Surgical Management of Giant Intracranial Meningioma: Operative Nuances, Challenges, and Outcome

doi:10.1016/j.wneu.2017.09.184

World Neurosurgery

Volume 110, February 2018, Pages e32-e41

https://doi.org/10.1016/j.wneu.2017.09.184 Get rights and content

Background

The giant intracranial meningioma (GIM) constitutes a different spectrum of brain tumors that invade the vital neurovascular structures, which makes the primary mode of treatment, surgery, a technically challenging one. The surgery for GIM is unique because of the large size of the tumor, prominent vascularity, entangling and limited visualization of various neurovascular structures, and severe cerebral edema. This study reports the authors surgical experience of 80 GIM cases, the operative challenges and surgical outcome.

Methods

A retrospective analysis of 80 patients with histologically proven meningioma (≥5 cm) who underwent surgical treatment at Louisiana State University Health Sciences Center (Shreveport, Louisiana, USA) over a 20-year period (1995–2015) is presented. The clinical and radiologic data were collected from the hospital database. The tumors were categorized into histologic groups according to World Health Organization (WHO) classification. The relevant statistical analysis of the study was conducted using SPSS software, version 22.0.

Results

The study included 27 male patients (33.8%) and 53 female patients (66.3%). The mean age of the cohort was 56 years (56.3±16.1). The mean size of the tumor was 56.4 ±4 mm with a range from 50 mm to 84 mm. Skull base was the most common location of GIM (57 patients, 71.3%). Simpson grade 1 excision was achieved in 9 patients (11.3%), whereas grade 2 excision was achieved in 57 patients (71.3%); 80% of the tumors belonged to WHO grade 1. The operative mortality was seen in 4 patients (5%). Regression analysis showed that age, sex, location of the tumor, neuronavigation, Simpson grade of excision, and histology of tumor were the factors that significantly affected the recurrence-free survival (RFS).

Conclusions

The surgery for GIM is unique in different ways. As surgery for GIM is formidable, radiologic characteristics can be useful adjuncts for planning an effective and safe surgical strategy. The factors such as young age, male sex, use of neuronavigation, and skull base location positively influenced RFS, whereas Simpson grade 3 or 4 and poor histologic grade adversely influenced RFS. A careful preoperative evaluation, understanding of the risk factors, effective surgical approach, and judicious use of intraoperative adjuncts are the key factors with pivotal roles in GIM resection.

Introduction

The giant intracranial meningioma (GIM) constitutes a different spectrum of brain tumors that invade the vital neurovascular structures and make the primary mode of treatment, surgery, a technically challenging one. The surgery for GIM is unique because of the large size of the tumor, prominent vascularity, entangling and limited visualization of various neurovascular structures and severe cerebral edema.1, 2 It usually arises in an area of maximal brain compliance; therefore, it may grow large before becoming symptomatic and being diagnosed.³ We consider the tumors more than 5 cm in maximum dimension as GIM in our series.2, 3, 4, 5, 6

Currently, different protocols are applied for meningioma tumors, including simple observation, partial resection, radiosurgery as primary or adjuvant therapy, and aggressive surgical removal. Usually this kind of large meningioma lesion requires surgery because of its mass effect and neurovascular involvement.⁷ The surgery for GIM is usually associated with a myriad of complications.⁸ The surgical strategy should be focused on survival and postoperative quality of life. The intricate location of tumor, the direction of growth, invasion of adjacent structure, patient age, and the experience of the surgeon are the key factors when choosing the best surgical approach for these lesions. The study reports the authors' experience with surgical management of 80 cases of GIM, its operative challenges, and surgical outcomes.

