Resection Of Intracranial Meningiomas Research Articles

RADT-28. MULTI-SESSION RADIOSURGERY FOLLOWING SURGERY FOR INTRACRANIAL MENINGIOMAS: 10-YEAR OUTCOMES FROM A SINGLE INSTITUTION PROTOCOL

Abstract INTRODUCTION Meningioma is the most common adult primary intracranial tumor. Surgical resection is the favored treatment with radiotherapy often utilized for residual or recurrent disease. Long-term outcomes are well-established for single-session radiosurgery but mature outcomes for multisession radiosurgery do not yet exist. We report our institution’s 10-year efficacy and toxicity outcomes for 5-fraction radiosurgery following surgical resection of intracranial meningiomas. METHODS All intracranial meningioma patients treated at our institution between 2002-2018 with 5-fraction radiosurgery following surgery were eligible for inclusion. Standard variables were analyzed to predict local failure and overall survival. RESULTS Forty-one consecutive patients with a female predominance (76%) and median age of 58 years (range: 27–84) were included. Thirty benign (73%) and 11 atypical meningiomas (27%) with a median gross tumor volume of 7.79cc (range: 0.38-52.63) were treated. All patients completed radiosurgery for residual tumor (41%) or recurrent disease (59%). A median dose of 3000cGy (range: 2500-3500cGy), was delivered to a median isodose line of 82% (range: 71%-90%). The median follow-up from the date of surgery was 10 years. Nine tumors (22.0%) progressed following radiosurgery. The local control rate at 10-years was significantly better for benign tumors than atypical tumors (93% vs 27%, p = 0.001). Factors found to be predictive of local failure on multivariate analysis were tumor grade (HR: 13.8, p = 0.002) and tumor volume (HR: 1.08, p = 0.031). For benign tumors all failures occurred at the margin of the unirradiated tumor bed, while atypical tumors failed predominately in-field (71%). Three patients with atypical meningioma developed radiation necrosis following aggressive treatment (3500cGy). Overall survival at 10-years was 93% for benign tumors and 60% for atypical tumors (p = 0.026). CONCLUSION Multisession radiosurgery following surgery for benign intracranial meningiomas provides excellent long-term tumor control with minimal toxicity. However, for atypical meningiomas this approach results in poor local control.

SURG-31. UTILITY OF TRANEXAMIC ACID (TXA) FOR RESECTION OF INTRACRANIAL MENINGIOMAS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Due to its anti-fibrinolytic action, tranexamic acid (TXA) can be utilized to help maintain hemostasis during surgical operations. With respect to surgery for intracranial tumors, we hypothesize that TXA could help mitigate blood loss during resection of highly vascular tumors such as meningiomas. We therefore conducted a systematic review of the literature and meta-analysis to analyze the effects of TXA administration in patients undergoing surgical resection of intracranial meningioma. Study inclusion criteria were (1) primary data articles describing use of TXA in surgical resection of meningioma. In this meta-analysis, which included four primary comparative studies, outcome measurements between TXA and non-TXA groups were compared. Primary outcomes included operative length, complications, transfusion requirements, estimated blood loss, and postoperative Hb for TXA versus non-TXA (control) groups. Pooled-comparative analysis was conducted for each of these perioperative variables and formal meta-analysis was applied toward statistically significant parameters. A total of 221 patients were analyzed (110 TXA, 111 non-TXA). Patient age (p = 0.1632), gender (p = 0.8317), and tumor location (p = -.8334) were similar for TXA and control groups. TXA was associated with decreased complication rate (logRR: -0.85; CI95% = -1.49 to -0.22; p = 0.0087), decreased transfusion requirement (logRR: -0.50; CI95% = -0.92 to -0.08; p = 0.0039), reduced blood loss (SMD: -1.76; CI95% = -3.21 to -0.31; p < 0.0001), and increased postoperative Hb (SMD: 0.46; CI95% = -0.15 to 1.07; p < 0.0001). In three trials, TXA was administered intravenously as a loading dose of 20 mg/kg for 20 minutes preoperatively with an intraoperative maintenance rate of 1mg/kg/hr; in one trial, administration design was identical except that infusion rate of the 20 mg/kg preoperative loading dose was unspecified. TXA may be associated with reduced complications, transfusion requirements, perioperative estimated blood loss, and increasedpostoperative Hb when administered perioperatively for surgical resection of intracranial meningiomas.

