficit (area 0.74; SE 0.0284; 95% Wald confidence limits (0.69; 0.80)) based on meningioma location and diameter. Consequently, a ROC model was developed to predict the probability of a postoperative decrease in KPS (area 0.80; SE 0.0289; 95% Wald confidence limits (0.74; 0.85)) based on the patient's age, meningioma location, diameter, presence of hyperostosis, and dural tail. To ensure an evidence-based therapeutic approach, treatment should be founded on known risk factors, scoring systems, and predictive models. We propose ROC models predicting the functional outcome of skull base meningioma resection based on the age of the patient, meningioma size, and location and the presence of hyperostosis and dural tail.

Impact of peritumoral brain edema on pre- and postoperative clinical conditions and on long-term outcomes in patients with intracranial meningiomas

BACKGROUND

Peritumoral brain edema (PTBE) is a common complication related to intracranial meningiomas. In several studies, researchers have investigated the pathogenesis of PTBE, and the factors involved in its development in patients with intracranial meningiomas have been reported. However, very little is known about the clinical effect of PTBE on patients with intracranial meningiomas; therefore, a systematic examination of this matter is necessary.

METHODS

In this study, we performed a systematic examination of 696 patients with primary intracranial meningiomas to assess the effect of preoperative PTBE on preoperative symptoms, neurological deficits and postoperative complications, and long-term outcomes with a follow-up period of 16.8 years. We performed a univariate analysis and multiple regression for specific outcomes and adjusted for other relevant clinical factors.

RESULTS

A total of 627 (90.1%) patients were symptomatic preoperatively. One hundred eighty-eight (90.8%) patients with small to moderate PTBE and 125 (98.4%) patients with severe PTBE presented with symptoms significantly more often than the 314 (86.7%) patients without PTBE (p < 0.001, univariate analysis). Cognitive deficits, palsy and seizure were significantly more present, preoperatively, in patients with PTBE than in patients without PTBE (p < 0.001, univariate analysis). Two hundred fifty-five (36.6%) patients experienced surgical and systemic complications postoperatively. The complication rate was significantly higher in patients with PTBE; 41.5% for patients with small to moderate PTBE and 52.8% for patients with severe PTBE, compared to 28.2% of patients without PTBE (p < 0.001, univariate analysis). Furthermore, pre- and postoperative KPS scores were significantly lower in patients with PTBE (p < 0.001). Patients with PTBE required additional medical support significantly more often (p < 0.001) and had a significantly longer hospital stay (p < 0.001). The mortality rate was higher in patients with PTBE immediately after surgery and in the follow-up period; however, the difference was not significant. The neurological condition of all patients improved in the follow-up and did not show significant differences between patients with and without preoperative PTBE (p = 0.6361). Multiple logistic regression analyses revealed a significant association between PTBE and the presence of preoperative cognitive deficits, the incidences of seizure and postoperative complications, and low pre- and postoperative KPS scores.

CONCLUSIONS

Preoperative PTBE significantly increased the incidences of specific preoperative symptoms, neurological deficits and postoperative complications in patients with intracranial meningiomas. After surgery, patients with preoperative PTBE required medical support significantly more often than patients without PTBE. However, all patients had favorable outcomes after surgery.

Surgical complications and recurrence factors for asymptomatic meningiomas: a single-center retrospective study

PURPOSE

Observation is the first management option in asymptomatic meningiomas, but when an enlargement or mass effect is observed, surgery is indicated. This study is aimed at exploring risk factors for complications and recurrence after surgery for asymptomatic meningioma. We also examined the impact of preoperative tumor embolization, which is considered controversial.

METHODS

We retrospectively reviewed 109 patients with primary asymptomatic meningiomas surgically treated at our institute between April 2007 and March 2021. Patients who only had headaches as a nonspecific complaint were included in the asymptomatic group. Complications, time to recurrence, and Glasgow Outcome Scale (GOS) score were the endpoints of the study. Risk factors for complications and recurrence were explored. Moreover, the effect of the resection on nonspecific headaches was also explored.

RESULTS

The permanent postoperative complication rate related to the surgical procedure was 1.8%. Of the total, 107 patients (98.2%) with asymptomatic meningiomas who were surgically treated achieved a GOS score of 5 1 year after the operation. Preoperative headache was present in 31 patients and improved postoperatively in 21 patients. Multivariate analysis using the Cox proportional hazard model showed that preoperative tumor embolization with > 80% resolution of tumor staining (p < 0.001) was negatively related to recurrence, whereas age (p = 0.046) and Simpson grade IV resection (p = 0.041) were positively related to recurrence.

CONCLUSION

Although surgery for asymptomatic meningiomas can, in many cases, be safe, it is not free of complications Thus, surgical intervention for asymptomatic meningiomas should be considered cautiously. However, more than half the patients with headaches showed improvement. Simpson grade IV resection cases should be assessed for recurrence, and preoperative tumor embolization might be effective in controlling recurrence.

[Risk factors in neurosurgeries: a cohort study in northern BrazilFactores de riesgo en neurocirugía: un estudio de cohorte en el norte de Brasil]

Introduction

Neurosurgical patients are at high risk of local and systemic complications that can increase the length of stay and the risk of death. This study aims to assess the incidence of healthcare-related infections and associated risk factors in patients undergoing neurosurgery.