Section snippets

Materials and Methods

A retrospective analysis of 80 patients of histologically proven meningioma measuring 5 cm or larger who underwent surgical treatment at Louisiana State University Health Sciences Center, (Shreveport, Louisiana, USA) over a 20-year period is presented. Information related to clinical history, neuroimaging such as computed tomography (CT) and magnetic resonance imaging (MRI), use of neuronavigation, microsurgical dissection and outcomes of patients with meningiomas between January 1995 and

Demographics and Clinical Parameters

The demographic data for 80 patients who underwent surgical intervention (January 1995 to December 2015) were analyzed. The study included 27 men (33.8%) and 53 women (66.3%). The mean age of the cohort was 56.3 years with SD of 16.1 years. On analysis of only older patients, we found 53 patients (66.3%) of which 18 were male (22.5%) and 35 (43.7%) were female. Forty-seven patients (58.8%) were white, 25 patients were African American (31.3%), and the remaining 8 patients (10%) were Hispanic.

Discussion

GIM usually shows a female preponderance and occurs around the age of 40 years.⁴ The clinical manifestations of tumor can vary according to the location. The most common clinical manifestation was headache (57.5%), and the most common tumor location was the skull base (71.3%) in the present study. A previous study reviewed the patients with supratentorial meningioma (n = 255) and analyzed the location of the tumors in descending order: cerebral convexity (27%), parasagittal sinus (20.7%),

Conclusion

The surgery for GIM is unique in different ways for various reasons. As surgery for GIM is formidable, clinicoradiologic characteristics can be useful adjuncts for planning an effective and safe surgical strategy. Safe, maximal resection should be the goal, especially for GIMs located at the skull base. We found that factors such as young age, male sex, use of neuronavigation, and skull base location positively influenced the RFS, whereas Simpson grade of excision (grade 3/4) and poor

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Cited by (27)