Impact of COVID-19 on Intracranial Meningioma Resection: Results from California State Inpatient Database.

Simple SummaryAll fields of healthcare were adversely affected by the COVID-19 pandemic. In this study, we sought to understand the effects of COVID-19 on hospitalizations for intracranial meningioma resection using a large database. We compared hospitalization rates as well as hospital outcomes such as Clavien–Dindo grade IV complications, in-hospital mortality, and prolonged length of stay for intracranial meningioma resection during 2019 and 2020. Our findings showed that though hospitalization rates decreased slightly during the COVID-19 pandemic, hospital outcomes were not adversely affected. The findings of our study show that with adequate planning and preparations, better hospital outcomes could be sustained even during healthcare emergencies such as COVID-19 pandemic. Our findings assure that neurosurgery practice in the US ensured the best quality of care to their patients even during COVID-19 pandemic.Purpose: To assess the effects of COVID-19 on hospitalizations for intracranial meningioma resection using a large database. Methods: We conducted a retrospective analysis of the California State Inpatient Database (SID) 2019 and 2020. All adult (18 years or older) hospitalizations were included for the analysis. The primary outcomes were trends in hospitalization for intracranial meningioma resection between 2019 and 2020. Secondary outcomes were Clavien–Dindo grade IV complications, in-hospital mortality, and prolonged length of stay, which was defined as length of stay ≥75 percentile. Results: There were 3,173,333 and 2,866,161 hospitalizations in 2019 and 2020, respectively (relative decrease, 9.7%), of which 921 and 788 underwent intracranial meningioma resection (relative decrease, 14.4%). In 2020, there were 94,114 admissions for COVID-19 treatment. Logistic regression analysis showed that year in which intracranial meningioma resection was performed did not show significant association with Clavien–Dindo grade IV complications and in-hospital mortality (OR, 1.23, 95% CI: 0.78–1.94) and prolonged length of stay (OR, 1.05, 95% CI: 0.84–1.32). Conclusion: Our findings show that neurosurgery practice in the US successfully adapted to the unforeseen challenges posed by COVD-19 and ensured the best quality of care to the patients.

노인 뇌수막종 수술에서 합병증 예측에 대한 스코어링 시스템의 비교

Background : Grading systems such as the Clinical-Radiological Grading System (CRGS), Geriatric Scoring System (GSS), and SKALE (sex, KPS [Karnofsky Performance Scale], American Society of Anesthesiology class, location of tumor, and peritumoral edema) grading system are useful for predicting outcomes in meningioma patients over 65 years. Given the increase in average life expectancy, it is required to identify the most effective grading system, which would help anticipate postoperative complications, as well as other risk factors, especially in elderly patients aged over 75 years. Materials and Methods : Scores were calculated retrospectively according to CRGS, SKALE, and GSS for patients aged over 75 years who underwent surgery for intracranial meningiomas in our hospital from 2009 to 2020 (n = 88). Various perioperative clinical and radiological factors were also measured to investigate their relationship with surgical complications. Results : In the 88 patients enrolled, the complication rate was 28.4% (n = 25), including three mortality cases (3.4%). Multivariate analysis of various risk factors revealed that peritumoral edema (P = 0.011), tumor location (P = 0.001), and KPS (P = 0.030) were independent prognostic factors for the development of postoperative complications. Despite slight differences in cut-off values, patients with SKALE ≥ 11 (area under the curve [AUC] = 0.7038), CRGS ≥ 14 (AUC = 0.7441), and GSS ≥ 17 (AUC = 0.7829) showed decreased rates of complications on ROC (receiver operating characteristic) curve analysis. Conclusions : In our study, with the slight modification of cut-off values, all three scoring systems were powerful predictors of postoperative complications in intracranial meningioma resection of elderly patients aged over 75 years.

Outcomes following surgical resection of cystic intracranial meningiomas.

