BACKGROUND: While several risk factors for recurrences have been defined, the topographic pattern of meningioma recurrences after surgical resection has been scarcely investigated. The possibility of theoretically predicting the site of recurrence not only allows us to better understand the pathogenetic bases of the disease and consequently to drive the development of new targeted therapies, but also guides the decision-making process for treatment strategies and tailored follow-ups to decrease/prevent recurrence.
METHODS: The authors performed a comprehensive and detailed systematic literature review of the EMBASE and MEDLINE electronic online databases regarding the topographic pattern of recurrence after surgical treatment for intracranial meningiomas. Demographics and histopathological, neuroradiological and treatment data, pertinent to the topography of recurrences, as well as time to recurrences, were extracted and analyzed.
RESULTS: Four studies, including 164 cases of recurrences according to the inclusion criteria, were identified. All studies consider the possibility of recurrence at the previous dural site; three out of four, which are the most recent, consider 1 cm outside the previous dural margin to be the main limit to distinguish recurrences closer to the previous site from those more distant. Recurrences mainly occur within or close to the surgical bed; higher values of proliferation index are associated with recurrences close to the original site rather than within it.
CONCLUSIONS: Further studies, including genomic characterization of different patterns of recurrence, will better clarify the main features affecting the topography of recurrences. A comparison between topographic classifications of intracranial meningioma recurrences after surgery and after radiation treatment could provide further interesting information.

Meningiomas show variable tendency to recur. While risk factors of recurrence have been largely investigated in literature, a paucity of data is available on the time to recurrence. Our purpose was to identify main factors affecting the time to recurrence to assist preoperative treatment decision-making strategy and to define a tailored clinical and neuroradiological follow-up.
Data of 35 patients with intracranial meningioma recurrences have been retrospectively reviewed. Demographic (patient age at initial diagnosis and sex), radiologic (meningioma location, pattern of regrowth and topography of recurrences at first reoperation), pathologic (WHO grade and Ki67-MIB1 at initial surgery and at first reoperation, progesterone receptor [PR] expression), and surgical (extent of resection at initial surgery according to Simpsons grading system, number of reoperations) factors were analyzed.
Time to recurrence ranged from 20 to 120 months. Extent of resection at initial surgery was Simpson grade I in 7 patients (20%), grade II in 10 (28.5%), grade III in 14 (40%), and grade IV in 4 (11.5%). Longer median time to recurrence was observed for skull base localization (P < 0.01), Simpson grades I and II versus grades III (P = 0.01) and IV (P = 0.02), values of Ki67-MIB1 ≤ 4% (P = 0.001), and PR > 60% (P = 0.03); conversely, sex, age, number of reoperations, unchanged/progression of Ki67, and/or World Health Organization grade between first surgery and reoperation did not correlate in statistically significant way with time to recurrence.
The extent of resection and the Ki67-MIB1 represent the most important factors predicting shorter recurrence time of intracranial meningiomas. Patients with incomplete (Simpson grades III and IV) resection and high Ki67-MIB1 values, especially at non-skull base localization and with low PR values, require a closer short-term clinical and radiologic follow-up in the first years after surgery.

Preoperative embolization for meningiomas is controversial regarding its effectiveness in reducing intraoperative blood loss and operative time. In contrast, some reports have documented improved surgical outcomes in large meningiomas. In this study, we retrospectively compared the outcomes of craniotomy for meningiomas with/without preoperative embolization with diluted N-butyl-2-cyanoacrylate (NBCA) primarily in a single institution.
Data (World Health Organization grade, Simpson grade, maximum tumor diameter, intraoperative bleeding, operative time, history of hypertension, and time from embolization to craniotomy) of patients with initial intracranial meningiomas were compared with or without preoperative embolization from January 2015 to April 2022.
The embolization group consisted of 56 patients and the nonembolization group included 76 patients. Diluted NBCA (13% concentration for all patients) was used in 51 of 56 patients (91.1%) who underwent transarterial embolization. Permanent neurological complications occurred in 2 (3.6%) patients. Intraoperative bleeding was significantly lower in the embolization group for a maximum tumor diameter ≥40 mm (155 vs. 305 ml, respectively, p < 0.01). In the nonembolization group, for a maximum tumor diameter ≥30 mm, patients with hypertension had more intraoperative bleeding than non-hypertensive ones.
Despite its limitations, the present results showed that, under certain conditions, preoperative embolization for intracranial meningiomas caused less intraoperative bleeding. The safety of treatment was comparable with that reported in the Japan Registry of NeuroEndovascular Therapy 3 (JR-NET3) with a complication rate of 3.7% for preoperative embolization of meningiomas, despite the treatment focused on the liquid embolization material.