Materials and Methods

prospective cohort study, carried out in a large hospital in the state of Rondonia, in the period from 2018 to 2019, including 36 patients.

Results

The incidence of healthcare-related infections was 19.4 per 100 patients (95% CI: 8,19 - 36,02). The use of nasoenteral tube increased the risk of HAI by 6.5 times (95% CI: 1,26 - 33,5), mechanical ventilation increased 5.52 times the risk (95% CI: 1,23 - 24,6), the presence of tracheostomy increased six times (95% CI: 1.34 - 26.8) and invasive examination increased the risk by 6.79 to have infection (95% CI: 1,31 - 35,05). In the adjusted analysis, the variables were not statistically significant.

Discussion

The incidence of infections was higher than in regions with better socioeconomic conditions, which may be related to lower adherence to good care practices.

Conclusion

in neurosurgeries, in addition to surgical site infections, other topographies should also be considered for investigation of infection. The use of invasive devices has been associated with the occurrence of healthcare-related infections, so good practices in their use are essential when referring and using these devices.

Visual Symptoms Outcomes in Cavernous Sinus Radiosurgery and a Systematic Review

Introduction

The complex anatomy of the cavernous sinus confers a true challenge when it comes to safe tumor resection. Due to its non-invasive nature, stereotactic radiosurgery (SRS) is expected to have lower mortality and morbidity rates than microsurgery. The purpose of this study was to evaluate clinical results regarding visual symptoms after SRS for benign tumors invading the cavernous sinus. We also conducted a systematic literature review to provide a robust analysis regarding visual outcomes.

Methods

The study included 58 patients (43 women and 15 men; mean age: 52 years) with benign tumors invading the cavernous sinus (27 pituitary adenomas and 31 meningiomas) who underwent SRS with different platforms between August 2011 and December 2021. Of these, 26 patients underwent surgery before SRS, and the remaining 32 had SRS as first-line therapy. We identified symptoms involving cranial nerves (CN) II, III, IV, and VI in 38 patients at the time of SRS. We conducted a systematic review to identify all original studies assessing visual outcomes. We searched PubMed, the Latin American and Caribbean Health Sciences Literature index, and Google Scholar using the Medical Subject Heading search terms “radiosurgery” and “cavernous sinus” for valid studies published until January 31, 2022.

Results

Regarding pituitary adenomas, median tumor volume was 2.05 cc, 3.12 cc, and 2.39 cc for Gamma Knife (GK), CyberKnife (CK), and tomotherapy (Tomo), respectively. Median doses were 14 Gy for GK, 17 Gy for CK, and 15 Gy for Tomo. For meningiomas, median tumor volume was 10.2 cc, 2.62 cc, and 16.3 cc for GK, CK, and Tomo, respectively. The median dose was 14 Gy for GK, 14 Gy for CK, and 14.5 Gy for Tomo. The overall tumor control rate was 100% with a median follow-up of 33 months (range: 6-128 months). A reduction of >30% in total tumor size per the Response Evaluation Criteria in Solid Tumors (RECIST) classification was documented in seven patients (RECIST II; 12.1%), 51 patients (87.9%) had stable disease (RECIST III), and no increase in tumor volume was documented in any patient. Visual symptoms improved in 51.7% of patients. In the systematic review, the mean visual improvement was 36% (range: 25.8-42.5%).

Conclusion

SRS is an effective treatment for benign tumors invading the cavernous sinus. In this series, patients who underwent SRS as a primary treatment showed improvement in pre-existing cranial neuropathy and visual symptoms. Given the natural history of these tumors, which tend to grow and cause visual alternations, treating asymptomatic patients is a feasible approach worth considering for the appropriate patients.

Comparison of outcomes of surgery for intracranial meningioma in elderly and young patients - A systematic review and meta-analysis

OBJECTIVE

The proportion of elderly patients with intracranial meningiomas is increasing as the life expectancy has improved. Increasing age is classically believed to be associated with higher perioperative morbidity and mortality in neurosurgical patients.

METHODS

We performed a systematic literature search in 'PUBMED' and 'EMBASE' databases and reviewed all the studies comparing outcomes of surgery between young and elderly patients with intracranial meningiomas (IM). Data related to 3-month mortality rates, length of hospital stay and complications, preoperative status and comorbidity, meningioma size, location, histology, peritumoral edema, and grade of excision were extracted and analyzed.

RESULTS

Thirteen retrospective studies fulfilled the eligibility criteria out of the 893 reviewed articles. Pooled analysis showed that the 3-month mortality rate (4.65% versus 1.42%) and length of stay (10d versus 6.8d) for elderly patients were significantly higher as compared to the young population. The rates of cardio-respiratory complications (16.3% v/s 8.3%), intracranial hemorrhage (10.2% v/s 4.2%) and new-onset neurologic deficit (20.7% v/s 10.1%) were also significantly high in the elderly group as compared to the young patients. Moreover, a higher prevalence of associated comorbidities and poor performance score was noted in the elderly patients of IM.

