Editorial: Meningioma surgery

Abstract

Over the past 20 years, the management of intracranial meningiomas has changed. Surgical removal remains the gold standard to which alternative therapies are compared. However, advanced radiation oncology techniques, such as stereotactic radiosurgery and intensity-modulated radiotherapy, have increasingly been applied in the treatment of smalland medium-sized tumors as well as incompletely resected lesions.1,2 Furthermore, as Sughrue et al.4 mention, conservative management of asymptomatic meningiomas is an increasingly viable option for some patients. The overall result is that the population that undergoes microsurgical removal of meningiomas are, on average, older, more likely to have neurological symptoms, and more likely to harbor larger lesions, as compared with patients 20 years ago.3 These characteristics underscore the need for neurosurgeons to be able to accurately assess risks associated with microsurgical resection. The following study by Sughrue et al.4 features a large series of patients and evaluates the rate and types of medical complications in those who have undergone microsurgical removal of meningiomas. The authors included all craniotomies for meningiomas during a 15year period, numbering 834 cases. Overall, the findings are not unexpected, but they do provide valuable insights into the specific risk factors and variables that may lead to postoperative medical complications. The rate of serious medical complications in these patients was low (6.8%), which, in the authors’ estimation, reflects the indolent nature of the disease and the careful selection of surgical candidates. Given the low rate of medical complications in these patients, large studies such as this are necessary to accurately investigate rates of medical and neurological complications. Statistically significant predictors of postoperative medical complications in this study, such as an age > 65 years, hypertension, and 2 or more cardiac medications, are not unexpected. However, it is interesting to note that the strongest predictor of a serious medical complication was a new or worsened postoperative neurological deficit. The explanation offered by the authors that seems most plausible is that in many cases the new neurological deficit (for example, weakness in 1 or more extremities) predisposed a patient to a medical complication (for example, deep vein thrombosis and pulmonary embolus). Given the efficacy of radiosurgery for residual tumor, these data and observations perhaps underscore the notion of conservative resection with postoperative observation or radiation, especially for tumors in locations more difficult to access such as the foramen magnum and petroclival region. In other words, tailoring the goals of resection to minimize neurological complications may help to minimize the risk of serious medical complications. Patients expect and deserve their neurosurgeons to be fully aware of all risks associated with their surgery and to anticipate and intervene appropriately when complications arise. Much of the literature regarding complications from meningioma surgery is devoted to surgical and neurological complications. The authors of this study are to be commended not only for reinforcing the need to be mindful of serious medical complications, but also for observing the association between postoperative neurological and medical complications. Understanding the rates and risk factors for both types of complications can only help to reduce the incidence of potentially devastating outcomes.