Single versus multiple reoperations for recurrent intracranial meningiomas

PURPOSE

To identify the risk factors and management of the multiple recurrences and reoperations for intracranial meningiomas.

METHODS

Data of a neurosurgical series of 35 patients reoperated on for recurrent intracranial meningiomas were reviewed. Analyzed factors include patient age and sex, tumor location, extent of resection, WHO grade, Ki67-MIB1 and PR expression at initial diagnosis, time to recurrence; pattern of regrowth, extent of resection, WHO grade and Ki67-MIB1 at first recurrence were also analyzed. All these factors were stratified into two groups based on single (Group A) and multiple reoperations (Group B).

RESULTS

Twenty-four patients (69%) belonged to group A and 11 (31%) to group B. The age < 65 years, male sex, incomplete resection at both initial surgery and first reoperation, and multicentric-diffuse pattern of regrowth at first recurrence are risk factors for multiple recurrences and reoperations. In group B, the WHO grade and Ki67-MIB1 increased in further recurrences in 54% and 64%, respectively. The time to recurrence was short in 7 cases (64%), whereas 4 patients (36%) further recurred after many years. Eight patients (73%) are still alive after 7 to 22 years and 2 to 4 reoperations.

CONCLUSION

The extent of resection and the multicentric-diffuse pattern of regrowth at first recurrence are the main risk factors for multiple recurrences and reoperations. Repeated reoperations might be considered even in patients with extensive recurrent tumors before the anaplastic transformation occurs. In such cases, even partial tumor resections followed by radiation therapy may allow long survival in good clinical conditions.

Surgical Outcome of Torcula Herophili Meningioma: An Institutional Experience

INTRODUCTION

Resection of meningiomas (THMs) at the torcular Herophili poses challenges to surgeons due to complex regional anatomy. The current study aims to evaluate factors affecting the extent of resections, progression-free survival, and the role of radiation.

METHODS

We did a retrospective study of all the THM patients treated at our institute between May 1987 and June 2022. The demographic data, signs and symptoms, surgical notes, postoperative details, and radiotherapy were gathered retrospectively. Survival analysis was done with Kaplan-Meier tests along with predictors of the extent of resection as well as recurrence.

RESULTS

A total of 39 patients qualified to be included in the study, with 10 male patients (male:female 1:2.9) and an average age of 50.8 years. The average follow-up duration was 75.9 months. Simpson's grade 2 excision was achieved in 19 (48.7%) patients, followed by Simpson's grade 3 excision in 17 patients (43.6%). Progression-free survival in subtotal resection was 60 months, and 100 months in gross total resection. Statistically, the extent of the resection was determined by the involvement of sinuses/torcula and the number of quadrants involved around torcula. A total of 16 patients received radiosurgery for the residual or small reccurrence of the lesion. Follow-up revealed reccurrence in 5 cases.

CONCLUSIONS

Torcular meningiomas are relatively uncommon, described in few reports, and represent a therapeutic dilemma. Though some experts recommend complete removal of tumor and reconstruction of the sinus, others suggest maximum safe resection, followed by radiosurgery. The present study reflects reasonable control of the residual lesion with radiosurgery after maximum safe resection.

Minimally Invasive Approaches in the Surgical Treatment of Intracranial Meningiomas: An Analysis of 54 Cases

BACKGROUND

Intracranial meningiomas, being a fairly common disease in the population, often require surgical treatment, which, in turn, can completely heal the patient. The localization of meningiomas often influences treatment even if they are asymptomatic. By modernizing approaches to surgical treatment, it is possible to minimize intra- and postoperative risks, while achieving complete removal of the tumor. One of these methods is minimally invasive neurosurgery, the development of which in recent years allows it to compete with standard surgical methods. The purpose of this study was the objectification of minimally invasive approaches, such as the calculation of the craniotomy area and the ratio of craniotomy area to the resected tumor volume.

METHODS

The retrospective study consisted of a group of 54 consecutive patients who were operated on in our neurosurgery clinic specialized on minimally invasive neurosurgery. Preoperative planning was carried out using the Surgical Theater visualization platform. Using this system, the tumor volume and craniotomy surface area were calculated. During the analysis, the symptoms before and after the surgery, classification of tumors, postoperative complications, further treatment and follow-up results were assessed.

RESULTS

Twelve (22.2%) patients were men and 42 (77.8%) were women. The mean age of the group was 64.2 years (median 67.5). The craniotomy area ranged from 202 to 2,108 mm² (mean 631 mm²). Tumor volume ranged from 0.85 to 110.1 cm3 (mean 21.6 cm3). The craniotomy size of minimally invasive approaches to the skull base was 3-5 times smaller than standard approaches. Skull base meningiomas accounted for 19 cases (35.2%), convexity meningiomas for 26 cases (48.1%), and falx and tentorium meningiomas for 9 cases (16.7%). Three complications were reported: postoperative hemorrhage, CSF leakage, and ophthalmoplegia. Relapse was detected in 2 patients with a mean follow-up of 26.3 months (median 20).

CONCLUSION

Minimally invasive approaches in the surgical treatment of intracranial meningiomas reduce the possibility of operating trauma by several times; they are safe and sufficient for complete removal of the tumor.

A systematic review and meta-analysis of the effects of tranexamic acid in surgical procedure for intracranial meningioma

PURPOSE

During intracranial meningioma surgery, surgeons experience considerable blood loss. Tranexamic acid (TXA) is used to minimize blood loss in several neurosurgical settings. However, evidence and trials are lacking. Our objective is to establish the most recent evidence on TXA safety and efficacy in intracranial meningioma surgery.