CONCLUSIONS

The overall mortality rate and rates of perioperative complications (cardio-respiratory, neurologic, intracranial hemorrhage) after surgery in elderly patients with IM patients are higher as compared to young patients and should be kept in mind when formulating treatment strategy for IM in this patient population.

Preoperative Prediction of Meningioma Consistency via Machine Learning-Based Radiomics

Objectives

The aim of this study was to establish and validate a radiomics nomogram for predicting meningiomas consistency, which could facilitate individualized operation schemes-making.

Methods

A total of 172 patients was enrolled in the study (train cohort: 120 cases, test cohort: 52 cases). Tumor consistency was classified as soft or firm according to Zada’s consistency grading system. Radiomics features were extracted from multiparametric MRI. Variance selection and LASSO regression were used for feature selection. Then, radiomics models were constructed by five classifiers, and the area under curve (AUC) was used to evaluate the performance of each classifiers. A radiomics nomogram was developed using the best classifier. The performance of this nomogram was assessed by AUC, calibration and discrimination.

Results

A total of 3840 radiomics features were extracted from each patient, of which 3719 radiomics features were stable features. 28 features were selected to construct the radiomics nomogram. Logistic regression classifier had the highest prediction efficacy. Radiomics nomogram was constructed using logistic regression in the train cohort. The nomogram showed a good sensitivity and specificity with AUCs of 0.861 and 0.960 in train and test cohorts, respectively. Moreover, the calibration graph of the nomogram showed a favorable calibration in both train and test cohorts.

Conclusions

The presented radiomics nomogram, as a non-invasive prediction tool, could predict meningiomas consistency preoperatively with favorable accuracy, and facilitated the determination of individualized operation schemes.

Meningioma surgical outcomes and complications in patients aged 75 years and older

OBJECTIVE

Meningioma incidence increases with age, yet limited data exist on how comorbidities impact complication rates in elderly patients undergoing meningioma resection. The objective of this study was to report surgical outcomes and identify risk factors for perioperative complications.

METHODS

We performed a retrospective study of patients 75 years and older undergoing meningioma resection. Outcomes included survival and complications. Major complications were those requiring surgical intervention or causing permanent neurological deficit. Recursive partitioning, Kaplan-Meier survival, univariate and multi-variate (MVA) analyses were performed.

RESULTS

From 1996 to 2014, 103 patients with a median age of 79 years (IQR 77-83 years) underwent cranial meningioma resection. Median follow-up was 5.8 years (IQR 1.7-8.7 years). Median actuarial survival was 10.5 years. Complications occurred in 32 patients (31.1%), and 13 patients (12.6%) had multiple complications. Major complications occurred in 16 patients (15.5%). Increasing age was not a significant predictor of any (p = 0.6408) or major complication (p = 0.8081). On univariate analysis, male sex, Charlson Comorbidity Index greater than 8, and cardiovascular comorbidities were significantly associated with major complications. On MVA only cardiovascular comorbidities (OR 3.94, 95% CI 1.05-14.76, p = 0.0238) were significantly associated with any complication. All patients with major complications had cardiovascular comorbidities, and on MVA male gender (OR 3.78, 95%CI 1.20-11.93, p = 0.0212) was associated with major complications.

CONCLUSIONS

Cardiovascular comorbidities and male gender are significant risk factors for complications after meningioma resection in patients aged 75 years and older. While there is morbidity associated with meningioma resection in this cohort, there is also excellent long-term survival.

Nation-wide Brain Tumor Registry-based Study of Intracranial Meningioma in Japan: Analysis of Surgery-related Risks

Although surgical resection is the most preferred treatment for intracranial meningiomas, a detailed analysis of the surgery-related risks based on large population data has not been conducted to date. In this study, we analyzed the nation-wide brain tumor registry to assess the surgical risk factors for intracranial meningiomas to provide information for an optimal treatment strategy. Data of 4081 meningioma patients who underwent initial resection between 2001 and 2008 were extracted from the Brain Tumor Registry of Japan (BTRJ) database and reviewed for postoperative mortality, aggravation of Karnofsky Performance Score (KPS), and complications. The total in-hospital mortality rate was 0.59%. Male sex and tumor size ≥30 mm were independent risk factors for mortality. Among 4081 cases, 4.4% of patients had KPS that were lowered by 20 or more points at the time of discharge after surgery. Age ≥65 years, higher WHO grading, tumor location at the skull base, tumor size ≥30 mm, and non-gross total resections were associated with lowering of KPS scores by 20 or more points. The overall incidence of surgical complications was 19.3%. The rate of occurrence of new postoperative seizure in patients with supratentorial meningioma was 10.9%. All complications except for vascular complications occurred with significantly lower frequencies in asymptomatic patients than in symptomatic patients. Our results provide useful information regarding the surgical risks when surgical intervention is being considered for intracranial meningiomas. Surgery is an important option for asymptomatic meningiomas as the mortality rate and complication rate in the current study were sufficiently low.

