Resection Of Intracranial Meningiomas Research Articles

Preoperative Radiographic Features Independently Predict High Blood Loss During Intracranial Meningioma Resection: A Case-Control Study

Surgical resection of intracranial meningioma carries the risk of several complications, including intraoperative blood loss. The objective of this study was to investigate preoperative clinical and radiographic factors predictive of intraoperative estimated blood loss (EBL). This case-control study evaluated EBL for all adults who underwent intracranial meningioma resection from January, 2010 to December, 2021 at our institution. Fifty cases of high EBL (i.e., ≥500mL) and 75 instances of low EBL (i.e., <500mL) were randomly selected. Patients were excluded if they had a recurrent meningioma, preoperative embolization, or lack of imaging data. A multivariable logistic regression model of high EBL likelihood was created. A total of 92 patients met eligibility criteria, with 48 (52%) cases of high EBL. Bivariable analyses identified maximal tumor diameter, intratumoral flow voids, skull base location, and dural venous sinus invasion as potential predictors of high EBL. Multivariable regression found intratumoral flow voids (adjusted odds ratio [aOR]= 5.68 [1.52-21.23], P= 0.009), maximal tumor diameter (aOR= 1.58 [1.11-2.25] per 1-cm increase, P= 0.01), and skull base location (aOR= 3.35 [1.19-9.41], P= 0.02) to be independent predictors of high EBL. Intratumoral flow voids, larger maximal tumor diameter, and skull base location were independently predictive of EBL ≥500mL. Intratumoral flow void presence was the strongest predictor, with 5.68 times the odds of high EBL. Each 1-cm increase in tumor diameter had 58% greater odds of high EBL. Skull base location was associated with 3.35 times the odds of high EBL. These results can inform preoperative patient counseling and blood management preparation.

Prediction of Intraoperative Blood Loss during Surgery of Brain Meningiomas

Abstract Background The utilization of preoperative embolization is a well-established method for reducing intraoperative blood loss during surgery of meningiomas. However, the exact indications and contraindications for this technique remain controversial. Objective The objective of this study is to determine the indications for preoperative embolization of brain meningiomas. Materials and Methods A retrospective analysis of 46 patients who underwent surgical resection of intracranial meningioma from 2020 to the end of 2022 was conducted. Preoperative magnetic resonance imaging (MRI) and computed tomography (CT) data were studied to assess their relationship with the volume of intraoperative blood loss. Results Invasive tumor growth and bone involvement (erosion, hyperostosis) were found to be the most significant factors influencing intraoperative blood loss (p = 0.001). Conclusion This study clearly demonstrates an association between preoperative imaging data and intraoperative blood loss, which may be useful in predicting massive bleeding during surgery.

Frailty in intracranial meningioma resection: the risk analysis index demonstrates strong discrimination for predicting non-home discharge and in-hospital mortality.

Frailty is an independent risk factor for adverse postoperative outcomes following intracranial meningioma resection (IMR). The role of the Risk Analysis Index (RAI) in predicting postoperative outcomes following IMR is nascent but may inform preoperative patient selection and surgical planning. IMR patients from the Nationwide Inpatient Sample were identified using diagnostic and procedural codes (2019-2020). The relationship between preoperative RAI-measured frailty and primary outcomes (non-home discharge (NHD), in-hospital mortality) and secondary outcomes (extended length of stay (eLOS), complication rates) was assessed via multivariate analyses. The discriminatory accuracy of the RAI for primary outcomes was measured in area under the receiver operating characteristic (AUROC) curve analysis. A total of 23,230 IMR patients (mean age = 59) were identified, with frailty statuses stratified by RAI score: 0-20 "robust" (R)(N = 10,665, 45.9%), 21-30 "normal" (N)(N = 8,895, 38.3%), 31-40 "frail" (F)(N = 2,605, 11.2%), and 41+ "very frail" (VF)(N = 1,065, 4.6%). Rates of NHD (R 11.5%, N 29.7%, F 60.8%, VF 61.5%), in-hospital mortality (R 0.5%, N 1.8%, F 3.8%, VF 7.0%), eLOS (R 13.2%, N 21.5%, F 40.9%, VF 46.0%), and complications (R 7.5%, N 11.6%, F 15.7%, VF 16.0%) significantly increased with increasing frailty thresholds (p < 0.001). The RAI demonstrated strong discrimination for NHD (C-statistic: 0.755) and in-hospital mortality (C-statistic: 0.754) in AUROC curve analysis. Increasing RAI-measured frailty is significantly associated with increased complication rates, eLOS, NHD, and in-hospital mortality following IMR. The RAI demonstrates strong discrimination for predicting NHD and in-hospital mortality following IMR, and may aid in preoperative risk stratification.