METHODOLOGY

Based upon Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), the authors collected fully published English literature on the administration of tranexamic acid for patients undergoing intracranial meningioma surgery using the keywords ["tranexamic acid" and "meningioma"] and its synonyms from Cochrane Central Database, the WHO International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, and PubMed. The primary outcome of the current study was total blood loss. The secondary outcomes include individuals requiring blood transfusion, anesthesia duration, surgical duration, and complication rate. Each included studies' quality was assessed using the JADAD scale.

RESULTS

For qualitative and quantitative data synthesis, we included five RCTs (n = 321) with the mean age was 47.5 ± 11.9 years for the intervention group and 47.2 ± 11.9 years for the control group. Our meta-analysis showed that the administration of TXA is associated with decreased total blood loss of standardized mean difference (SMD) of -1.40 (95% CI [-2.49, -0.31]), anesthetic time SMD -0.36 (95% CI [-0.63, -0.09]), and blood transfusion requirements RR 0.58 (95% CI [0.34, 0.99]).

CONCLUSIONS

The current study showed that TXA was associated with reduced intraoperative blood loss and intra- and postoperative blood transfusion. However, the studies are small. More RCT studies with a greater sample size are favorable.

The coexistence of anterior communicating artery aneurysm and meningioma: A literature review and illustrative case

Background

Anterior communicating artery (Acom) aneurysm has an association with many types of intracranial lesions. However, its association with meningioma can be challenging, which is not well addressed in the literature. Herein, we described a literature review focused on the association between Acom aneurysm and meningioma, explicitly highlighting the spatial presence between these two pathologies. We analyzed the literature according to that association with particular emphasis on location-based challenges. Furthermore, we present an illustrative case of surgically treating both lesions in one surgery utilizing the same approach.

Methods

A Medline database search was conducted by the following combined formula: (Meningioma [Title/ Abstract]) AND (Aneurysm [Title/Abstract]) AND (((Anterior communicating artery [Title/Abstract]) OR (Acom [Title/Abstract])) OR Acomm [Title/Abstract]))). Additional resources were added after screening the references of the included papers.

Results

Nine patients with coexistence of Acom aneurysm and meningioma were found in the literature. The coexistence of both pathologies was found in seven females and two males. The presence of an aneurysm was found to be solitary in 66.67% (n = 6/9). Furthermore, meningioma was found to be an isolated lesion in all included cases, and in 22.2% (n = 2/9), they were located ipsilaterally. The location of the meningioma to the aneurysm seems to be in proximity.

Conclusion

Acom aneurysm can coexist with intracranial meningioma; this association can be spatially related intracranially. Such coexistence entails a variety of nuances and challenges that neurosurgeons encounter during the management of these complex lesions.

Preliminary report of patients with meningiomas exposed to Cyproterone Acetate, Nomegestrol Acetate and Chlormadinone Acetate - Monocentric ongoing study on progestin related meningiomas

INTRODUCTION

The relationship between meningioma and progestins has not been elucidated. Meningioma regression after acetate cyproterone (CA) withdrawal has been reported. Our purpose was to evaluate the meningioma evolution after withdrawal of progestins in patients who underwent long-term exposure to CA, nomegestrol acetate (NA), chlormadinone acetate (ChlA).

METHODS

Our study retrospectively included 69 patients with intracranial meningioma and exposed to one of these 3 progestins between December 2006 and March 2019. In each patient, clinico-radiological (MRI) follow-up was performed every 6 months after diagnosis and treatment withdrawal recommendation. Statistical analyses were applied to compare tumor location and respect of prescription rules between the 3 groups.

RESULTS

The mean hormonal exposure was 16 years in CA group (n = 46), 16 years in NA group (n = 12) and 9.7 years in ChlA group (n = 11). A higher rate of "out of label" use was observed in the CA group (p = 0.003). Multiple meningiomas were demonstrated in more than 60% of cases in each group. Anterior skull base location was noted in 60.5% of cases in CA group, 25% of cases in NA group and 36.7% of cases in ChlA group (p = 0.05). Incomplete tumor regression was recorded in 11 cases of CA group and in 2 cases of ChlA group.

CONCLUSION

In CA group, our results suggest a strong relationship between this treatment and development of intracranial meningioma. In presence of voluminous asymptomatic meningioma, treatment can be delayed due to the potential regression after withdrawal. On the contrary in NA and ChlA groups, further studies are needed.

Intraoperative tranexamic acid use in patients undergoing excision of intracranial meningioma: Randomized, placebo-controlled trial

Background:

Intracranial meningioma resection is associated with substantial intraoperative bleeding. Intraoperative tranexamic acid (TXA) use can reduce bleeding in a variety of surgical procedures. The objective of this study was to evaluate the effects of TXA treatment on blood loss and transfusion requirements in patient undergoing resection of intracranial meningioma.

Methods:

We conducted a prospective, randomized double-blind clinical study. The patient scheduled to undergo excision of intracranial meningioma were randomly assigned to receive intraoperatively either intravenous TXA or placebo. Patients in the TXA group received intravenous bolus of 20 mg/kg over 20 min followed by an infusion of 1 mg/kg/h up to surgical wound closure. Efficacy was evaluated based on total blood loss and transfusion requirements. Postoperatively, thrombotic complications, convulsive seizure, and hematoma formation were noted.

Results:

Ninety-one patients were enrolled and randomized: 45 received TXA (TXA group) and 46 received placebo (group placebo). Total blood loss was significantly decreased in TXA group compared to placebo (283 ml vs. 576 ml; P < 0.001). Transfusion requirements were comparable in the two groups (P = 0.95). The incidence of thrombotic complications, convulsive seizure, and hematoma formation was similar in the two groups.

Conclusion:

TXA significantly reduces intraoperative blood loss, but did not significantly reduced transfusion requirements in adults undergoing resection of intracranial meningioma.