Convexity meningiomas (CM) can be successfully treated with neurosurgery. However, clinical complications due to CM have been reported. Moreover, systematic investigations of CM with respect to all relevant clinical factors are currently lacking.
We performed a systematic investigation in 210 patients with supratentorial CM considering all relevant clinical and radiological factors, with a follow-up time of 19.5 years.
Among 812 patients with intracranial meningiomas treated in our department (2003-2020), 28.2 % of intracranial meningiomas were located over the supratentorial convexity, and the patients had a median age of 62 years (95 % CI:59-64). The median follow-up was 30.4 months (95 % CI:21.6-37.1). Tumor-related symptoms were observed in 88.1 % of patients. The most common preoperative symptom was headache (28.1 %), followed by seizure (19.5 %). Symptomatic patients had significantly higher tumor volumes than asymptomatic patients (p = 0.0003; 24.5 cm3 and 6.98 cm3, respectively). Complete tumor resection was achieved in 92.9 % of patients. The most common postoperative complication was bleeding (7.1 %) in the approach area. Of all bleedings, only three were intracerebral hemorrhages and did not require surgical intervention. The second most common complication was postoperative seizure (4.7 %). The multiple logistic regression analyses showed that tumor volume (OR:1.007; 95 % CI:1.001-1.013; p = 0.02) and brain infiltration by the tumor (OR:1.961; 95 % CI:1.028-3.741; p = 0.04) had a significant impact on postoperative complications. The postoperative and final KPS scores significantly improved (p < 0.001). The tumor recurrence rate was 6.2 %, with a median time of 38 months. No surgery-related deaths occurred.
A large tumor volume and brain infiltration by the tumor were significant factors for postoperative complications. The clinical conditions significantly improved postoperatively and further during the follow-up period.

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.

UNASSIGNED: The evolution of cavernous sinus meningiomas (CSMs) might be unpredictable and the efficacy of their treatments is challenging due to their indolent evolution, variations and fluctuations of symptoms, heterogeneity of classifications and lack of randomized controlled trials. Here, a dedicated task force provides a consensus statement on the overall management of CSMs.
UNASSIGNED: To determine the best overall management of CSMs, depending on their clinical presentation, size, and evolution as well as patient characteristics.
UNASSIGNED: Using the PRISMA 2020 guidelines, we included literature from January 2000 to December 2020. A total of 400 abstracts and 77 titles were kept for full-paper screening.
UNASSIGNED: The task force formulated 8 recommendations (Level C evidence). CSMs should be managed by a highly specialized multidisciplinary team. The initial evaluation of patients includes clinical, ophthalmological, endocrinological and radiological assessment. Treatment of CSM should involve experienced skull-base neurosurgeons or neuro-radiosurgeons, radiation oncologists, radiologists, ophthalmologists, and endocrinologists.
UNASSIGNED: Radiosurgery is preferred as first-line treatment in small, enclosed, pauci-symptomatic lesions/in elderly patients, while large CSMs not amenable to resection or WHO grade II-III are candidates for radiotherapy. Microsurgery is an option in aggressive/rapidly progressing lesions in young patients presenting with oculomotor/visual/endocrinological impairment. Whenever surgery is offered, open cranial approaches are the current standard. There is limited experience reported about endoscopic endonasal approach for CSMs and the main indication is decompression of the cavernous sinus to improve symptoms. Whenever surgery is indicated, the current trend is to offer decompression followed by radiosurgery.