Cystic meningiomas are rare, accounting for 2-7% of all intracranial meningiomas. Little is known regarding whether these meningiomas behave differently compared to solid meningiomas. We sought to study this relatively uncommon imaging appearance of meningioma and to evaluate its clinical significance. A single-institution retrospective cohort study of surgically-treated meningioma patients between 2000 and 2019 was conducted. Cystic meningioma was defined as a tumor with an intratumoral or peritumoral cyst present on preoperative imaging. Demographics, preoperative imaging, histopathology characteristics, operative data, and surgical outcomes were reviewed. Imaging variables, histopathology and outcomes were reported for cystic meningiomas and compared with non-cystic meningiomas. Univariate/multivariable analyses were conducted. Of 737 total meningiomas treated surgically, 38 (5.2%) were cystic. Gross total resection (GTR) was achieved in 84.2% of cystic meningioma patients. Eighty-two percent of cystic meningiomas were WHO grade I (n = 31), 15.7% were grade II and 2.6% were grade III. Most cystic meningiomas had low Ki-67/MIB-1 proliferation index (n = 24, 63.2%). A total of 18.4% (n = 7) patients with cystic meningioma had recurrence compared to 12.2% (n = 80) of patients with non-cystic meningioma (p = 0.228). No significant difference in median time to recurrence was observed between cystic and non-cystic meningiomas (25.4, Q1:13.9, Q3:46.9months vs. 13.4, Q1:8.6, Q3:35.5months, p = 0.080). A small portion of intracranial meningiomas have cystic characteristics on imaging. Cystic meningiomas are frequently WHO grade I, have low proliferation index, and had similar outcomes compared to non-cystic meningioma. Cysts in meningioma may not be a surrogate to determine aggressive meningioma behavior.

Perioperative Clinical Course Variables Associated with Length of Hospital Stay after Primary Intracranial Meningioma Resection.

The relationship between perioperative clinical course variables and postoperative length of hospital stay (LOS) in patients undergoing primary intracranial meningioma resection has not been fully elucidated. We therefore aimed to identify the perioperative clinical course variables that predict postoperative LOS in such patients. We retrospectively collected data concerning demographics, tumor characteristics, and perioperative clinical course variables in 76 patients who underwent primary intracranial meningioma resection between January 2010 and December 2019, and tested for associations with postoperative LOS. Univariate analyses showed that younger age, fewer days to postoperative initiation of standing/walking, preoperative independence in activities of daily living (ADL), and ADL independence one week after surgery were associated with shorter postoperative LOS. Multiple regression analyses with these factors identified that days to stand/walk initiation and ADL independence one week after surgery were associated with postoperative LOS. Based on these results, we conclude that rehabilitation programs that promote early mobilization and the early acquisition of independence may reduce postoperative LOS in patients who undergo primary intracranial meningioma resection.

Clinical presentation, diagnostic findings and outcome of dogs undergoing surgical resection for intracranial meningioma: 101 dogs

BackgroundMeningioma is the most common primary brain neoplasm in dogs. Further information is required regarding the expected long-term prognosis of dogs following the surgical resection of an intracranial meningioma together with the influence of adjunctive therapies. Whilst there have been several studies reporting the long-term outcome of intracranial meningioma resection following surgery alone, surgery with the use of an ultrasonic aspirator, surgery combined with radiotherapy and surgery combined with the addition of hydroxyurea, it is currently unclear which type of adjunctive therapy is associated with the most favourable outcomes. The objective of this study is to describe the presentation and outcome of dogs undergoing surgery for the resection of an intracranial meningioma and the effect of clinical factors, adjunctive therapies and meningioma histopathological subtype on the long-term outcome.ResultsA hundred and one dogs that had intracranial surgery for meningioma resection were investigated from four referral centres. 94% of dogs survived to hospital discharge with a median survival time of 386 days. Approximately 50% of dogs survived for less than a year, 25% survived between 1 and 2 years, 15% survived between 2 and 3 years and 10% survived for greater than 3 years following discharge from hospital. One or more adjunctive therapies were used in 75 dogs and the analysis of the data did not reveal a clear benefit of a specific type of adjunctive therapy. Those dogs that had a transfrontal approach had a significantly reduced survival time (MST 184 days) compared to those dogs that had a rostrotentorial approach (MST 646 days; p < 0.05). There was no association between meningioma subtype and survival time.ConclusionsThis study did not identify a clear benefit of a specific type of adjunctive therapy on the survival time. Dogs that had a transfrontal approach had a significantly reduced survival time. Intracranial surgery for meningioma resection offers an excellent prognosis for survival to discharge from hospital with a median long term survival time of 386 days.