World Health Organization Grade III Meningiomas: A Retrospective Study at an Academic Medical Center

BACKGROUND

Meningiomas are the most common primary brain tumors and are generally considered benign. However, a rare subgroup of meningiomas, classified as World Health Organization (WHO) grade III meningiomas, can show extremely aggressive behavior and high rates of recurrence. Despite ongoing research, data on the clinical outcome of this subgroup of meningiomas are still limited.

METHODS

Medical records of patients with WHO grade III meningiomas diagnosed between 2000 and 2018 at the Coimbra University Hospital Center were retrospectively reviewed and several variables of interest and their relation to patients' survival were analyzed.

RESULTS

Of the 26 patients included in the final analysis, 23 had anaplastic meningiomas, 2 had papillary meningiomas, and 1 had a rhabdoid meningioma. Median overall survival and median progression-free survival were 2.45 and 1.22 years, respectively. Overall survival at 1, 2 and 5 years was 73%, 57%, and 35%, respectively. Adjuvant radiotherapy correlated with improved survival for subtotally resected meningiomas but not for gross totally resected meningiomas. There was a trend toward improved overall survival with gross total resection versus subtotal resection, but this difference failed to reach statistical significance.

CONCLUSIONS

This study provides insight into the clinical outcomes of WHO grade III meningiomas and suggests that adjuvant radiotherapy may not be beneficial for patients who underwent gross total resection. This rare subset of meningiomas still portends a devastating prognosis and the impact of extent of resection and adjuvant therapies in these patients needs further clarification.

Neurosurgery for intracranial meningioma in patients aged more than 80 years: benefits and rationale

BACKGROUND

Elderly patients with symptomatic benign intracranial tumours such as meningioma pose particular problems in decision making. We report on the outcome, morbidity and mortality in patients aged over 80 years after undergoing cranial surgery for meningiomas.

METHODS

In this retrospective study, 37 patients aged more than 80 years underwent surgery at our neurosurgery department. The Karnofsky Performance Scale (KPS) was used to assess functional status. The American Society of Anesthesiologists (ASA) classification system, the Geriatric Scoring System, the Clinical-Radiological Grading System and the Sex, Karnofsky, ASA, Location and Edema score were used to define clinical status and tumour characteristics. The Charlson Comorbidity Index and Clavien-Dindo classification scores reflected therapeutic morbidity.

RESULTS

Preoperative KPS scores were generally higher than 60 (n = 32). Of the 37 patients, 24 (64.8%) were in ASA class I or II, and 27 (73.0%) had one or more comorbidities. The median length of follow-up was 80.0 months (range: 1-96 months). The 1-year mortality rate was 2.7% (n = 1). Tumour control was achieved in 33 patients. At discharge, KPS scores were improved in 21 patients (with an average gain of +18.1 ± 8.7), stable in 10 patients and poorer in 6 patients. KPS scores improved or were stable in patients with shorter lengths of hospital stay (15.5 ± 17.9 days vs 51.4 ± 25.4 days; p < 0.01), those with Clavien-Dindo scores lower than 2 (p < 0.01) and those with less favourable preoperative KPS scores (69.4 ± 10.9 vs 82.0 ± 11.0; p = 0.04).

CONCLUSION

Historically, surgery for intracranial meningiomas in patients aged >80 years has been feasible; this series demonstrated decreasing rates of postoperative mortality. Functional benefit should be the main goal of surgery. Perioperative morbidity should be better assessed and predicted because it significantly influences functional outcomes.

Effect of Surgeon Experience on Surgical Outcome of 80-Year-Old or Older Intracranial Meningioma Patients

OBJECTIVE

Previous reports suggest that more experienced surgeons have better postoperative outcomes in neurosurgery. We studied whether this association is found in a fragile cohort of ≥80-year-old intracranial meningioma (IM) patients.

METHODS

We identified 83 very old IM patients who were operated on by 12 different surgeons between 2010 and 2018. Besides general patient- and tumor-related characteristics, we collected information about the surgeons' case volume and length of surgical career (LSC). We classified neurosurgeons into 3 different categories: 1) low-volume (8 surgeons; 1-4 operations per surgeon); 2) moderate-volume (3 surgeons; 8-12 operations per surgeon); and 3) high-volume (1 reference surgeon; 37 operations). We calculated odds ratios (ORs) with 95% confidence intervals for 1-year mortality and 3-month independency (capability to live at home) by surgeon volume categories and per 5-year increase of LSC.

RESULTS

We found no significant differences in any preoperative characteristics between the surgeon volume categories. IM patients operated on by low-volume surgeons had the lowest risk of first-year mortality (OR, 0.15 [0.01-2.05]) and the highest likelihood of living at home 3 months after surgery (OR, 12.61 [1.21-131.03]). Increasing LSC was associated with 1-year mortality (OR, 1.34 [1.03-1.73]) and with lower likelihood to live at home 3 months after surgery (OR, 0.83 [0.69-1.00]), but these associations were slightly nonsignificant after adjusting for IM patients' age, sex, and preoperative independency.

CONCLUSIONS

In a high-volume academic hospital, less experienced neurosurgeons seem to achieve similar results as the more experienced neurosurgeons, even when operating on selected highly fragile meningioma patients.

Treatment Outcome of Gamma Knife Radiosurgery for Petroclival Meningiomas: Retrospective Analysis of a Single Institution Experience

Background

Although Gamma Knife radiosurgery (GKRS) has been widely used for intracranial meningiomas as an alternative or adjuvant treatment, guidelines have not been established for the selection of patients with petroclival meningioma (PCM) for GKRS. In this study, we reported the factors related to tumor progression and postoperative complications in PCM patients treated by GKRS, with a review of the literatures.