The association of thromboembolic complications and the use of tranexamic acid during resection of intracranial meningiomas: systematic review and meta-analysis of randomized controlled trials.

Antifibrinolytics, such as tranexamic acid (TXA), have been shown to decrease intraoperative blood loss across multiple surgical disciplines. However, they carry the theoretical risk of thromboembolic events secondary to induced hypercoagulability. Therefore, the aim of this study was to systematically review the available literature and perform a meta-analysis on the use of TXA in meningioma resection to assess thromboembolic risks. The PubMed, Web of Science, and Google Scholar databases were reviewed for all randomized controlled trials presenting primary data on TXA use during resection of intracranial meningiomas. Data were gathered on operative duration, venous thromboembolic complications, deep venous thrombosis, use of allogeneic blood transfusion, estimated blood loss (EBL), and postoperative hemoglobin. Patients who received TXA were compared with controls who did not receive TXA intraoperatively using random-effects models. A total of 508 unique articles were identified, of which 493 underwent full-text review. Ultimately, 6 studies with 381 total patients (190 receiving TXA) were included in the final analysis. All 6 trials were randomized, blinded, and placebo controlled with a TXA administration rate of a 20-mg/kg load followed by a 1-mg/kg/hr infusion. All studies were performed in lower-middle-income countries. There were no reported instances of venous thromboembolism (VTE) in the TXA and non-TXA cohorts. Patients receiving TXA exhibited fewer allogeneic transfusions (21.5% vs 41.6% [OR 0.26, 95% CI 0.09-0.77], p = 0.02) and lower EBL (MD -282.48 mL [95% CI -367.77 to -197.20 mL], p < 0.001) compared with patients who did not receive TXA, and they also had lower rates of perioperative complications (10.7% vs 19.9% [OR 0.47, 95% CI 0.2-0.95], p = 0.04). Current literature suggests that TXA is not associated with increased risk for VTE when administered during resection of intracranial meningioma. TXA appears to decrease intraoperative blood loss and allogeneic transfusion requirements during meningioma resection and thus may improve the safety of surgical management of this pathology.

Lumbar clear cell meningioma mimicking schwannoma 7 years after resection of the same type of intracranial tumor: a case report

BackgroundMeningioma is the second most common intradural extramedullary tumor, following schwannoma. Meningioma is primarily categorized as benign World Health Organization grade 1, but clear cell meningioma is grade 2 of the intermediate malignant category. Clear cell meningiomas are rare, accounting for less than 1% of all meningioma tumors. There is no previous report of multiple intraspinal clear cell meningiomas without dural attachment.Case presentationA 27-year-old Asian male patient presented with lower right extremity pain, and had undergone tumor resection for intracranial clear cell meningioma 7 years previously, with re-resection and radiotherapy for local tumor recurrence at our hospital’s department of neurosurgery being carried out 4 years previously. No recurrence was observed since then. Preoperative lumbar magnetic resonance imaging showed two tumors at the L1 and L4 levels, both mimicking schwannoma with well-defined margins, no dural tail sign and homogeneous internal contrast. Intraoperative findings on tumor resection showed two tumors contiguous with the right L2 and L5 roots, which were not attached to the dura mater, similar to a schwannoma. After gross total resection, the postoperative pathology revealed no nuclear SMARCE1 antibody staining. The patient was diagnosed with clear cell meningioma. The patient’s postoperative course went well, with no symptoms of nerve dropout and no recurrence 2 years after surgery. In this case, both lumbar lesions were well demarcated and spherical in shape, occurring with single roots. Tumor characteristics suggested a primary rather than a metastatic lesion. Clear cell meningioma is characterized by a SMARCE1 mutation and is different from other types of meningiomas.ConclusionTo the best of our knowledge, this is the first report of multiple intraspinal clear cell meningiomas without dural attachment at the lumbar spine after resection of intracranial clear cell meningioma. We speculate that the two tumors were de novo lesions on the basis of the features of the tumors, although they were detected 7 years after the resection of intracranial clear cell meningioma.

Perioperative blood transfusion management in surgical resection of intracranial meningiomas: A meta-analysis.