Meningiomas are the most common non-glial tumor of the central nervous system (CNS). Seen in middle age with a female preponderance, most of the tumors are solitary and supratentorial with benign histology (WHO grade I). Atypical and anaplastic (malignant) meningiomas (WHO grade II and III), comprise 15-20% of all intracranial meningiomas [12345]. Magnetic resonance imaging (MRI) is the imaging modality of choice.

BACKGROUND: While surgery is the primary treatment choice for intracranial meningiomas in young patients, surgery in elderly patients, especially those with pre-existing comorbidities, has been the subject of repeated discussion. This study investigated the postoperative risks and neurological benefits of meningioma surgery in elderly patients compared to young patients.
METHODS: In total, 768 patients were included and divided into two main groups: group I (age: ≤ 64 years; 484 young patients) and group II (age: ≥ 65 years; 284 elderly patients). Group II was subdivided into: IIa (age: 65-69 years), IIb (age: 70-79 years); and IIc (age: ≥ 80 years).
RESULTS: The total tumor resection rate was higher in the elderly cohort than in the young cohort (84.5 and 76.2%, respectively). 154 young patients (31.8%) and 132 elderly patients (46.5%) developed postoperative morbidities, with the three most common being bleeding (12.9%), cranial nerve disorder (10%) and CSF fistula (8.1%). Postoperative bleeding, palsy, speech disorder, pneumonia and renal insufficiency were dependent on age (r = 0.123, p = 0.001; r = 0.089, p = 0.014; r = 0.100, p = 0.006; r = 0.098, p = 0.007 and r = 0.084, p = 0.020) and presented more often in elderly patients. 6 young and 15 elderly patients died during the 17.4-year observation period. Most patients showed a significant improvement in postoperative KPS (p < 0.001), except those over 80 years old (p = 0.753). The KPS at the last follow-up was significantly improved in all patients (p < 0.001).
CONCLUSIONS: Meningioma surgery is associated with a higher rate of postoperative complications in elderly patients than in young patients. Most elderly patients, similar to young patients, show a significant improvement in neurological status postoperatively.

Background  To describe our operative strategy and analyze its safety and effectiveness for the removal of medial sphenoid wing meningiomas (MSWMs) through the extended pterional approach. Method  We identified 47 patients with MSWMs who were operated using this approach between 1986 and 2016. Medical charts, operative reports, imaging results, and clinical follow-up evaluations were reviewed and retrospectively analyzed. Results  No surgical mortality was observed in this sample. Gross total resection was achieved in 30 (63.8%) patients. Intradural clinoidectomy was performed in 16 (34%) patients. The median length of follow-up was 8.5 years (range, 1-30 years). Conclusion  The extended pterional approach associated with microsurgery techniques provided excellent results for the removal of MSWMs.