Methods

Between 2004 and 2019, 64 patients (52 patients for alternative and 12 patients for adjuvant treatment) with PCM underwent GKRS in our institution. The clinical and radiological factors were retrospectively analyzed. The mean radiologic follow-up duration was 58.4 months (range, 6–164 months). The mean tumor volume and diameter before GKRS were 13.4 cm³ and 2.9 cm, respectively. The median marginal dose was 12 Gy (range, 10–14 Gy) with a 50% median isodose line. Fractionation was used in 19 cases (29%, two fractionations in 5 cases & three fractionations in 14 cases).

Results

Progression was noted in 7 cases (10.9%) and the progression-free survival rates were 91.1% at 5 years and 69.6% at 10 years. Although large in volume, moderate to severe peritumoral edema and male gender were somewhat related to progression, they did not reach statistical significance. Ten patients (15.6%) developed complications after GKRS. The most common complication was cranial nerve deficit (n=8), followed by hemiparesis, cognitive dysfunction, and hydrocephalus. Large size (maximal diameter ≥5 cm) [hazard ratio (HR) 0.091, 95% confidence interval (CI) 0.014–0.608; p=0.013] and multiplicity (HR 0.102, 95% CI 0.018–0.573; p=0.009) were independent factors for developing complications after GKRS.

Conclusion

GKRS can be considered an effective and safe treatment for large-volume PCM. However, for patients with large size or multiple masses, the treatment method should be determined with caution because the probability of complications after GKRS may increase.

Feeding artery aneurysms associated with large meningiomas: case report and review of the literature

Though brain tumors and intracranial aneurysms co-exist, the occurrence of feeding artery aneurysms with meningiomas are unusual. We describe here a large falcine meningioma that was associated with three feeding artery aneurysms of the anterior circulation. These aneurysms can be treated either by pre-operative endovascular therapy or during the meningioma surgery. The management strategy for these patients will depend on the clinical presentation, morphology and localization of these aneurysms with respect to the tumor.

Surgical treatment of rostrotentorial meningioma complicated by foraminal herniation in the cat

OBJECTIVES

This study was performed to evaluate retrospectively the clinical signs, complications and postoperative outcomes of feline intracranial meningioma (IM) with concurrent cingulate, transtentorial and foramen magnum herniations.

METHODS

The medical records and MRI scans of cats with IM and cerebral herniation were reviewed. Cases involving concurrent cingulate, transtentorial and foramen magnum herniations were included. Owners were contacted to obtain long-term follow-up information.

RESULTS

Seven cats (four castrated males and three spayed females) met the inclusion criteria. Median age was 13.0 years (range 9.9-16.1 years) and median duration of clinical signs was 35 days (range 21-163 days). The clinical signs of cats with cerebral herniation included visual impairment (n = 5 [71.4%]), ataxia (n = 4 [57.1%]), impaired consciousness (n = 2 [28.6%]), head pressing (n = 2 [28.6%]), paresis (n = 1 [14.3%]), torticollis (n = 1 [14.3%]) and personality changes (n = 1 [14.3%]). Median tumour volume, cranial cavity volume and tumour volume:intracranial volume ratio before surgery were 3.37 cm³ (range 3.23-11.5 cm³), 32.6 cm³ (range 29.8-78.3 cm³) and 10.4% (range 5.3-35.3%), respectively. Median overall tumour excision rate was 90.6%. Preoperative intracranial pressure (ICP) ranged from 15 to 32 mmHg (median 29 mmHg). In all cases, the ICP dropped to 0 mmHg immediately after tumour removal. No adjuvant therapy was required after surgery. The median survival period was 612 days (range 55-1453 days).

CONCLUSIONS AND RELEVANCE

The results of this study indicate that surgical treatment of rostrotentorial IM is effective and allows prolonged survival, even in cats with concurrent cingulate, transtentorial and foramen magnum herniations.

Is surgery justified for 80-year-old or older intracranial meningioma patients? A systematic review

Since the number of elderly people with intracranial meningiomas (IM) continues to rise, surgical treatment has increasingly become a considerable treatment option, even in very old (≥ 80 years old) meningioma patients. Since little is known about whether meningioma surgery in this age group is safe and justified, we conducted a systematic review to summarize the results of surgical outcomes in very old meningioma patients. We performed a systematic literature search in Pubmed, Cochrane Library, and Scopus databases. Primarily, we extracted 1-month and 1-year survival rates, and 1-year morbidity rates, as well as information about preoperative morbidity, operative complications, meningioma size, location, histology, and peritumoral edema. Quality of the included studies was evaluated by Cochrane Collaboration Handbook and Critical Appraisal Skills Program. From the 1039 reviewed articles, seven retrospective studies fulfilled our eligibility criteria. Motor deficits (27–65%) and mental changes (51–59%) were the most common indications for surgery. One-month and 1-year mortality rates varied between 0–23.5% and 9.4–27.3%, respectively. Most of the operated IM patients (41.2–86.5%) improved their performance during postoperative follow-up. Impaired preoperative performance and comorbidities were most commonly related to higher postoperative mortality. None of the studies fulfilled the criteria of high quality. Based on the evidence currently available, surgical treatment of very old IM patients seems to improve the performance of highly selected individuals. Given the rapid increase of the aging population, more detailed retrospective studies as well as prospective studies are needed to prove the outcome benefits of surgery in this patient group.

Multisession radiosurgery for intracranial meningioma treatment: study protocol of a single arm, monocenter, prospective trial

Background

Single session radiosurgery represents a widely accepted treatment for intracranial meningiomas. However, this approach could involve a high risk of treatment-related complications when applied to large volume lesions. In these cases and for those not suitable for surgical resection, radiosurgery in multisession setting could represents a viable option. The literature results are reassuring in terms of correlated adverse events as well as in terms of tumor control. However, no prospective long-term results are available. In this scenario, we design a prospective monocentric phase II study, in order to verify the safety of a multisession radiosurgery schedule delivering 25 Gy in 5 daily fractions.