In-Hospital Complications After Surgery in Elderly Patients with Asymptomatic or Minor Symptom Meningioma: A Nationwide Registry Study

BACKGROUND

Asymptomatic or minor symptom meningiomas (AMSMs) in the elderly are incidental findings, with no consensus reached on the optimal management strategy. In the present study, we aimed to determine the surgical risk factors for elderly patients with AMSMs using a nationwide registry database in Japan.

METHODS

We identified patients with surgically treated AMSMs using the Diagnosis Procedure Combination database from 2010 to 2015 and reviewed the medical records for age (<65 years; pre-elderly, 65-74 years; and elderly, ≥75 years), sex, Barthel index (BI) score, medical history, tumor location, and complications. An AMSM was defined by a BI score of 100 points at admission. The risk factors for all stroke complications, BI deterioration at discharge, and in-hospital mortality were determined using multivariate logistic regression analyses.

RESULTS

From a total of 10,535 patients with meningioma, 6628 were included. Advanced age was a significant risk factor (odds ratio, 3.54; 95% confidence interval, 2.80-4.46) for BI deterioration but not for all-stroke complications or in-hospital mortality. Midline and posterior fossa tumors, diabetes mellitus, and chronic heart disease were significant risk factors for in-hospital mortality.

CONCLUSIONS

For elderly patients with surgically treated AMSMs, advanced age was a prominent risk factor for functional decline at discharge. Our study identified several factors that should be evaluated before proceeding with surgery for AMSMs in elderly and pre-elderly patients. These findings could, not only improve decision-making among clinicians treating patients with AMSMs, but also help in predicting the results of surgery for elderly patients with AMSMs.

Indications and outcome in surgically treated asymptomatic meningiomas: a single-center case-control study

BACKGROUND

Many meningiomas are detected incidentally and remain asymptomatic until intervention. The goal of this study was to describe the management and outcome in this group of surgically treated asymptomatic meningiomas.

METHODS

From 2004 to 2017, 45 patients with asymptomatic meningioma were surgically treated at Sahlgrenska University Hospital, and their medical records and imaging data were analyzed. The asymptomatic cases were matched with symptomatic ones with respect to age at diagnosis, location, WHO (World Health Organization) grade, and Simpson grade.

RESULTS

Time from diagnosis to surgery differed between the asymptomatic and symptomatic patients (8.6 vs. 1.3 months; p < 0.001). Of symptomatic patients, 32.6% still used anti-epileptic drugs > 1 year after surgery, compared with 7.7% of the asymptomatic (p = 0.003). Thirty-day complication rate was significantly higher among the asymptomatic cases (35.6% vs. 24.4%; 0.001), as well as the proportion of older asymptomatic individuals (> 70 years) experiencing postoperative complication compared with symptomatic patients of the same age group.

CONCLUSION

As expected, asymptomatic cases had smaller tumors and waited longer for surgery. Surprisingly, complication rate was significantly higher among asymptomatic cases compared with their symptomatic control. Taken into account that many asymptomatic tumors are removed surgically due to patient's wish, one might suggest a more restrictive approach, especially in the elderly.

Postoperative Neurological Complications after a Cranial Surgery: A Multicentre Prospective Observational Study

Background  Cranial surgery is associated with multiple postoperative complications varying from simple nausea and vomiting to devastating complications such as stroke and death. This multicentre collaborative effort was envisioned to collect observational data regarding postoperative complications in cranial surgeries among the Indian population. The aim of this study was to describe the postoperative neurological complications occurring within the first 24 hours after surgery and to identify the predictive factors.

Methods Data was collected from three participating tertiary care academic institutions. The study was prospective, observational, multicentre design with data collected over a period of two months or 100 cases, whichever is earlier, from each participating institute. A predesigned Microsoft excel sheet was distributed among all three centers to maintain uniformity. All patients aged 18 years and above of both sexes undergoing elective or emergency craniotomies were included in the study. The postoperative neurological complications (within 24 hours) assessed were: (1) Neurological deficit (ND) defined as new focal neurological motor deficit relative to preoperative status. (2) Sensorium deterioration (SD) defined as reduction in Glasgow coma score (GCS) by 2 or more points compared with preoperative GCS. (4) Postoperative seizures (SZs) defined as any seizure activity. All possible variables associated with the above neurological complications were tested using Chi-square/Fisher exact test or Mann–Whitney U test. The predictors, which were statistically significant at p < 0.2, were entered into a multiple logistic regression model. Alpha error of 5% was taken as significant.

Results Data from three institutions was collected with a total of 279 cases. In total, there were 53 (19%) neurological complications. There were 28 patients with new postoperative NDs (10.04%), 24 patients had SD (8.6%), and 17 patients had seizures (6.1%). Neurological deficits were significantly less in institution 2. Diagnosis of traumatic brain injury (TBI) was associated with very low risk of ND, and vascular pathology was associated with higher chance of a ND. The duration of anesthesia was found to be significantly predictive of SD (OR/CI = 1.01 / 1–1.02). None of the factors were predictive of PS.

Conclusion The incidences of postoperative ND, SD and postoperative seizures were 10%, 8.6%, and 6.1%, respectively. Studies with a much larger sample size are required for a better and detailed analysis of these complications.