Fluorescence diagnostics has been extensively applied in surgery of malignant brain gliomas. However, the use of this technique in surgery of intracranial meningiomas has remained controversial.
OBJECTIVE: The study objective was to assess the sensitivity of 5-aminolevulinic acid-based (5-ALA) fluorescence diagnostics in surgery of brain meningiomas and to clarify the clinical and biological factors that may influence the fluorescent effect.
METHODS: The study consistently included 101 patients with intracranial meningiomas of various locations who were operated on using 5-ALA. There were 28 (27.72%) males and 73 (72.27%) females (median age, 54 years). In all patients, surgery was performed using an operating microscope equipped with a fluorescent module; in 24 of these, laser spectroscopy was used. For comparison of chances to observe the fluorescent effect of 5-ALA in patients having meningiomas with different WHO histological grades (Grade I vs Grade II-III), we performed a meta-analysis that included 10 studies (the largest series) on outcomes of surgical treatment of meningiomas using intraoperative fluorescence diagnostics.
RESULTS: Of 101 patients included in this series, observable fluorescence was detected in 95 (94.1%) patients: weak fluorescence in 12 (11.9%), moderate fluorescence in 23 (22.8%) cases, and strong fluorescence in 60 (59.4%) patients. There was no statistically significant relationship (p>0.05) between the rate and intensity of observable fluorescence and the tumor growth pattern (primary/continued), location, WHO grade of malignancy, and histological subtype. In the absence of intraoperative bleeding, tumor fluorescence was statistically significantly brighter (p=0.02). Of 26 patients with hyperostosis, bone fluorescence was observed in 11 (42.3%) cases. There was no statistically significant relationship between administration of dexamethasone, its dose, administration of anticonvulsants, gastrointestinal tract diseases, as well as diabetes mellitus and the fluorescence intensity. There was also no significant relationship between the extent of tumor resection (Simpson scale) and the presence of fluorescence as well as its intensity. Comparison of the observable fluorescence intensity and the laser spectroscopy indicators revealed a significant correlation (r=0.75; p=0.005).
CONCLUSIONS: Meningioma is a well fluorescent tumor, with the technique sensitivity being 94.1%. In some cases, the use of fluorescence diagnostics in surgery of meningiomas improves identification of residual tumor fragments and enables correction of a surgical approach. To assess the effect of fluorescence diagnostics on the recurrence rate and disease-free duration, further research is required.
Использование флуоресцентной диагностики (ФД) нашло широкое применение в хирургии злокачественных глиом головного мозга. Однако использование данного метода в хирургии интракраниальных менингиом остается дискутабельным. Цель исследования - оценить чувствительность метода ФД с использованием 5-аминолевулиновой кислоты (5-АЛК) в хирургии менингиом головного мозга и уточнить клинические и биологические факторы, влияющие на флуоресцентный эффект. Материал и методы. В исследование последовательно включен 101 пациент (28 (27,72%) мужчин и 73 (72,27%) женщины, средний возраст 54 года) с интракраниальными менингиомами различной локализации, которые были оперированы с использованием 5-АЛК. Все операции проводили под операционным микроскопом, оснащенным флуоресцентным модулем, и у 24 из них была использована лазерная спектроскопия. Для сравнения шансов получить флуоресцентный эффект при использовании 5-АЛК у пациентов с разным гистологическим типом менингиом по классификации ВОЗ (Grade I в сравнении с Grade II-III) проведен метаанализ 10 работ (наиболее крупные серии), посвященных хирургическому лечению менингиом с применением интраоперационной ФД. Результаты. Из 101 пациента, включенного в данную серию, видимая флуоресценция наблюдалась у 95 (94,1%) пациентов: слабая - у 12 (11,9%), умеренная - у 23 (22,8%) и выраженной интенсивности - у 60 (59,4%). Статистически значимой взаимосвязи частоты эффекта флуоресценции и степени ее выраженности с характером роста опухоли (первичный/продолженный), локализацией, степенью злокачественности по классификации ВОЗ, гистологическим подтипом не выявлено (p>0,05). При отсутствии кровотечения во время оперативного вмешательства флуоресценция опухоли была статистически значимо ярче (p=0,02). Из 26 пациентов с гиперостозом флуоресценция кости наблюдалась у 11 (42,3%). Статистически значимой зависимости между приемом дексаметазона, его дозой, приемом противосудорожных препаратов, наличием заболеваний ЖКТ, СД и степенью флуоресценции не выявлено. Достоверной зависимости между радикальностью удаления опухоли по Simpson и свечением, а также интенсивностью флуоресценции также не выявлено. При сопоставлении визуальной степени флуоресценции с показателями лазерной спектроскопии выявлена достоверная корреляция (r=0,75; р=0,005). Заключение. Менингиома является хорошо флуоресцирующей опухолью c чувствительностью метода 94,1%. Применение ФД в хирургии менингиом позволяет в ряде случаев улучшить выявление остаточных фрагментов опухоли и изменить тактику хирургического вмешательства. Для оценки влияния флуоресцентной диагностики на частоту рецидивов и длительность безрецидивного периода необходимы дальнейшие исследования.