Association of baseline frailty status and age with outcomes in patients undergoing intracranial meningioma surgery: Results of a nationwide analysis of 5818 patients from the National Surgical Quality Improvement Program (NSQIP) 2015–2019

PurposeThe objective of this study was to compare the effect of frailty, as measured by the 5-factor modified frailty index (mFI-5), with that of age on postoperative outcomes of patients undergoing surgery for intracranial meningiomas, using data from a large national registry. MethodsThe National Surgical Quality Improvement Program (NSQIP) database (2015–2019) was queried to analyze data from patients undergoing intracranial meningioma resection (N = 5,818). Univariate and multivariate analyses of age and mFI-5 score were performed for 30-day mortality, major complications, unplanned reoperation, unplanned readmission, extended hospital length of stay (eLOS), and discharge to a non-home destination. ResultsBoth univariate and multivariate analyses (adjusted for sex, body mass index, transfer status, smoking, and operative time) demonstrated that mFI-5 and age were significant predictors of adverse postoperative outcomes in patients with intracranial meningioma. However, based on odds ratios (OR) and effect sizes, increasing frailty tiers were better predictors than age of adverse outcomes. Severely frail patients showed highest effects sizes for all postoperative outcome variables [OR 11.17 (95% CI 3.45–36.19), p<0.001 for mortality; OR 4.15 (95% CI 2.46–6.99), p<0.001 for major complications; OR 4.37 (95% CI 2.68–7.12), p<0.001 for unplanned readmission; OR 2.31 (95% CI 1.17–4.55), p<0.001 for unplanned reoperation; OR 4.28 (95% CI 2.74–6.68), p<0.001 for eLOS; and OR 9.34 (95% CI 6.03–14.47, p<0.001) for discharge other than home. ConclusionIn this national database study, baseline frailty status was a better independent predictor for worse postoperative outcomes than age in patients with intracranial meningioma.

Awake Craniotomy for Resection of Intracranial Meningioma: First Case Series From a Low- and Middle-Income Country.

IntroductionAwake craniotomy (AC) has emerged as a better modality for resection of intra-axial brain tumors. The advantages are not just related to the preservation of neurological function, but also include early recovery, short hospital stay and possibly lower costs. However, data on AC for meningioma resection is deficient, likely because of concerns related to intra-operative pain and blood loss.MethodsAll patients who underwent AC, using awake through-out technique for resection of meningioma, during the last five years, were included in the study. Non-probability consecutive sampling technique was employed. Variables for demographics, and details of diagnosis and surgical procedure were recorded. The outcomes measured were length of hospital stay, worsening of neurological function during surgery and significant intra-operative or post-operative pain.ResultsSeventeen patients underwent AC for resection of meningioma during the study period. Eleven of these were grade I meningioma, and six were grade II meningioma. The mean age was 45.8 ± 10.5 years. Presenting complaints were variable, with seizures being the most common (n = 7; 41.2%). The mean duration of surgery was 180.8 ± 36.2 minutes and median estimated blood loss was 450 ml (IQR: 225 ml - 737.5 ml). The mean length of stay in the hospital was 3.1 ± 1.3 days. Only one patient had a prolonged hospital stay of seven days, because of post-operative seizures. Eleven patients (58.3%) had convexity meningioma, 4 (33.3%) had parasagittal meningioma and 1 each had a parafalcine and anterior skull-base meningioma. Simpson grade I resection was performed in 6 (41.7%) patients, grade II resection in 10 (50%) patients, and grade III resection in 1 (5.9%) patient. None of our patients had deterioration in their neurological deficits after surgery and no one required emergency intubation, conversion of surgery to general anesthesia, or redo exploration.ConclusionAC may be considered a safe modality for surgical resection of convexity and parasagittal meningioma, with no significant risk of intra-operative or post-operative pain, although it requires more evidence. It can be offered to patients who are at higher risk, or are not willing to undergo general anesthesia. Ultimately, it might also be beneficial in terms of reducing overall costs.

OS06.5A Fluorescence image-guided resection of intracranial meningioma: an experimental in vivo study on nude mice