Widening the Operative Corridor–Evaluating the Transcortical Approach to Giant Falcine Meningiomas
2024, World Neurosurgery
Giant falcine meningiomas are surgically complex as they are deep in location, concealed by normal brain parenchyma, in close proximity to various neurovascular structures, and frequently involve the falx bilaterally. Although classically accessed using a bifrontal craniotomy and interhemispheric approach, little data exist on alternative operative corridors for these challenging tumors. We evaluated perioperative and long-term outcomes in patients undergoing transcortical resection of giant bilateral falcine meningiomas.
From 2013 to 2022, fourteen patients with giant bilateral falcine meningiomas treated via a transcortical approach at our institution were identified. Perioperative and long-term outcomes were evaluated to determine predictors of adverse events. Corticectomy depth was also analyzed to determine if it correlated with increased postoperative seizure rates.
57.1% of cases were WHO grade 2 meningiomas. Average tumor volume was 77.8 ± 46.5 cm³ and near/gross total resection was achieved in 78.6% of patients. No patient developed a venous infarct or had seizures in the 6 months after surgery. Average corticectomy depth was 0.83 ± 0.71 cm and increasing corticectomy depth did not correlate with higher risk of postoperative seizures (P = 0.44). Increasing extent of tumor resection correlated with lower tumor grade (P = 0.011) and only 1 patient required repeat resection during a median follow-period of 24.9 months.
The transcortical approach is a safe alternative corridor for accessing giant, falcine meningiomas, and postoperative seizures were not found to correlate with increasing corticectomy depth. Further prospective studies are necessary to determine the best approach to these surgically complex lesions.
Quality indicators and early adverse in surgery for atypical meningiomas: A 16-year single centre study and systematic review of the literature
2023, Brain and Spine
Atypical meningiomas represent approximately 20% of all intracranial meningiomas and are characterized by distinct histopathological criteria and an increased risk of postoperative recurrence. Recently, quality indicators have been introduced to monitor quality of the delivered care.
Which quality indicators/outcome measures are being applied in patients being operated for atypical meningiomas? What are risk factors associated with poor outcome? How is the surgical outcome and which quality indicators are reported in the literature?
The primary outcomes of interest were 30-days readmission-, 30-day reoperation-, 30-day mortality-, 30-day nosocomial infection- and the 30-day surgical site infection (SSI) rate, CSF-leakage, new neurological deficit, medical complications, and lengths of stay. The secondary aim was the identification of prognostic factors for the mentioned primary outcomes. A systematic review of the literature was performed screening studies for the mentioned outcomes.
We included 52 patients. 30-days outcomes in terms of unplanned reoperation were 0%, unplanned readmission 7.7%, mortality 0%, nosocomial infection 17.3%, and SSI 0%. Any adverse event occurred in 30.8%. Preoperative C-reactive protein over 5 mg/l was independent factor for the occurrence of any postoperative adverse event (OR: 17.2, p = 0.003). A total of 22 studies were included into the review.
The 30-days outcomes at our department were comparable with reported outcomes in the literature. Currently applied quality indicators are helpful in determining the postoperative outcome but mainly report the indirect outcome after surgery and are influenced of patient, tumor and treatment related factors. Risk adjustment is vital.
Histopathological Correlation (World Health Organization Classification) of Meningiomas and Their Anatomical Localization: A Multicenter Epidemiological Study in Mexico
2021, World Neurosurgery
Citation Excerpt :
Concerning histological grade, some characteristics on magnetic resonance imaging, such as cerebral invasion, invasion of bone, and peritumoral edema, have been associated with meningiomas of highest histological grade.26 In the experience of some authors regarding the tumors, the larger the size, the greater the association with WHO grade II histological grade, with tumors >5–6 cm having the highest probability of being WHO grade II or WHO grade III.10,27 The reason why a site-specific meningioma shows a completely different histology probably depends on the cell of origin and the microenvironment of the original site of the meningioma.
To determine the epidemiology of the localization and histological type of meningiomas in the Mexican population and the distribution of the different histological patterns and their relationship to tumor localization and patient demographics.
A retrospective analysis was performed in 5 hospitals in Mexico from 2009 to 2019. For qualitative variables, mean values were compared using Pearson χ² test for the correlation between location and histological pattern as well as the clinical presentation and the patient’s sex. Student t test was performed for age and its correlation with location and histology.
Analysis of 179 patients revealed significant differences in histopathological pattern, patient sex, and tumor location. No significant differences were found for age or clinical presentation in association with any specific histological pattern.
There was a correlation between the histology of the 15 histopathological varieties of meningiomas and the predilection site of appearance as well as certain demographic aspects, such as sex. This study lays the foundation for future studies in Mexico on the differentiation and typing of meningiomas regardless of the histological grade to which they belong, as the exact behavior of these tumors, including grade I tumors, remains unknown to date.
The Co-Pilot Project: An International Neurosurgical Collaboration in Ukraine
2021, World Neurosurgery
Citation Excerpt :
Although we tended to operate on patients with benign brain tumors, a wide variety of patients were treated (Table 2). Operative outcomes are described in accordance with accepted standards.7-11 One of the trips was executed in cooperation with SpineHope, an Austin-based organization led by Matthew Geck, who performed complex spinal deformity surgery.
We aim to provide a thorough description of the efforts and outcomes of the Co-Pilot Project in Ukraine, which facilitates neurosurgical collaboration between American and Ukrainian physicians.
The Co-Pilot Project, which operates under its parent nonprofit organization, Razom, organized multiple trips for American physicians to Ukraine. Activities included consulting in clinic, assisting with neurosurgical operations, and providing didactic lectures. Further efforts have included coordinating training opportunities for Ukrainian surgeons. We retrospectively reviewed all operations performed by Ukrainian partner physicians alongside American co-pilot physicians across Ukraine since August 2016.
Teams of Ukrainian and American physicians operated on 78 patients (24 children and 54 adults) for a total of 84 procedures in 5 different cities (Kyiv, Lutsk, Lviv, Odessa, and Stryi) of Ukraine. Operations were classified into the following categories: adult brain tumors (n = 39), adult spine tumors (n = 1), epilepsy (n = 9), pain (n = 2), pediatric brain tumors (n = 11), vascular/endovascular (n = 10), and miscellaneous (n = 12). Four illustrative cases are described in detail. Of the patients with brain tumors, 43.5% (20/46) had giant tumors, and gross total resection or near-total resection was achieved in 78.3% (36/46).
Profound disparities in neurosurgical care exist globally, which has led to the formation of collaborative relationships between physicians from various countries. We hope that the work of the Co-Pilot Project in Ukraine can serve as a template for effective international neurosurgical collaboration in other low-to-middle-income countries.
One Hundred Skull Base Meningiomas Operated at Black Lion Specialized Hospital, Addis Ababa, Ethiopia
2019, World Neurosurgery
Citation Excerpt :
In addition to the advanced stage, a striking finding was our patients' young age. First, it has been demonstrated that young individuals are prone to harbor large meningiomas.20 Second, and probably more important, is the contribution of the large young population and the short life expectancy in Ethiopia.
After 10 years of training in their home country, neurosurgeons at Black Lion Specialized Hospital (Addis Ababa, Ethiopia) operated on skull base meningiomas independent of their external teachers. The present study used a retrospective design of an in-hospital series with short-term follow-up.
A total of 100 patients (mean age, 40.2 years; 80% women) had undergone surgery for skull base meningiomas from 2016 to 2017. Their symptoms included headache in 90%, impairment of vision in 47%, gait impairment in 25%, cognitive dysfunction in 29%, and seizures in 18%. Of the 100 tumors, 44% had a diameter >50 mm. Microsurgery was performed using the Hudson drill, Gigli saw, and conventional microsurgical instruments.
A total of 59 complications in 39 patients occurred. Eleven patients had died within 3 months postoperatively. The cranial infection rate was 14%. The rate of Simpson grade I and II was 63%. We present the 3–12-month outcomes for 84 of the 100 patients. Of the 16 remaining patients, 4 were lost to follow-up (mean, 6.7 months) and 12 had died. Headache was noted in 65 of 74 patients preoperatively and in 20 during follow-up. Overall, 33 patients reported better vision, 48 reported similar vision, and 3 patients reported worse vision. Finally, 20 patients had gait difficulties preoperatively and 9 reported impaired gait during follow-up.
A young faculty of neurosurgeons in a low income country was trained to perform neurosurgery for skull base meningiomas. The patients had presented at a young age with severe disabilities due to advanced disease. Surgery led to symptom improvement in a large proportion of patients; however, the complication and mortality rates were high.
A nomogram for predicting the risk of major postoperative complications for patients with meningioma
2023, Neurosurgical Review