Methods

Patients diagnosed with large and/or near to critical structures, intracranial meningiomas have been treated by means of multisession radiosurgery in both exclusive and postoperative settings. The primary study aim is safety that has been being prospectively scored based on international scales, including NCI Common Toxicity criteria, version 4.03, Barrow Neurological Institute pain intensity score, Barrow Neurological Institute facial numbness score and House-Brackmann Facial Nerve Grading System for qualitative analysis. Secondary aim is treatment efficacy in terms of local control that has been being assessed on volumetric analysis.

Discussion

This is the first prospective phase II trial on multisession radiosurgery for large and/or near to critical structures intracranial meningiomas. If positive results will be found, this study could represent the starting point for a phase III trial exploring the role of multisession radiosurgery in the exclusive and postoperative radiation therapy treatment of intracranial meningiomas.

Trial registration

Trial registration: clinicaltrials.gov platform (Multisession Radiosurgery in Large Meningiomas –MuRaLM- identifier NCT02974127). Registered: November 28, 2016. Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02974127?term=radiosurgery&cond=Intracranial+Meningioma&draw=2&rank=1

Gorlin-Goltz Syndrome with Intracranial Meningioma: Case Report and Review of Literature

BACKGROUND

Gorlin-Goltz syndrome is a rare hereditary disease affecting multiple organ systems. Medulloblastoma is the most common intracranial malignancy in these patients, radiotherapy makes them more susceptible to intracranial meningioma. Here we report an intracranial meningioma without radiation exposure.

CASE DESCRIPTION

We present a case of intracranial meningioma in a young woman who was postoperatively diagnosed to have Gorlin-Goltz syndrome based on presence of calcification of bilateral tent and falx. Further clinical and radiological assessment helped us identify many other syndromic features and patient was promptly advised multispecialty consultations to screen for other malignancies and counselled regarding risk factors.

CONCLUSIONS

Early identification of the syndrome is important for prevention of secondary radiation-induced malignancies, both intracranial and extracranial. Patients need multidisciplinary approach for management.

Intracranial Meningiomas: A Systematic Analysis of Prognostic Factors for Recurrence in a Large Single Institution Surgical Series

BACKGROUND

Meningioma is the most common primary intracranial tumor. Surgical resection is the first choice of treatment, whereas the role of adjuvant radiotherapy (RT) is still unclear. Aim of the study was to evaluate prognostic factors influencing the local recurrence rate.

METHODS

Patients who had grade I-II meningiomas and underwent surgery were included in the present study. The extent of surgical resection was defined according to Simpson criteria, and were dichotomized as gross total and subtotal resection (STR). Adjuvant RT was considered in case of STR. Clinical outcome was evaluated by neurological examination and brain magnetic resonance imaging, which was performed every 6 months for the first year and yearly thereafter.

RESULTS

From January 2000 to December 2015, 296 patients were analyzed. Most were women (65.9%), with a Karnofsky performance status ≥80 (94.6%), grade I meningioma (79.4%), and symptoms at diagnosis (91.5%). STR was performed in 58%, followed by adjuvant RT in 10%. Improvement or stability of neurological status was obtained in 90.4% of patients. The median follow-up time was 79 months (range, 24-214 months). Local recurrence occurred in 87 (29.4%) patients, at a median time of 56 months (range, 6-214 months). No patients, who underwent surgery plus adjuvant RT, had local relapse. The median, 2-, 5-, 10-year progression-free survival were 172 months, 91.1%, 80.7%, and 67.2%, respectively. On univariate and multivariate analysis factors impacting on progression-free survival were grade, extent of surgical resection, and adjuvant RT in case of STR, regardless of meningioma grade.

CONCLUSIONS

Overall, our findings suggest that recurrence rates are influenced by grade, extent of surgical resection, and use of adjuvant RT in not completely resected meningioma, regardless of tumor grade.

SSTR-2 as a potential tumour-specific marker for fluorescence-guided meningioma surgery

BACKGROUND

Meningiomas are the most frequently occurring primary intracranial tumours in adults. Surgical removal can only be curative by complete resection; however surgical access can be challenging due to anatomical localization and local invasion of bone and soft tissues. Several intraoperative techniques have been tried to improve surgical resection, including intraoperative fluorescence guided imaging; however, no meningioma-specific (fluorescent) targeting has been developed yet. Here, we aimed to identify the most promising biomarkers for targeted intra-operative fluorescence guided meningioma surgery.

METHODS

One hundred forty-eight meningioma specimens representing all meningioma grades were analysed using immunohistochemistry (IHC) on tissue microarrays (TMAs) to determine expression patterns of meningioma biomarkers epithelial membrane antigen (EMA), platelet-derived growth factor β (PDGF-β), vascular endothelial growth factor α (VEGF-α), and somatostatin receptor type 2 (SSTR-2). Subsequently, the most promising biomarker was selected based on TArget Selection Criteria (TASC). Marker expression was examined by IHC in 3D cell culture models generated from freshly resected tumour material.

RESULTS

TMA-IHC showed strongest staining for SSTR-2. All cases were positive, with 51.4% strong/diffuse, 30.4% moderate/diffuse and only 18.2% focal/weak staining patterns. All tested biomarkers showed at least weak positivity in all meningiomas, regardless of WHO grade. TASC analysis showed that SSTR-2 was the most promising target for fluorescence guided imaging, with a total score of 21 (out of 22). SSTR-2 expression was determined on original patient tumours and 3D cultures of three established cultures.

