Meningiomas: criteria for modern surgical indications

Journal of Medical - Clinical Research & Reviews, 2018

Statement of the Problem: Meningiomas are benign extra-axial tumors, originating from the meningeal arachnoidal cells, making up 20% of the intracranial primary tumors. Surgical management of meningiomas is one of the most challenging procedures posing a high risk of affecting the critical neurovascular centers of the brain. Our study attempts to identify the way paraclinical brain investigations coupled with a well-established surgical procedure lead to an efficient and strategic treatment of meningioma, starting with a case of a 50-year-old woman. Case presentation: The clinical background of the patient included frontal headaches, rare epileptic crises, and sudden dizziness. In addition to the MRI which presented a homogenous irregular expanding tumor process in the frontal-orbital left space, several other investigations such as Digital Angiography and Computed Tomography were performed. The treatment was mainly focused on the neurosurgical intervention, having several purposes: rejecting the meningioma, establishing the anatomopathological diagnosis and developing the therapeutic plan. The surgical approach involved a step-by-step incision, tumor fragmentation and Simpson 2 excision. The final result was favourable-the patient regained her balance. Conclusion & Significance: Getting a better understanding of the neurosurgical steps of treating meningiomas will lead to finding strategies that will improve the patient's treatment and his quality of life.

Clinical Neurology and Neurosurgery, 2017

Surgical resection of petroclival meningiomas remains challenging due to their deep location and relationship to vital neurovascular structures. Although the natural history of these tumors involves a slow course, the incidence of cranial nerve deficits and the extent of tumor resection vary widely in the literature. Some reviews on this topic have been conducted, but data remain fragmentary and based on retrospective case series, which hinders attempts at meta-analysis. Within this context, research into the use of minimally invasive approaches, including in neuroendoscopy, continues to emerge. The objective of this narrative review is to analyze the available literature on the surgical treatment of petroclival meningiomas, with a focus on attempts at endoscopy-assisted resection.

Scientific Reports, 2016

Atypical and malignant meningiomas are rare. Our aim was to examine the treatment outcomes following surgical resection, and analyze associations between clinical characteristics and overall survival (OS) or relapse free survival (RFS). 102 patients with atypical or malignant meningiomas underwent microsurgical resection between June 2001 and November 2009 were analyzed retrospectively. We compared demographics, clinical characteristics, treatment, and complications. The five-year and ten-year overall survival rates were 93.5% and 83.4%, respectively. Three factors significantly reduced OS: Malignant meningiomas (p < 0.001), which also decreased RFS (p < 0.001); female patients (p = 0.049), and patients with Karnofsky Performance Status (KPS) < 70 at diagnosis (p = 0.009). Fifty two patients (51%) experienced tumor relapse. Total resection of tumors significantly impacted RFS (p = 0.013). Tumors located at parasagittal and posterior fossa area lead to higher relapse rate (p = 0.004). Subtotal resection without adjuvant radiotherapy lead to the worst local control of tumor (p = 0.030). An MIB-1 index <8% improved OS and RFS (p = 0.003). Total resection of atypical and malignant meningiomas provided better outcome and local control. Adjuvant radiation therapy is indicated for patients with malignant meningiomas, with incompletely excised tumors; or with tumors in the parasagittal or posterior fossa area. The MIB-1 index of the tumor is an independent prognostic factor of clinical outcome. Meningiomas, one of the most common intracranial tumors, accounts for 13% to 26% of brain tumors and have an annual incidence of 6 per 100,000 people 1. In 2000 and 2007, World Health Organization(WHO) graded meningiomas with histological standards. The standards are based on both of subjective and objective (mitotic index) criteria 2 : around 90% are benign (WHO grade I), 5-7% are atypical (WHO grade II), and only 1-3% are considered anaplastic or malignant (WHO grade III) 3. This recent adoption of modern grading criteria and the rarity of the malignant subtype have limited the amount of available data on the clinical behavior, outcomes, and optimal treatment of meningiomas 4. Benign meningiomas contribute to relatively good prognosis, but atypical and malignant meningiomas show rapid progression and more invasion. Five-year progression-free survival and overall survival of approximately 50% and 60%, respectively was shown 1,4-6. Gross total resection (GTR) is the optimal surgical principle for benign meningiomas, but the standard of care for atypical and malignant meningiomas has yet to be established 7,8. The two high grade histopathology tumor types are more brain invasive, and radical surgical strategies can lead to high morbidity and poor overall outcome 9. Previous literature shows that age less than 40 years, cranial base meningiomas, and male sex are associated with recurrence in benign meningiomas that have been subtotally excised, but such data are not available for atypical and anaplastic meningiomas 1,10. Both benign and malignant meningiomas have an equal propensity to bleed, whereas malignant tumors are not necessarily more vascular than benign tumors 1. Pre-operative embolization of meningiomas helps reduce intra-operative tumor bleeding, which may decrease surgical time and make surgical resection easier 11. The