Gross total resection (GTR) of intracranial meningiomas is curative in most cases. However, perioperative blood transfusions may be necessary for complex skull bases and/or high-grade meningiomas. Guidelines for blood transfusions during intracranial meningioma surgery remain unclear. This scoping review aims to delineate the main characteristics of patients who underwent intracranial meningioma surgery, the prevalence of the selected patients who required blood transfusions, and common causes for transfusion. A scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews guidelines to include studies reporting eligibility, protocols, and potential complications related to blood transfusion within the perioperative management of intracranial meningiomas. A total of 33 articles encompassing 3009 meningioma patients were included in the study. The most common symptom was headache (18%), and the most frequent type of meningioma was World Health Organization grade-1 meningothelial (50.4%). The lateral supraorbital approach was the most common surgical corridor (59.1%) in skull base meningiomas, and most patients underwent GTR (69%). Blood transfusion was required for 20% of patients, with a mean estimated intraoperative blood loss of 703 mL (ranging from 200 mL to 2000 mL). The main indications for blood transfusion in meningioma surgery were intraoperative blood loss (86%) and preoperative anemia (7.3%). This scoping found that 20% of the included patients required blood transfusion. It also points out that several factors could influence the necessity for a transfusion, encompassing surgical blood loss, pre-existing anemia, and the surgery's length. This scoping review may provide surgeons with a potential guide to inform their decision-making process regarding blood transfusions during meningioma surgeries.

Evaluation of the health-related quality of life in dogs following intracranial meningioma resection using a specifically developed questionnaire.

As advanced treatments are becoming increasingly feasible in veterinary medicine, the evaluation of the health-related quality of life (HRQOL) of treated animals is becoming more relevant. We evaluated owner-perceived HRQOL of 10 dogs that underwent craniotomy for meningioma resection between 2002 and 2022 at our institution through telephone interview. For this purpose, we developed a disease-specific questionnaire containing 52 items (mostly of scoring nature) patterned after previously validated instruments and organised into eight domains. Approval by the Human Ethical Committee and respondents' consent were obtained. We analysed the scores for all domains and dogs. The effect of different variables on the HRQOL score was determined via log-rank test and Pearson correlation. Scores for all included dogs (range, 0-235 points) were totaled, with a higher number of points indicating a better HRQOL. The dogs included in this study yielded a mean score of 200.6 points (range, 176-227 points), implying a good overall quality of life. There were no significant associations between individual parameters and outcomes. Our questionnaire represents a structured tool for the specific evaluation of postoperative HRQOL in dogs with meningioma, placing a minimal burden on respondents. Few instruments have been developed to assess animal welfare in a disease-specific context. Implementing these tools, however, is essential to accurately evaluate not only the impact of treatments on biologic parameters, but also their implications on patient welfare. Thus, treatment plans may consider HRQOL for a more comprehensive clinical decision-making process.

Timing and Morbidity of Intracranial Meningioma Resection Complications

Intracranial meningioma resection is associated with multiple acute postoperative complications, including cerebrovascular accidents, surgical site infections, and pneumonia. There is a paucity of research on the postoperative timeframe of these complications. Therefore, our objective is to characterize intracranial meningioma resection complications' time courses. The National Surgical Quality Improvement Project registry was queried for intracranial meningioma resection cases using CPT codes 61512 and 61519 from years 2016 to 2021. Baseline patient characteristics and 30-day complication frequency were calculated. The mean, median, and interquartile range of postoperative days to occurrence for 17 complications were calculated. Percent incidence predischarge was recorded. Time-to-occurrence curves were created. Rates of 30-day mortality and increased length-of-stay were compared between patients with and without each complication using a χ2 test. A covariance matrix showing associations between 11 complications using the Pearson method was made. Significance was set at P < 0.05. Ten thousand eight hundred ninety cases were analyzed. The most frequent complications' median and interquartile range of postoperative days to occurrence and percentage occurring predischarge were bleeding requiring transfusion (0.0, 0.0-0.0, 99.9%), cerebrovascular accident/stroke with neurological deficit (2.0, 1.0-6.0, 83.8%), unplanned intubation (4.0, 1.0-8.0, 75.1%), on a ventilator for >48hours (3.0; 2.0-5.5; 88.1%), deep vein thrombosis/thrombophlebitis (12.5, 5.2-19.7, 41.3%), urinary tract infection (13.0, 7.0-20.0, 44.2%), pneumonia (8.0, 4.0-16.0, 60.5%), and pulmonary embolism (14.0, 6.0-20.0, 29.1%). Most complications were associated with increased mortality and length-of-stay. Postoperative meningioma resection complications have varying morbidity and timeframes. Surgeons should be aware of complication timing to better manage postoperative care.

Imaging and Pathological Features and Recurrence Causes of Cystic Meningioma

Objective: This study aims to establish preoperative imaging features, establish how they are correlating with post-operative pathological features, and discover the causes of recurrence. Results: Data on imaging procedures in the preoperative period, records of surgical operations, and reports from pathology conclusions were collected. Among 623 patients who were undergoing neurosurgery resection of intracranial meningioma, 24 cases of cystic meningioma were identified, corresponding to a world incidence of 3.8 %. The hemispheric convexity was the most frequent place of localization. The apparent diffusional coefficient was significantly lower in grade 2 and grade 3 tumors if compared to grade 1. Full resection of the cystic component was possible in 18/24 cases. Partial resection in 3/24 cases. In 2/24 cases, it was not possible to make total or partial resection, but multiple biopsies were performed from the cystic walls.