A practical predictor of the growth potential of benign meningiomas: Hypointensity of surface layer in T2-weighted magnetic resonance imaging

BACKGROUND

Accurate evaluation of proliferative potential is particularly important in the clinical management of individual patients with meningiomas. We introduce a new feature in the parenchyma of meningioma, namely, hypointensity of the surface layer (HSL), on T2-weighted MR images and compare it with a cellular proliferation index and growth speed.

MATERIALS AND METHODS

We retrospectively analyzed the records of consecutive patients with WHO grade I meningiomas in two institutes: an operated group with 124 meningiomas resected in one institute, and an observed group with 89 meningiomas monitored without surgery in the other. Proliferative potential was evaluated using the MIB-1 labeling index (MIB-1 LI) for the operated group and using the relative growth rate on serial MR images for the observed group.

RESULTS

In the operated group, 60 (48.4%) meningiomas exhibited HSL. HSL-positive meningiomas were significantly smaller in size and more often calcified than HSL-negative ones. Univariate analysis showed that HSL negativity, large size, no calcification, and surrounding brain edema were significantly associated with high MIB-1 LI (p < 0.05). Multivariate analysis demonstrated that only HSL was significantly related to MIB-1 LI (p = 0.001). HSL did not correlate with tumor recurrence after resection. In the observed group, 43 (48.3%) meningiomas exhibited HSL and they presented a significantly slow relative growth rate.

CONCLUSIONS

HSL is a simple and new radiological feature indicative of low proliferative potential and a low risk of enlargement of meningiomas. The presence or absence of HSL may serve as a key parameter for the selection of aggressive treatment or active observation.

A National Consensus Survey for Current Practice in Brain Tumor Management II: Diffuse Midline Glioma and Meningioma

Background

The Guideline Working Group of the Korean Society for Neuro-Oncology (KSNO) conducted a nationwide questionnaire survey for diverse queries faced in the treatment of brain tumors. As part II of the survey, the aim of this study is to evaluate the national patterns of clinical practice for patients with diffuse midline glioma and meningioma.

Methods

A web-based survey was sent to all members of the KSNO by email. The survey included 4 questions of diffuse midline glioma and 6 questions of meningioma (including 2 case scenarios). All questions were developed by consensus of the Guideline Working Group.

Results

In the survey about diffuse midline glioma, 76% respondents performed histologic confirmation to identify H3K27M mutation on immunohistochemical staining or sequencing methods. For treatment of diffuse midline glioma, respondents preferred concurrent chemoradiotherapy with temozolomide (TMZ) and adjuvant TMZ (63.8%) than radiotherapy alone (34.0%). In the survey about meningioma, respondents prefer wait-and-see policy for the asymptomatic small meningioma without peritumoral edema. However, a greater number of respondents had chosen surgical resection as the first choice for all large size meningiomas without exception, and small size meningiomas with either peritumoral edema or eloquent location. There was no single opinion with major consensus on long-term follow-up plans for asymptomatic meningioma with observation policy. As many as 68.1% of respondents answered that they would not add any adjuvant therapies for World Health Organization grade II meningiomas if the tumor was totally resected including dura.

Conclusion

The survey demonstrates the prevailing clinical practice patterns for patients with diffuse midline glioma and meningioma among members of the KSNO. This information provides a point of reference for establishing a practical guideline in the management of diffuse midline glioma and meningioma.

Surgical outcomes after reoperation for recurrent non-skull base meningiomas

OBJECTIVE

Recurrent meningiomas are primarily managed with radiation therapy or repeat resection. Surgical morbidity after reoperation for recurrent meningiomas is poorly understood. Thus, the objective of this study was to report surgical outcomes after reoperation for recurrent non-skull base meningiomas.

METHODS

A retrospective review of patients was performed. Inclusion criteria were patients with recurrent meningioma who had prior resection and supratentorial non-skull base location. Univariate and multivariate logistic regression and recursive partitioning analysis were used to identify risk factors for surgical complications.

RESULTS

The authors identified 67 patients who underwent 111 reoperations for recurrent supratentorial non-skull base meningiomas. The median age was 53 years, 49% were female, and the median follow-up was 9.8 years. The most common presenting symptoms were headache, weakness, and seizure. The WHO grade after the last reoperation was grade I in 22% of cases, grade II in 51%, and grade III in 27%. The tumor grade increased at reoperation in 22% of cases. Tumors were located on the convexity (52%), parasagittal (33%), falx (31%), and multifocal (19%) locations. Tumors involved the middle third of the sagittal plane in 52% of cases. In the 111 reoperations, 48 complications occurred in 32 patients (48%). There were 26 (54%) complications requiring surgical intervention. There was no perioperative mortality. Complications included neurological deficits (14% total, 8% permanent), wound dehiscence/infection (14%), and CSF leak/pseudomeningocele/hydrocephalus (9%). Tumors that involved the middle third of the sagittal plane (OR 6.97, 95% CI 1.5-32.0, p = 0.006) and presentation with cognitive changes (OR 20.7, 95% CI 2.3-182.7, p = 0.001) were significantly associated with complication occurrence on multivariate analysis. The median survival after the first reoperation was 11.5 years, and the 2-, 5-, and 10-year Kaplan-Meier survival rates were 91.0%, 68.8%, and 50.0%, respectively.