Abstract BACKGROUND The use of photodynamic agents in malignant cranial tumor surgery is quite common. For example five-aminolevulinic acid (5-ALA)-induced porphyrins in malignant gliomas are potent photosensitizers. Until today there is no comparable selective fluorescent substance available for meningiomas. Nevertheless, there is a demand for intraoperative fluorescent identification of e.g. invasive skull base meningiomas to increase radicality. This study was established to investigate fluorescent image-guided resection with somatostatin receptor labelled fluorescence dye for intracranial meningioma in the nude mice. MATERIAL AND METHODS Primary meningioma cell culture samples were stereotactically implanted subdural into 20 nude mice. 90 days after inoculation of the cells, a cranial MRI with contrast agent revealed tumor growth. After detection of tumor mass in MRI, FAM-TOC5,6-Carboxyfluoresceine-Tyr3-Octreotide was injected intravenously and tumor mass was hereafter resected under visualization via fluorescence microscope and endoscope. After attempted total resection, animal were sacrificed brain slices were obtained and histologically analysed to verify the resection extent. RESULTS In 18 mice tumor growth was detected in MRI after 90 days of inoculation. The tumor mass could be clearly identified with fluorescence microscope and endoscope after injecting FAM-TOC5,6-Carboxyfluoresceine-Tyr3-Octreotide. The tumor margins could be better visualized. After fluorescence-guided resection no remaining tumor could be identified in histological analysis. CONCLUSION This study describes for the first time the use of FAM-TOC5,6-Carboxyfluoresceine-Tyr3-Octreotide and demonstrates its value of fluorescent identification of meningioma cells in vivo. Furthermore, the authors established a new experimental animal model for fluorescence meningioma surgery.

Association of baseline frailty status and age with postoperative morbidity and mortality following intracranial meningioma resection.

Although numerous studies have established advanced patient age as a risk factor for poor outcomes following intracranial meningioma resection, large-scale evaluation of frailty for preoperative risk assessment has yet to be examined. Weighted discharge data from the National Inpatient Sample were queried for adult patients undergoing benign intracranial meningioma resection from 2015 to 2018. Complex samples multivariable logistic regression models and receiver operating characteristic curve analysis were performed to evaluate adjusted associations and discrimination of frailty, quantified using the 11-factor modified frailty index (mFI), for clinical endpoints. Among 20,250 patients identified (mean age 60.6years), 35.4% (n = 7170) were robust (mFI = 0), 34.5% (n = 6985) pre-frail (mFI = 1), 20.1% (n = 4075) frail (mFI = 2), and 10.0% (n = 2020) severely frail (mFI ≥ 3). On univariable analysis, these sub-cohorts stratified by increasing frailty were significantly associated with the development of Clavien-Dindo grade IV (life-threatening) complications (inclusive of those resulting in mortality) (1.3% vs. 3.1% vs. 6.5% vs. 9.4%, p < 0.001) and extended length of stay (eLOS) (15.4% vs. 22.5% vs. 29.3% vs. 37.4%, p < 0.001). Following multivariable analysis, increasing frailty (aOR 1.40, 95% CI 1.17, 1.68, p < 0.001) and age (aOR 1.20, 95% CI 1.05, 1.38, p = 0.009) were both independently associated with development of life-threatening complications or mortality, whereas increasing frailty (aOR 1.20, 95% CI 1.10, 1.32, p < 0.001), but not age, was associated with eLOS. Frailty (by mFI-11) achieved superior discrimination in comparison to age for both endpoints (AUC 0.69 and 0.61, respectively). Frailty may be more accurate than advanced patient age alone for prognostication of adverse events and outcomes following intracranial meningioma resection.

Predicting the consistency of intracranial meningiomas using apparent diffusion coefficient maps derived from preoperative diffusion-weighted imaging.

The consistency of meningiomas is a critical factor affecting the difficulty of resection, operative complications, and operative time. The apparent diffusion coefficient (ADC) is derived from diffusion-weighted imaging (DWI) and is calculated using two optimized b values. While the results of comparisons between the standard ADC and the consistency of meningiomas vary, the shifted ADC has been reported to be strongly correlated with liver stiffness. The purpose of the present prospective cohort study was to determine whether preoperative standard and shifted ADC maps predict the consistency of intracranial meningiomas. Standard (b values 0 and 1000 sec/mm2) and shifted (b values 200 and 1500 sec/mm2) ADC maps were calculated using preoperative DWI in patients undergoing resection of intracranial meningiomas. Regions of interest (ROIs) were placed within the tumor on standard and shifted ADC maps and registered on the navigation system. Tumor tissue located at the registered ROI was resected through craniotomy, and its stiffness was measured using a durometer. The cutoff point lying closest to the upper left corner of a receiver operating characteristic (ROC) curve was determined for the detection of tumor stiffness such that an ultrasonic aspirator or scissors was always required for resection. Each tumor tissue sample with stiffness greater than or equal to or less than this cutoff point was defined as hard or soft tumor, respectively. For 76 ROIs obtained from 25 patients studied, significant negative correlations were observed between stiffness and the standard ADC (ρ = -0.465, p < 0.01) and the shifted ADC (ρ = -0.490, p < 0.01). The area under the ROC curve for detecting hard tumor (stiffness ≥ 20.8 kPa) did not differ between the standard ADC (0.820) and the shifted ADC (0.847) (p = 0.39). The positive predictive value (PPV) for the combination of a low standard ADC and a low shifted ADC for detecting hard tumor was 89%. The PPV for the combination of a high standard ADC and a high shifted ADC for detecting soft tumor (stiffness < 20.8 kPa) was 81%. A combination of standard and shifted ADC maps derived from preoperative DWI can be used to predict the consistency of intracranial meningiomas.