CONCLUSIONS

SSTR-2 expression was highly sensitive and specific in all 148 meningiomas, regardless of WHO grade. According to TASC analysis, SSTR-2 is the most promising receptor for meningioma targeting. After establishing in vitro meningioma models, SSTR-2 cell membrane expression was confirmed in two of three meningioma cultures as well. This indicates that specific fluorescence in an experimental setting can be performed for the further development of targeted fluorescence guided meningioma surgery and near-infrared fluorescent tracers targeting SSTR-2.

Surgical outcome in elderly patients with intracranial meningioma

The aim of this study was to examine the utility of surgical management of intracranial meningioma in elderly patients. A total of 138 patients with intracranial meningiomas who underwent surgery from 2008 to 2017 were divided into elderly (≥75 years old, n = 34) and younger (<75 years old, n = 104) groups. Clinical and radiological data were retrospectively analyzed. Total tumor removal was achieved in 79% of elderly patients, which was similar to that in young patients (85%, p = .81). The average preoperative Karnofsky performance scale score in elderly patients was significantly lower than that in young patients (70.6 vs. 90.4, respectively; p < .0001). However, the average change in the Karnofsky performance scale score after surgery was similar between the two groups (0.3 vs. -0.4, respectively; p = .36). Histopathological grading revealed that the incidence of malignant meningioma (World Health Organization grades II and III) was significantly higher in elderly patients than that in young patients (44% vs. 14%, respectively; p = .004). Among meningiomas showing chronological progression, World Health Organization grade II and III meningiomas accounted for 67% of tumors in elderly patients, but only 23% in younger patients (p = .01). These data suggest that surgical removal of meningiomas may be a safe and useful treatment strategy in elderly patients.

Cystic Meningiomas: Correlation between Radiologic and Histopathologic Features

Background

Tumors with cysts often correlate with gliomas, metastatic tumors, or hemangioblastomas, which require differentiation.

Methods

Thirty-eight cases of cyst associated-meningioma based on preoperative radiologic studies and histologic confirmations were reviewed from November 1998 to July 2017.

Results

A total of 395 cases of meningioma were observed in the 20 years, and surgical treatment of intracranial meningioma was performed in 120 cases. Thirty-eight (9.6%) cases of cyst associated meningiomas were analyzed. Nauta type I was the most common type of cyst (39.5%) and the most frequent histopathological subtype was meningothelial type (36.8%).

Conclusion

Statistically there were no significant associations between meningioma histopathological type and associated cysts; however, the rate of World Health Organization grade II was higher in cyst associated meningiomas than in unrelated meningiomas. This correlation was weak, in accordance with the meningioma grade.

Long-term control and predictors of seizures in intracranial meningioma surgery: a population-based study

BACKGROUND

The aim of this retrospective study was to investigate the long-term seizure control and antiepileptic drug (AED) prescriptions, as well as identifying predictors of seizure(s) before and after surgery in a population-based cohort of operated intracranial meningioma patients.

METHODS

A total of 113 consecutive adult (> 18 years old) patients with newly diagnosed meningioma operated at the Karolinska University Hospital between 2006 and 2008 were included and followed up until the end of 2015. Data on seizure activity and AED prescriptions were obtained through chart review and telephone interview. Logistic regression and survival analysis were applied to identify risk factors for pre- and postoperative seizures.

RESULTS

A total of 21/113 (18.6%) patients experienced seizures before surgery of which 8/21 (38.1%) went on to become seizure-free after surgery. Thirteen (14%) patients experienced new-onset seizures after surgery. The regression analysis revealed tumor diameter ≥ 3.5 cm as a risk factor for preoperative seizures (OR 3.83, 95% CI 1.14-12.87). Presence of headache (OR 0.19, 95% CI 0.05-0.76) and skull base tumor location (OR 0.14, 95% CI 0.04-0.44) decreased the risk of preoperative seizures. Postoperative seizures were associated with tumor diameter ≥ 3.5 cm (OR 2.65, 95% CI 1.06-6.62) and history of preoperative seizures (OR 3.50, 95% CI 1.55-7.90).

CONCLUSION

Seizures are common before and after intracranial meningioma surgery. Approximately one third of patients with preoperative seizures become seizure-free on long-term follow-up after surgery, while 14% experienced new-onset seizures after surgery. Larger tumor size, absence of headache, and non-skull base location were associated with preoperative seizures, while tumor size and preoperative seizures were associated with postoperative seizures.

Recurred Intracranial Meningioma: A Retrospective Analysis for Treatment Outcome and Prognostic Factor

Background

In this study, we aimed to compare repeated resection and radiation treatment, such as Gamma knife radiosurgery (GKRS) or conventional radiotherapy (RT), and investigate the factors influencing treatment outcome, including overall survival (OS), progression-free survival (PFS), and complication rates.

Methods

We retrospectively reviewed 67 cases of recurred intracranial meningiomas (repeated resection: 36 cases, radiation treatment: 31 cases) with 56 months of the median follow-up duration (range, 13–294 months).

Results

The incidence of death rate was 29.9% over follow-up period after treatment for recurred meningiomas (20/67). As independent predictable factors for OS, benign pathology [hazard ratio (HR) 0.132, 95% confidence interval (CI) 0.048–0.362, p<0.001] and tumor size <3 cm (HR 0.167, 95% CI 0.061–0.452, p<0.001) were significantly associated with a longer OS. The incidence of progression rate was 23.9% (16/67). Only treatment modality was important for PFS as an independent predictable factor (GKRS/RT vs. open resection; HR 0.117, 95% CI 0.027–0.518, p<0.005). The complication rate was 14.9% in our study (10/67). Larger tumor size (≥3 cm, HR 0.060, 95% CI 0.007–0.509, p=0.010) was significant as an independent prognostic factor for development of complications. Although treatment modality was not included for multivariate analysis, it should be considered as a predictable factor for complications (p=0.001 in univariate analysis).