CNS Oncology, 2021

Meningiomas are the most common primary intracranial tumors. The majority of meningiomas are benign, but they can present different grades of dedifferentiation from grade I to grade III (anaplastic/malignant) that are associated with different outcomes. Radiological surveillance is a valid option for low-grade asymptomatic meningiomas. In other cases, the treatment is usually surgical, aimed at achieving a complete resection. The use of adjuvant radiotherapy is the gold standard for grade III, is debated for grade II and is not generally indicated for radically resected grade I meningiomas. The use of systemic treatments is not standardized. Here we report a review of the literature on the clinical, radiological and molecular characteristics of meningiomas, available treatment strategies and ongoing clinical trials.

The Lancet. Oncology, 2016

Although meningiomas are the most common intracranial tumours, the level of evidence to provide recommendations for the diagnosis and treatment of meningiomas is low compared with other tumours such as high-grade gliomas. The meningioma task force of the European Association of Neuro-Oncology (EANO) assessed the scientific literature and composed a framework of the best possible evidence-based recommendations for health professionals. The provisional diagnosis of meningioma is mainly made by MRI. Definitive diagnosis, including histological classification, grading, and molecular profiling, requires a surgical procedure to obtain tumour tissue. Therefore, in many elderly patients, observation is the best therapeutic option. If therapy is deemed necessary, the standard treatment is gross total surgical resection including the involved dura. As an alternative, radiosurgery can be done for small tumours, or fractionated radiotherapy in large or previously treated tumours. Treatment conc...

International journal of radiology and imaging technology, 2018

Turkish Neurosurgery, 2016

cularized mucosal flap reconstruction, rates of cerebrospinal fluid (CSF) leak have dropped to between 3-5% (8, 11, 12, 17), which is comparable to the reported 3.9% leak rate following standard microscopic transsphenoidal pituitary surgery (3). These advancements in reconstruction techniques have led to renewed enthusiasm for the expanded endonasal approach (EEA) at many centers. However, while the endonasal approach yields some advantages over transcranial surgery, it is not always possible or even advisable to attempt to resect all meningiomas endonasally. How to select between these op-█ INTRODUCTION Experience with endonasal transsphenoidal pituitary procedures has taught us that whenever anatomically feasible, surgery through the nose is better tolerated than transcranial surgery. Initial clinical reports of the utility of the endonasal approach for midline skull base meningiomas were published more than a decade ago (14, 15, 18). However, the widespread acceptance of the expanded endonasal route has only been made possible with advances in skull base reconstruction. With the introduction of multilayered closure and a vas-AIm: Reconstruction technique advances have created renewed enthusiasm for the expanded endonasal approach (EEA). However, as with any new technique, early experiences inevitably lead to more selective use of these techniques. We reviewed our experience of the expanded endonasal endoscopic approach for skull base meningiomas and place it in context of the literature. mATERIAl and mEThODS: We performed retrospective review of all endonasal cases performed at our center for histologically proven meningioma. Tumor locations in 26 patients included the olfactory groove (n=9), tuberculum sellae (n=7), optic nerve sheath (n=1), planum sphenoidale (n=2), clival (n=1) petroclival (n=3), cavernous sinus (n=2) and extensive pan-basal meningioma (n=1). RESUlTS: The median follow-up was 38.6 months. Excluding 3 patients with tumors found incidentally, pre-operative symptoms improved in 14 of 23 (61%), were the same in 8 of 23 (35%) and worsened in one of 23 patients (4%) at time of last follow-up. Of all 26 patients, 16 (62%) had complete macroscopic resection of their tumor, 5 (19%) underwent at least 90% resection, and 5 (19%) underwent subtotal resection. There were two neurological complications and one cerebrospinal fluid leak. CONClUSION: This study presents outcomes of patients treated with endonasal endoscopic meningioma surgery. We believe that very low rates of morbidity can be achieved in carefully selected patients, thus avoiding brain manipulation.