CONCLUSIONS

Reoperation for recurrent supratentorial non-skull base meningioma is associated with a high rate of complications. Patients with cognitive changes and tumors that overlap the middle third of the sagittal plane are at increased risk of complications. Nevertheless, excellent long-term survival can be achieved without perioperative mortality.

Treatment of Asymptomatic Meningioma With Gamma Knife Radiosurgery: Long-Term Follow-up With Volumetric Assessment and Clinical Outcome

BACKGROUND

Some patients are diagnosed with asymptomatic meningioma(s) after undergoing a screening CT and MRI for minor ailments or postresection.

OBJECTIVE

To help clinicians in decision making for treatment of asymptomatic meningiomas.

METHODS

A single center retrospective cohort study of 117 patients with 122 tumors treated with Gamma Knife radiosurgery (GKRS; Elekta AB, Stockholm, Sweden). Patients were followed with longitudinal imaging and clinical evaluations. Tumor volumetry and developments of new signs or symptoms after GKRS were the end points in the study.

RESULTS

Median patient age at GKRS was 60 yr (range 21-86 yr) with a median clinical follow-up of 53 mo (range 20-252 mo). The median pre-GKRS tumor volume was 3.6 ± 3.8 cc (±standard deviation). Tumors were treated with a median margin dose of 14 ± 2 Gy. At last follow-up, median tumor volume was 2.5 ± 3.6 cc. Radiological progression-free survival (PFS) rates were 97% and 94.4% at 5 yr and 10 yr, respectively. Clinical PFS rates were 86% and 70% at 5 yr and 10 yr, respectively. Development of neurological complications was seen in 21 (18%) patients, and 11 (52%) of them had undergone surgical resection prior to GKRS.

CONCLUSION

GKRS is a reasonable treatment strategy for asymptomatic meningiomas and compares favorably to natural history studies in terms of tumor control and neurological preservation. It results in relatively low morbidity in previously untreated meningiomas and serves as an appealing alternative treatment modality for recurrent meningiomas in asymptomatic patients.

Incidental intracranial meningiomas: a systematic review and meta-analysis of prognostic factors and outcomes

BACKGROUND

Incidental discovery accounts for 30% of newly-diagnosed intracranial meningiomas. There is no consensus on their optimal management. This review aimed to evaluate the outcomes of different management strategies for these tumors.

METHODS

Using established systematic review methods, six databases were scanned up to September 2017. Pooled event proportions were estimated using a random effects model. Meta-regression of prognostic factors was performed using individual patient data.

RESULTS

Twenty studies (2130 patients) were included. Initial management strategies at diagnosis were: surgery (27.3%), stereotactic radiosurgery (22.0%) and active monitoring (50.7%) with a weighted mean follow-up of 49.5 months (SD = 29.3). The definition of meningioma growth and monitoring regimens varied widely impeding relevant meta-analysis. The pooled risk of symptom development in patients actively monitored was 8.1% (95% CI 2.7-16.1). Associated factors were peritumoral edema (OR 8.72 [95% CI 0.35-14.90]) and meningioma diameter ≥ 3 cm (OR 34.90 [95% CI 5.17-160.40]). The pooled proportion of intervention after a duration of active monitoring was 24.8% (95% CI 7.5-48.0). Weighted mean time-to-intervention was 24.8 months (SD = 18.2). The pooled risks of morbidity following surgery and radiosurgery, accounting for cross-over, were 11.8% (95% CI 3.7-23.5) and 32.0% (95% CI 10.6-70.5) respectively. The pooled proportion of operated meningioma being WHO grade I was 94.0% (95% CI 88.2-97.9).

CONCLUSION

The management of incidental meningioma varies widely. Most patients who clinically or radiologically progressed did so within 5 years of diagnosis. Intervention at diagnosis may lead to unnecessary overtreatment. Prospective data is needed to develop a risk calculator to better inform management strategies.

Surgical outcomes after reoperation for recurrent skull base meningiomas

OBJECTIVE

Skull base meningiomas are surgically challenging tumors due to the intricate skull base anatomy and the proximity of cranial nerves and critical cerebral vasculature. Many studies have reported outcomes after primary resection of skull base meningiomas; however, little is known about outcomes after reoperation for recurrent skull base meningiomas. Since reoperation is one treatment option for patients with recurrent meningioma, the authors sought to define the risk profile for reoperation of skull base meningiomas.

METHODS

A retrospective review of 2120 patients who underwent resection of meningiomas between 1985 and 2016 was conducted. Clinical information was extracted from the medical records, radiology data, and pathology data. All records of patients with recurrent skull base meningiomas were reviewed. Demographic data, presenting symptoms, surgical management, outcomes, and complications data were collected. Kaplan-Meier analysis was used to evaluate survival after reoperation. Logistic regression was used to evaluate for risk factors associated with complications.