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.

Effect of tranexamic acid on blood loss, coagulation profile, and quality of surgical field in intracranial meningioma resection: A prospective randomized, double-blind, placebo-controlled study.

Background: Resection of intracranial meningioma has been associated with significant blood loss. Providing a clear surgical field and maintaining hemodynamic stability are the major goals of anesthesia during meningioma surgery. Tranexamic acid has been used to reduce blood loss in various neurosurgical settings with limited evidence in literature. A randomized, double-blind, and placebo-controlled trial was conducted to evaluate the efficacy of tranexamic acid on blood loss, coagulation profile, and quality of surgical field during resection of intracranial meningioma.Methods: Thirty patients aged 18–65 years undergoing elective meningioma resection surgery were given either tranexamic acid or placebo (0.9% saline), tranexamic acid at a loading dose of 20 mg/kg, and infusion of 1 mg/kg/h during surgery. The intraoperative blood loss, coagulation profile, and the surgical field using Likert scale were assessed.Results: The patients in tranexamic group had significantly decreased intraoperative blood loss compared to the placebo group (616.42 ± 393.42 ml vs. 1150.02 ± 416.1 ml) (P = 0.02). The quality of the surgical field was better in the tranexamic group (median score 4 vs. 2 on Likert Scale) (P < 0.001). Patients in tranexamic group had an improved coagulation profile and decreased blood transfusion requirement (p=0.016). The blood collected in closed suction drain in 24 h postsurgery was less in the tranexamic acid group compared to placebo group (84.7 ± 50.4 ml vs. 127.6 ± 62.2 ml) (P = 0.047).Conclusion: Tranexamic acid bolus followed by infusion reduces perioperative blood loss by 46.43% and blood transfusion requirement with improved surgical field and coagulation profile in patients undergoing intracranial meningioma resection surgery.

Fluorescence image-guided resection of intracranial meningioma: an experimental in vivo study on nude mice

IntroductionThe use of photodynamic agents in malignant cranial tumor surgery is quite common. For example five-aminolevulinic acid (5-ALA)-induced porphyrins in malignant gliomas are potent photosensitizers. Until today there is no comparable selective fluorescent substance available for meningiomas. Nevertheless, there is a demand for intraoperative fluorescent identification of e.g. invasive skull base meningiomas to increase radicality. This study was established to investigate fluorescent image-guided resection with somatostatin receptor labelled fluorescence dye for intracranial meningioma in the nude mice. MethodsPrimary meningioma cell culture samples were stereotactically implanted subdural into 20 nude mice. 90 days after inoculation of the cells, a cranial MRI with contrast agent revealed tumor growth. After detection of tumor mass in MRI, FAM-TOC5,6-Carboxyfluoresceine-Tyr3-Octreotide was injected intravenously and tumor mass was hereafter resected under visualization via fluorescence microscope and endoscope. After attempted total resection, animal were sacrificed brain slices were obtained and histologically analysed to verify the resection extent. ResultsIn 18 mice tumor growth was detected in MRI after 90 days of inoculation. The tumor mass could be clearly identified with fluorescence microscope and endoscope after injecting FAM-TOC5,6-Carboxyfluoresceine-Tyr3-Octreotide. The tumor margins could be better visualized. After fluorescence-guided resection no remaining tumor could be identified in histological analysis. ConclusionsThis study describes for the first time the use of FAM-TOC5,6-Carboxyfluoresceine-Tyr3-Octreotide and demonstrates its value of fluorescent identification of meningioma cells in vivo. Furthermore, the authors established a new experimental animal model for fluorescence meningioma surgery.

Meningioma Surgery in Patients ≥70 Years of Age: Clinical Outcome and Validation of the SKALE Score.