World Neurosurgery, 2016

The objective of this study was to identify clinico-radiologic factors associated with incomplete anterior cranial fossa (ACF) meningioma resection via an endoscopic endonasal approach. Methods Patients undergoing endoscopic endonasal resection of an ACF meningioma were retrospectively accrued from two university-affiliated centers. Demographic profiles and radiologic findings, including tumor dimensions and morphology, anatomic location and vascular involvement were stratified based on the extent of resection. Results In total, 25 patients were included in this study. Factors associated with incomplete surgical resection via an endonasal route were: presence of hyperostosis (p=0.04), cavernous internal carotid artery (ICA) involvement (p=0.001), maximal dural tail length in the transverse plane (p=0.006) and its ratio to the inter-fovea ethmoidalis distance (p=0.01). Using a multiple regression analysis, only cavernous ICA involvement (p=0.002) and a large dural tail length to inter-foveal distance ratio (p=0.04) were significant predictors of incomplete resection (multiple correlation coefficient 0.71). The combination of predictive factors to determine the likelihood of complete endoscopic resection produced a scoring system with a sensitivity and specificity of 85.7% CI [42.1-99.6] and 100% CI [81.5-100], respectively. Conclusion Use of a simple scoring system outlined in our study may facilitate proper patient selection for endoscopic endonasal resection of ACF meningiomas.

Neurosurgical Focus, 2013

Object Petroclival meningiomas remain a formidable challenge for neurosurgeons because of their location deep within the skull base and proximity to eloquent neurovascular structures. Various skull base approaches have been used in their treatment, and deciding which is the optimal one remains controversial. Attempts at achieving gross- or near-total resections are associated with an increased rate of morbidity and mortality. As adjunctive treatment options such as stereotactic radiosurgery have been developed and become widely available, there has been a trend toward accepting subtotal resections in an effort to minimize neurological morbidity. This paper reviews a recent series of patients with petroclival meningiomas and highlights current management trends and important considerations useful in surgical decision making. Methods The records of patients with large (&gt; 3 cm) petroclival meningiomas surgically treated by the senior author over the past 5 years were reviewed. The c...

Mini-invasive Surgery , 2020

How to cite this article: Azab WA, Elmaghraby MA, Zaidan SN, Mostafa KH. Endoscope-assisted transcranial surgery for anterior skull base meningiomas. Mini-invasive Surg 2020;4:88. http://dx. Abstract Anterior skull base meningiomas are benign, dural-based tumors that originate from the tuberculum sellae, planum sphenoidale or olfactory groove. A multitude of traditional transcranial approaches have been effectively used for resection of these tumors. However, in the era of minimally invasive neurosurgery, the endoscopic endonasal and the endoscope-assisted or endoscope-controlled supraorbital keyhole eyebrow approaches stand out as the two main options utilized to resect these tumors. The supraorbital keyhole approach minimizes brain retraction, tissue dissection and length of the skin incision. Consequently, this approach is associated with a lower complication profile and much better cosmetic results in comparison to classic approaches. With endoscopic assistance or control, the approach provides an excellent view of anterior skull base meningiomas and enables optic nerve decompression when angled scopes are used. In our opinion, endoscopes will ultimately replace the surgical microscopes as the viewing tools in this type of surgery. A limited number of studies have directly compared the endoscopic endonasal approach versus the supraorbital keyhole one for resection of anterior cranial base meningiomas. In these studies, scores and algorithms have been suggested to help select the suitable approach. The practical value of these algorithms still needs to be validated by further research. Although the endoscope-assisted or-controlled supraorbital keyhole approach offers a minimally invasive and highly effective approach for excision of anterior cranial base meningiomas, the ideal approach should be tailored to the individual patient according to the tumor size, lateral extension, optic canal involvement, extent of vascular encasement and surgeon's experience.