RESULTS

Seventy-eight patients underwent 100 reoperations for recurrent skull base meningiomas. Seventeen patients had 2 reoperations, 3 had 3 reoperations, and 2 had 4 or more reoperations. The median age at diagnosis was 52 years, and 64% of patients were female. The median follow-up was 8.5 years. Presenting symptoms included cranial neuropathy, headache, seizure, proptosis, and weakness. The median time from initial resection to first reoperation was 4.4 years and 4.1 years from first to second reoperation. Seventy-two percent of tumors were WHO grade I, 22% were WHO grade II, and 6% were WHO grade III. The sphenoid wing was the most common location (31%), followed by cerebellopontine angle (14%), cavernous sinus (13%), olfactory groove (12%), tuberculum sellae (12%), and middle fossa floor (5%). Forty-four (54%) tumors were ≥ 3 cm in maximum diameter at the time of the first reoperation. In 100 reoperations, 60 complications occurred in 30 cases. Twenty of the 60 complications required surgical intervention (33%). Complications included hydrocephalus (12), CSF leak/pseudomeningocele (11), wound infection (9), postoperative hematoma (4), venous infarction (1), and pneumocephalus (1). Postoperative neurological deficits included new or worsened cranial nerve deficits (10) and hemiparesis (3). There were no perioperative deaths in this series. On multivariate analysis, posterior fossa location was significantly associated with complications (OR 3.45, p = 0.0472). The 1-, 2-, 5-, and 10-year overall survival rates according to Kaplan-Meier analysis after the first reoperation were 94%, 92%, 88%, and 76%, respectively. The median survival after the first reoperation was 17 years.

CONCLUSIONS

Recurrent skull base meningiomas are surgically challenging tumors, and reoperation is associated with high morbidity and complication rates. Despite these cautionary data, repeat resection of recurrent skull base meningiomas in appropriately selected patients provides excellent long-term survival.

Neurosurgical treatment and outcome patterns of meningioma in Sweden: a nationwide registry-based study

Background

Surgery is the main treatment modality for intracranial meningiomas, but data on short-term surgical outcome are limited. The aim of this Swedish nationwide registry-based study was to benchmark the 30-day complication rate in a cohort of meningioma patients using data from the Swedish brain tumor registry (SBTR). Furthermore, we investigated outcomes for asymptomatic patients.

Methods

Data were collected from the SBTR for all adults with histopathologically verified intracranial meningioma between 2009 and 2015. Patient symptoms, tumor characteristics, and complications within 30 days postoperatively were analyzed.

Results

In total, 2324 patients, with a mean age of 58.7 years (SD 13.5), underwent surgery for intracranial meningioma and 14.1% of the patients were asymptomatic before the intervention. The most common symptom prior to treatment was focal deficit, which occurred in 1450 patients (62.4%). Moreover, within 30 days after surgery, 344 patients (14.8%) developed new neurological deficits and new-onset seizures occurred in 105 patients (4.5%), while 8.3% of asymptomatic patients developed neurological deficit and 3.7% new-onset seizures. Due to complications, reoperations were performed in 120 patients (5.2%). The postoperative 30-day mortality in the whole cohort was 1.5%.

Conclusion

This study benchmarks the 30-day complication rate after meningioma surgery and provides outcome data in the highly relevant group of asymptomatic patients using data from the Swedish brain tumor registry. Since surgical decision-making is a careful consideration of short-term risk versus long-term benefit, this information may be useful for both caregivers and patients.

Magnetic Resonance Imaging-Based Screening for Asymptomatic Brain Tumors: A Review

Brain tumors comprise 2% of all cancers but are disproportionately responsible for cancer-related deaths. The 5-year survival rate of glioblastoma, the most common form of malignant brain tumor, is only 4.7%, and the overall 5-year survival rate for any brain tumor is 34.4%. In light of the generally poor clinical outcomes associated with these malignancies, there has been interest in the concept of brain tumor screening through magnetic resonance imaging. Here, we will provide a general overview of the screening principles and brain tumor epidemiology, then highlight the major studies examining brain tumor prevalence in asymptomatic populations in order to assess the potential benefits and drawbacks of screening for brain tumors. IMPLICATIONS FOR PRACTICE: Magnetic resonance imaging (MRI) screening in healthy asymptomatic adults can detect both early gliomas and other benign central nervous system abnormalities. Further research is needed to determine whether MRI will improve overall morbidity and mortality for the screened populations and make screening a worthwhile endeavor.

Surgery for meningioma in the elderly and long-term survival: comparison with an age- and sex-matched general population and with younger patients

OBJECTIVE

The purpose of this study was to compare long-term prognosis after meningioma surgery in elderly and younger patients as well as to compare survival of elderly patients with surgically treated meningioma to survival rates for the general population.

METHODS

Five hundred meningioma patients (median follow-up 90 months) who underwent surgery between 1994 and 2009 were subdivided into “elderly” (age ≥ 65 years, n = 162) and “younger” (age < 65 years, n = 338) groups for uni- and multivariate analyses. Mortality was compared with rates for the age- and sex-matched general population.