Conclusion

The role of repeated resection is questionable for recurred intracranial meningiomas, considering high progression and complication rates. Frequent and regular imaging follow-up is required to detect recurred tumor sized as small as possible, and radiation treatment can be a preferred treatment.

Application of arterial spin labeling perfusion MRI to differentiate benign from malignant intracranial meningiomas

PURPOSE

Differentiating WHO grade I-III of meningioma by non-invasive imaging is challenging. This study investigated the potential of MR arterial spin labeling (ASL) to establish tumor grade in meningioma patients.

MATERIAL AND METHODS

Pseudo-continuous ASL with 3D background suppressed gradient and spin echo (GRASE) was acquired on 54 patients with newly diagnosed or recurrent intracranial meningioma. Perfusion patterns characterized in CBF color maps were independently evaluated by three neuroradiologists blinded to patient history, and correlated with tumor grade from histo-pathological review.

RESULTS

Three perfusion patterns could be discerned by visual evaluation of CBF maps. Pattern 1 consisted of homogeneous hyper-perfusion of the entire tumor; pattern 2 demonstrated heterogeneous hyper-perfusion; pattern 3 showed no substantial hyper-perfusion. Evaluation of the perfusion patterns was highly concordant among the three readers (Kendall W=0.9458, P<0.0001). Pattern 1 was associated with WHO Grade I meningioma of (P<0.0001). Patterns 2 and 3 were predictive of WHO Grade II and III meningioma (P<0.0001), with an odds ratio (OR, versus pattern 1) of 49.6 (P<0.01) in a univariate analysis, and an OR of 186.4 (P<0.01) in a multivariate analysis.

CONCLUSION

Qualitative evaluation of ASL CBF maps can help differentiate benign (WHO Grade I) from higher grade (WHO Grade II and III) intracranial meningiomas, potentially impacting therapeutic strategy.

Laser biospectroscopy and 5-ALA fluorescence navigation as a helpful tool in the meningioma resection

5-aminolevulinic acid (5-ALA) is a natural precursor of protoporphyrin IX (PP IX), which possesses fluorescent properties and is more intensively accumulated in tumor cells than in normal tissue. Therefore, the use of 5-ALA in the surgical treatment of intracranial tumors, particularly gliomas, has gained popularity in the last years, whereas its use in other intracranial pathological entities including meningiomas has been reported occasionally. This study describes a series of 28 patients with intracranial meningiomas, who were administered 5-ALA for a better visualization of tumor boundaries. Twelve patients underwent also laser spectroscopic analysis in order to confirm the visual impression of tumor tissue visualization. Bone infiltration was readily demonstrated. In one case, the tumor recurrence could have been prevented by removal of a tumor remnant, which would possibly have been better recognized if spectroscopic analysis had been used. Fluorescent navigation (FN) is a useful method for maximizing the radicality of meningioma surgery, particularly if the tumor infiltrates the bone, the skull base, and/or the surrounding structures.

Intracranial Meningiomas: A 30-Year Experience and Literature Review

Intracranial meningiomas are tumors arising from the covering cells of the arachnoid layer of the dura mater or from the intraventricular choroid plexus. While mostly benign tumors, they still represent a major challenge to neurosurgeons and other medical disciplines involved in their diagnostic and therapeutic management. Although this review intends to give some state-of-the-art information from the literature, it is mainly based on personal experiences since more than 30 years caring for more than 1500 meningioma patients and point to a few new strategies to further improve on patient outcome.Diagnostics are based on magnetic resonance imaging which shows the relationship between tumor and surrounding intracranial structures, particularly the brain but also the vasculature and to some extent the cranial nerves. Furthermore, it may suggest the grading of the tumor and is very helpful in the postoperative diagnosis of complications and later follow-up course.Surgery still is the main treatment with the aim to completely remove the tumor; also in cases of recurrence, other additional options include radiotherapy and radiosurgery for incompletely removed or recurrent meningiomas. Postoperative chemotherapy has not been shown to provide substantial benefit to the patient especially in highly malignant meningiomas.All therapy options should be intended to provide the patient with the best possible functional outcome. Patients' perspective is not always equivalent to surgeons' perspectives. Neuropsychological evaluation and additional guidance of patients harboring meningiomas have proven to be important in modern neurosurgical intracranial tumor treatment. Their help beyond neurosurgical care facilitates the patients to lead an independent postoperative life.

Surgical Experience of Infratentorial Meningiomas : Clinical Series at a Single Institution during the 20-Year Period

Objective

Based on surgical outcomes of patients with infratentorial meningiomas surgically treated at our institution, we analyzed the predictors for surgical resection, recurrence, complication, and survival.

Methods

Of surgically treated 782 patients with intracranial meningioma, 158 (20.2%) consecutive cases of infratentorial location operated on between April 1993 and May 2013 at out institute were reviewed retrospectively. The patients had a median age of 57.1 years (range, 16--77 years), a female predominance of 79.7%, and a mean follow-up duration of 48.4 months (range, 0.8--242.2 months).

Results

Gross total resection (Simpson's grade I & II) was achieved in 81.6% (129/158) of patients. Non-skull base location was an independent factor for complete resection. The recurrence rate was 13.3% (21/158) and the 5-, 10-, and 15-year recurrence rates were 8.2%, 12.0%, and 13.3%, respectively. Benign pathology, postoperative KPS over than 90, low peritumoral edema, and complete resection were significantly associated with longer recurrence-free survival rate. The 5-, 10-, and 15-year survival rates were 96.2%, 94.9%, and 94.9%, respectively. Benign pathology, postoperative KPS over than 90 and complete resection were significantly associated with a longer survival rate. The permanent complication rate was 13% (21/158). Skull base location and postoperative KPS less than 90 were independent factors for the occurrence of permanent complication.