Along with increasing average life expectancy, the number of elderly meningioma patients has grown proportionally. Our aim was to evaluate whether these specific patients benefit from surgery and to investigate a previously published score for decision-making in meningioma patients (SKALE). Of 421 patients who underwent primary intracranial meningioma resection between 2009 and 2015, 71 patients were ≥70 years of age. We compared clinical data including World Health Organization (WHO) grade, MIB-1 proliferation index, Karnofsky Performance Status Scale (KPS), progression free survival (PFS) and mortality rate between elderly and all other meningioma patients. Preoperative SKALE scores (Sex, KPS, ASA score, location and edema) were determined for elderly patients. SKALE ≥8 was set for dichotomization to determine any association with outcome parameters. In 71 elderly patients (male/female 37/34) all data were available. Postoperative KPS was significantly lower in elderly patients (p < 0.0001). Pulmonary complications including pneumonia (10% vs. 3.2%; p = 0.0202) and pulmonary embolism (12.7% vs. 6%; p = 0.0209) occurred more frequently in our elderly cohort. Analyses of the Kaplan Meier curves revealed differences in three-month (5.6% vs. 0.3%; p = 0.0033), six-month (7% vs. 0.3%; p = 0.0006) and one-year mortality (8.5% vs. 0.3%; p < 0.0001) for elderly patients. Statistical analysis showed significant survival benefit in terms of one-year mortality for elderly patients with SKALE scores ≥8 (5.1 vs. 25%; p = 0.0479). According to our data, elderly meningioma patients face higher postoperative morbidity and mortality than younger patients. However, resection is reasonable for selected patients, particularly when reaching a SKALE score ≥ 8.

Predictors of recurrence and high growth rate of residual meningiomas after subtotal resection.

The extent of resection has been shown to improve outcomes in patients with meningiomas. However, resection can be complicated by constraining local anatomy, leading to subtotal resections. An understanding of the natural history of residual tumors is necessary to better guide postsurgical management and minimize recurrence. This study seeks to identify predictors of recurrence and high growth rate following subtotal resection of intracranial meningiomas. Adult patients who underwent primary surgical resection of a WHO grade I meningioma at a tertiary care institution from 2007-2017 were retrospectively reviewed. Volumetric tumor measurements were made on patients with subtotal resections. Stepwise multivariate proportional hazards regression analyses were performed to identify factors associated with time to recurrence, as well as stepwise multivariate regression analyses to assess for factors associated with high postoperative growth rate. Of the 141 patients (18%) who underwent radiographic subtotal resection of an intracranial meningioma during the reviewed period, 74 (52%) suffered a recurrence, in which the median (interquartile range, IQR) time to recurrence was 14 (IQR 6-34) months. Among those tumors subtotally resected, the median pre- and postoperative tumor volumes were 17.19 cm3 (IQR 7.47-38.43 cm3) and 2.31 cm3 (IQR 0.98-5.16 cm3), which corresponded to a percentage resection of 82% (IQR 68%-93%). Postoperatively, the median growth rate was 0.09 cm3/year (IQR 0-1.39 cm3/year). Factors associated with recurrence in multivariate analysis included preoperative tumor volume (hazard ratio [HR] 1.008,95% confidence interval [CI] 1.002-1.013, p = 0.008), falcine location (HR 2.215, 95% CI 1.179-4.161, p = 0.021), tentorial location (HR 2.410, 95% CI 1.203-4.829, p = 0.024), and African American race (HR 1.811, 95% CI 1.042-3.146, p = 0.044). Residual volume (RV) was associated with high absolute annual growth rate (odds ratio [OR] 1.175, 95% CI 1.078-1.280, p < 0.0001), with the maximum RV benefit at < 5 cm3 (OR 4.056, 95% CI 1.675-9.822, p = 0.002). By identifying predictors of recurrence and growth rate, this study helps identify potential patients with a high chance of recurrence following subtotal resection, which are those with large preoperative tumor volume, falcine location, tentorial location, and African American race. Higher RVs were associated with tumors with higher postoperative growth rates. Recurrences typically occurred 14 months after surgery.