RESULTS

The median age at diagnosis was 71 in the elderly group and 51 years in the younger group. Sex, intracranial tumor location, grade of resection, radiotherapy, and histopathological subtypes were similar in the 2 groups. High-grade (WHO Grades II and III) and spinal tumors were more common in older patients than in younger patients (15% vs 8%, p = 0.017, and 12% vs 4%, p = 0.001, respectively). The progression-free interval (PFI) was similar in the 2 groups, whereas mortality at 3 months after surgery was higher and median overall survival (OS) was shorter in older patients (7%, 191 months) than in younger patients (1%, median not reached; HR 4.9, 95% CI 2.75–8.74; p < 0.001). Otherwise, the median OS in elderly patients did not differ from the anticipated general life expectancy (HR 1.03, 95% CI 0.70–1.50; p = 0.886). Within the older patient group, PFI was lower in patients with high-grade meningiomas (HR 24.74, 95% CI 4.23–144.66; p < 0.001) and after subtotal resection (HR 10.57, 95% CI 2.23–50.05; p = 0.003). Although extent of resection was independent of perioperative mortality, the median OS was longer after gross-total resection than after subtotal resection (HR 2.7, 95% CI 1.09–6.69; p = 0.032).

CONCLUSIONS

Elderly patients with surgically treated meningioma do not suffer from impaired survival compared with the age-matched general population, and their PFI is similar to that of younger meningioma patients. These data help mitigate fears concerning surgical treatment of elderly patients in an aging society.

Complicações pós-operatórias em neurocirurgia eletiva e não eletiva

Resumo Objetivo Avaliar a incidência de complicações pós-operatorias e mortalidade entre pacientes submetidos a neurocirurcia eletiva e não eletiva. Metodos Estudo de coorte prospectivo com pacientes adultos, acompanhados desde o período pré-operatório até a alta hospitalar ou óbito. Resultados Foram incluídos 127 pacientes no grupo cirúrgico eletivo e 75 pacientes no grupo cirúrgico não eletivo. O grupo eletivo teve mais vômitos (p=0,010) e dor (p<0,001) e o grupo não eletivo apresentou mais hipertensão intracraniana (p=0,001), anisocoria (p=0,002), vasoespasmo cerebral (p=0,043), pupilas não fotorreagentes (p=0,006) e reoperação (p=0,046). A taxa de mortalidade foi de 5,5% no grupo de cirurgia eletiva e 26,7% no grupo de cirurgia não eletiva (p<0,001). Conclusão Os procedimentos eletivos em neurocirurgia estão relacionados a maior frequência de complicações sistêmicas, enquanto as cirurgias não eletivas tiveram taxas significativamente mais altas de complicações neurológicas e mortalidade.

Incidental Meningiomas: Management in the Neuroimaging Era

The number of patient imaging studies has increased because of precautious physicians ordering scans when a vague symptom is presented; subsequently, the number of incidental meningiomas detected has increased as well. These brain tumors do not present with related symptoms and are usually small. MRI and computed tomographic scans most frequently capture incidental meningiomas. Incidental meningiomas are managed with observation, radiation, and surgical resection. Ultimately, a conservative approach is recommended, such as observing an incidental meningioma and then only radiating if the tumor displays growth, whereas a surgical approach is to be used only when proven necessary.

Predicting outcome of epilepsy after meningioma resection

BACKGROUND

Surgical excision is the standard treatment for intracranial meningiomas. Epilepsy is a major cause of morbidity in meningioma patients, but postoperative control of epilepsy is not achieved in a substantial fraction of patients. The purpose of this study was to define risk factors for postoperative epilepsy.

METHODS

Patients treated for histologically confirmed intracranial meningioma at the University Hospital Zurich between 2000 and 2013 were retrospectively analyzed. Demographic, clinical, imaging, and electroencephalographic data were assessed. A binary regression model was applied to identify risk factors for postoperative epilepsy.

RESULTS

Of the 779 patients analyzed, epileptic seizures occurred in 244 (31.3%) patients before surgery and in 204 (26.6%) patients after surgery. Of the 244 patients with preoperative epilepsy, 144 (59.0%) became seizure-free after surgery; of the 535 patients without preoperative seizures, 104 (19.4%) suffered from epilepsy after surgery. Risk factors for postoperative epilepsy were preoperative epilepsy (odds ratio [OR]: 3.46 [95% confidence interval {CI}: 2.32-5.16]), major surgical complications including CNS infections (OR: 5.89 [95% CI: 1.53-22.61]), hydrocephalus (OR: 3.27 [95% CI: 1.35-7.95]), recraniotomy (OR: 2.91 [95% CI: 1.25-6.78]), and symptomatic intracranial hemorrhage (OR: 2.60 [95% CI: 1.17-5.76]) as well as epileptiform EEG potentials (OR: 2.52 [95% CI: 1.36-4.67]), younger age (OR: 1.74 [(95% CI: 1.18-2.58]), and tumor progression (OR: 1.92 [95% CI: 1.16-3.18]). Postoperative improvement or recovery from preoperative neurologic deficits was associated with improved seizure control (OR: 0.46 [95% CI: 0.25-0.85], P = .013).

CONCLUSION

We suggest prospective validation of a score ("STAMPE2") based on clinical findings, EEG, and brain-imaging measures to estimate postoperative seizure risk and guide anticonvulsant treatment in meningioma patients.