Conclusion

Our experience shows that infratentorial meningiomas represent a continuing challenge for contemporary neurosurgeons. Various factors are related with resection degree, complications, recurrence and survival.

Management of intracranial meningiomas in Enugu, Nigeria

Background:

Meningiomas may range on presentation from incidentally identified small lesions to large symptomatic tumors in eloquent areas of the brain. Management options correspondingly vary and include careful observation, surgical excision, and palliative application of very limited therapeutic maneuvers in select cases. This paper discusses the options and difficulties in the management of meningiomas in a developing country.

Methods:

This study is a retrospective analysis of prospectively recorded data of patients managed for intracranial meningioma between January 2006 and September 2011 at Memfys Hospital for Neurosurgery, Enugu. Radiographic diagnosis of meningioma was based on computed tomography (CT) and or magnetic resonance imaging (MRI) criteria in all cases, but only patients who had surgery and a histological diagnosis were analyzed.

Results:

Seventy-four patients were radiographically diagnosed with intracranial meningioma over the period under review. Fifty-five patients were operated upon and 52 (70.3%) with histological diagnosis of meningioma were further analyzed. Histological diagnosis was complete in 42 (56.8%) patients and in 10 (13.5%) patients the subtype of meningioma was not determined. The male to female ratio was 1:1.08. The peak age range for females was in the 6th decade and for males in the 5th decade. The locations were olfactory groove (26.9%), convexity (21.2%), parasagittal/falx (19.2%), sphenoid ridge (15.4%), tuberculum sellae (7.7%), tentorial (3.8%), and posterior fossa (5.8%). The most common clinical presentation was headaches in 67.3% followed by seizures (40.4%) and visual impairment (38.5%). Histology was benign (World Health Organization [WHO] grade 1) in 39 patients. One patient harbored an atypical and two had anaplastic tumors. Gross total resection of the tumor was achieved in 41 patients. Surgical mortality was 3.9%.

Conclusion:

Effective management of meningioma depends largely on adequate and complete surgical resection and results in good outcomes. Adequate preoperative assessment, including visual assessment, and hormonal assessment in olfactory groove and sphenoid region meningiomas, is necessary.

Radiation-induced intratumoral necrosis and peritumoral edema after gamma knife radiosurgery for intracranial meningiomas

Objective

To study the clinical significance and relevant factors of radiation-induced intratumoral necrosis (RIN) and peritumoral edema (PTE) after Gamma knife radiosurgery (GKRS) for intracranial meningiomas.

Methods

We retrospectively analyzed the data of 64 patients who underwent GKRS for intracranial meningioma. The mean lesion volume was 4.9 cc (range, 0.3-20), and the mean prescription dose of 13.4 Gy (range, 11-18) was delivered to the mean 49.9% (range, 45-50) isodose line. RIN was defined as newly developed or enlarged intratumoral necrosis after GKRS.

Results

RIN and new development or aggravation of PTE were observed in 21 (32.8%) and 18 (28.1%) cases of meningioma, respectively during the median follow-up duration of 19.9±1.0 months. Among various factors, maximum dose (>25 Gy) and target volume (>4.5 cc) were significantly related to RIN, and RIN and maximum dose (>24 Gy) were significantly related to the development or aggravation of PTE. In 21 meningiomas with development of RIN after GKRS, there was no significant change of the tumor volume itself between the times of GKRS and RIN. However, the PTE volume increased significantly compared to that at the time of GKRS (p=0.013). The median interval to RIN after GKRS was 6.5±0.4 months and the median interval to new or aggravated PTE was 7.0±0.7 months.

Conclusion

A close observation is required for meningiomas treated with a maximum dose >24 Gy and showing RIN after GKRS, since following or accompanying PTE may deteriorate neurological conditions especially when the location involves adjacent critical structures.

Peritumoral brain edema in meningiomas : correlation of radiologic and pathologic features

OBJECTIVE

The primary objective of this study was to perform a retrospective evaluation of the radiological and pathological features influencing the formation of peritumoral brain edema (PTBE) in meningiomas.

METHODS

The magnetic resonance imaging (MRI) and pathology data for 86 patients with meningiomas, who underwent surgery at our institution between September 2003 and March 2009, were examined. We evaluated predictive factors related to peritumoral edema including gender, tumor volume, shape of tumor margin, presence of arachnoid plane, the signal intensity (SI) of the tumor in T2-weighted image (T2WI), the WHO histological classification (GI, GII/GIII) and the Ki-67 antigen labeling index (LI). The edema-tumor volume ratio was calculated as the edema index (EI) and was used to evaluate peritumoral edema.

RESULTS

Gender (p=0.809) and pathological finding (p=0.084) were not statistically significantly associated with peritumoral edema by univariate analysis. Tumor volume was not correlated with the volume of peritumoral edema. By univariate analysis, three radiological features, and one pathological finding, were associated with PTBE of statistical significance: shape of tumor margin (p=0.001), presence of arachnoid plane (p=0.001), high SI of tumor in T2WI (p=0.001), and Ki-67 antigen LI (p=0.049). These results suggest that irregular tumor margins, hyperintensity in T2WI, absence of arachnoid plane on the MRI, and high Ki-67 LI can be important predictive factors that influence the formation of peritumoral edema in meningiomas. By multivariate analysis, only SI of the tumor in T2WI was statistically significantly associated with peritumoral edema.

CONCLUSION

Results of this study indicate that irregular tumor margin, hyperintensity in T2WI, absence of arachnoid plane on the MRI, and high Ki-67 LI may be important predictive factors influencing the formation of peritumoral edema in meningiomas.