Surgery on giant meningiomas in very old patients entails frequent postoperative intracranial hemorrhages and atypical histopathology

PurposeSurgical resection of intracranial meningiomas in patients that are 80 years old and older, i.e. very old patients, is increasingly considered. Meningiomas with a largest diameter of at least 5 cm—‘giant meningiomas’—form a distinct entity, and their surgical resection is considered more difficult and prone to complications. Here, we evaluated functional outcome, morbidity and mortality, and the prognostic value of tumor size in very old patients who underwent resection of giant supratentorial meningiomas.MethodsWe retrospectively reviewed clinical and radiological data, functional performance (Karnofsky Performance Score), histopathological diagnosis and complications of very old patients who underwent surgery of a supratentorial meningioma at the Helsinki University Hospital between 2010 and 2018.ResultsWe identified 76 very old patients, including 28 with a giant meningioma. Patients with a giant meningioma suffered from major complications more commonly than those with a non-giant meningioma (36% vs. 17%, p = 0.06), particularly from postoperative intracranial hemorrhages (ICH). At the 1-year follow-up, functional performance and mortality rate were comparable between patients with giant meningiomas and those with non-giant meningiomas. An exceptionally high rate of giant meningiomas were diagnosed as atypical meningiomas (WHO II) at an (11 out of 28 cases).ConclusionsGiant meningioma surgery entails a high complication rate in frail, very old patients. The prevention of postoperative ICH in this specific patient group is of utmost importance. An atypical histopathology was notably frequent among very old patients with a giant meningioma, which should be taken into account when planning the surgical strategy.

The incidence of venous thromboembolism following surgical resection of intracranial and intraspinal meningioma. A systematic review and retrospective study

IntroductionHistorically, the development of venous thromboembolism (VTE) including deep venous thrombosis (DVT) and pulmonary thromboembolism (PE) was cited as a higher post-operative risk for patients harboring meningiomas. However, recent literature has suggested that there may be no elevated risk for VTE among these patients. The authors perform both a retrospective review of their own cases as well as a systematic review of the literature in order to determine the frequency of the VTE and rate of post-operative hemorrhage in this patient population. MethodologyPatients undergoing surgery for intracranial and spinal meningioma from 2012 to 2019 were retrospectively reviewed for patient demographics, clinical characteristics, and post-operative complications. Logistic regression was used to determine risk factors for the development of VTE. Additionally, a PubMed search was performed to identify patients addressing this topic. ResultsOur retrospective review included 189 patients who underwent 197 operations. The rate of VTE for patients receiving LMWH was 3.55 % vs. 4.06 % for those not receiving LMWH. There were no observed hemorrhages after initiation of LMWH. Multivariate analysis found tumor volume, history of DVT, and length of hospital stay as independent risk factors for VTE. In the systematic review, 11 papers describing 28,954 patients were included. The risk of developing a VTE with or without LMWH was 2.71 % versus 4.07 %, respectively. The hemorrhage risk was 2.23 % on LMWH versus 4.20 % not on LMWH. DiscussionIn several heterogeneous series of all types of neurosurgical procedures, the reported rate of VTE was 11.1 %. In our review of the literature, the VTE rate of 2.71 % was similar to our cohort's rate of 3.55 %, for patients administered LMWH postoperatively. Higher rates of VTE with meningiomas may not be the case as once thought. Regular use of LMWH appears to be a safe, but it also did not necessarily lower the rates of VTE in our cohort. The use of routine lower-extremity duplex ultrasound, mechanical prophylaxis, and early mobilization, may have contributed to these lower rates of VTEs in patients with meningiomas.

Frailty predicts worse outcomes after intracranial meningioma surgery irrespective of existing prognostic factors.

Frailty has been recognized as a predictor of adverse surgical outcomes across multiple surgical disciplines, but until now the relationship between frailty and intracranial meningioma surgery has not been studied. The goal of the present study was to determine the relationship between increasing frailty (determined using the modified Frailty Index [mFI]) and intracranial meningioma resection outcomes (including hospital length of stay [LOS], discharge location, and reoperation and readmission rates). This is a single-center retrospective cohort study of patients who underwent intracranial meningioma resection between August 2012 and May 2018. Seventy-six patients met the inclusion criteria. Frailty was associated with increased hospital LOS (p = 0.0218), increased reoperation rate (p = 0.029), and discharge to a higher level of care: an inpatient rehabilitation facility or a skilled nursing facility (p = 0.0002). After multivariable analysis, frailty was determined to be an independent risk factor for increased LOS, worse discharge disposition, and subsequent readmission. Frailty is an independent risk factor for worse outcomes following intracranial meningioma resection, including increased LOS, reoperations, and worse discharge disposition. Frailty may help stratify preoperative surgical risk, and thus may provide important clinical information to help neurosurgeons and elderly patients weigh the risks and benefits of resection.