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: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Original ArticleSurgical Management of Giant Intracranial Meningioma: Operative Nuances, Challenges, and Outcome

Background

Methods

Results

Conclusions

Introduction

Section snippets

Materials and Methods

Demographics and Clinical Parameters

Discussion

Conclusion

World Neurosurg

World Neurosurg

World Neurosurg

World Neurosurg

A modified far-lateral approach for large or giant meningiomas of the posterior fossa

J Neurosurg

Giant anterior clinoidal meningiomas: surgical technique and outcomes

J Neurosurg

Huge meningiomas: a review of 93 cases

Skull Base Surg

The lion's mane sign: surgical results using the bilateral fronto-orbito-nasal approach in large and giant anterior skull base meningiomas

J Neurosurg

Vision salvage after resection of a giant meningioma in a patient with a loss in light perception

J Neurosurg

Large and giant skull base meningiomas: the role of radical surgical removal

Surg Neurol Int

Large and giant medial sphenoid wing meningiomas involving vascular structures: clinical features and management experience in 53 patients

Chin Med J (Engl)

The 2016 World Health Organization Classification of Tumors of the Central Nervous System: a summary

Acta Neuropathol

Morbidity, mortality, and quality of life following surgery for intracranial meningiomas. A retrospective study in 257 cases

J Neurosurg

Original Article
Surgical Management of Giant Intracranial Meningioma: Operative Nuances, Challenges, and Outcome