Augmented reality for intracranial meningioma resection: a mini-review.

Augmented reality (AR) integrates computer-generated content and real-world scenarios. Artificial intelligence's continuous development has allowed AR to be integrated into medicine. Neurosurgery has progressively introduced image-guided technologies. Integration of AR into the operating room has permitted a new perception of neurosurgical diseases, not only for neurosurgical planning, patient positioning, and incision design but also for intraoperative maneuvering and identification of critical neurovascular structures and tumor boundaries. Implementing AR, virtual reality, and mixed reality has introduced neurosurgeons into a new era of artificial interfaces. Meningiomas are the most frequent primary benign tumors commonly related to paramount neurovascular structures and bone landmarks. Integration of preoperative 3D reconstructions used for surgical planning into AR can now be inserted into the microsurgical field, injecting information into head-up displays and microscopes with integrated head-up displays, aiming to guide neurosurgeons intraoperatively to prevent potential injuries. This manuscript aims to provide a mini-review of the usage of AR for intracranial meningioma resection.

MENINGIOMA-03 FUNCTIONAL OUTCOME AFTER SURGERY FOR INTRACRANIAL MENINGIOMA AT THE KENYATTA NATIONAL HOSPITAL

Abstract BACKGROUND Intracranial meningiomas represent 34.4% to 41.4% of all brain tumors at the Kenyatta National Hospital. Surgical outcomes have been asessed priviously by Simpson grade achieved at surgery, recurrence rates, rates of complication, overall and progression free survival amongst other surgical outcomes. The functional outcome that assess the performance of these patients in activities of daily life is a less studied outcome. BROAD OBJECTIVE This was a retrospective observational cross-sectional study to determine the functional outcome after surgery for intracranial meningioma among adult patients operated at the Kenyatta National Hospital MATERIALS AND METHOD Exposure data was collected on age, sex, extent of resection (Simpson grade) of intracranial Meningioma, and WHO grade of meningioma. Outcome data was the Functional Independent Measure. RESULTS 42 participants were enrolled, with an average age of 46.8 years and a male-to-female ratio of 1:4.25. Mean presentation was within 13.6 months with headaches 97.7% and seizures 41.9%. Average size of meningioma was 138.4 cm3, and perilesional edema was observed in 90.6% of cases. Surgical resection achieved a Simpson grade II in 52.4% of cases and Simpson grade I in 38.1% of cases. Histologic grade was commonly WHO grade 1 (95.2%), specifically the Meningothelial variant (61.9%). Functional status improved with a mean total gain of 161.9% in the Functional Independent Measure (FIM), a motor sub score gains of 174%, and a cognitive sub score gain of 149.6%. There was no statistically relevant association between the functional outcome and extent of surgical resection. CONCLUSION There was statistically significant improvement in the functional outcome after surgery for intracranial meningioma measured using the Functional Independence Measure. The Simpson grade achieved at surgery did not influence the functional outcome.

Utilization of a Cogmed working memory training program in patients with neurocognitive impairment following the resection of intracranial meningioma: Case series and review of the literature

Meningioma is the most common primary brain tumor in adults. Patients may become symptomatic due to the resultant mass effect and the peritumoral vasogenic edema. The majority of existing research on neurocognitive impairment in patients with brain tumors has focused on gliomas while less research has been conducted on the effects of tumor and/or surgical intervention on neurocognitive function in patients with meningioma. We conducted a prospective study on the utilization of the Cogmed Working Memory Training (CWMT) program in patients who underwent surgical resection of WHO grade I intracranial meningioma and experienced neurocognitive impairment after surgery. All patients had a significant improvement in their post-CWMT neurocognitive function evaluation compared to their baseline post-surgical neurocognitive evaluation, and the improvement was maintained at a three-month follow-up. This study is the first to evaluate the effectiveness of a neurocognitive rehabilitation program in augmenting the neurocognitive functioning of patients with Intracranial WHO Grade I Meningioma. The results of this study demonstrate the efficacy of the CWMT program in improving postoperative impaired neurocognitive function and potentially improving the quality of life of our patients.

Risk factors for intraoperative blood loss in resection of intracranial meningioma: Analysis of 530 cases.

Excision of intracranial meningioma has been associated with major intraoperative blood loss (IBL). The objective of the study was to identify factors affecting IBL during removal of meningioma. We retrospectively studied medical records of 530 adult patients who underwent surgery for intracranial meningioma at Sichuan Provincial People's Hospital between September 2018 and May 2022. We obtained the following data from each patient's medical chart: age, sex, height, weight, comorbidities, blood pressure, history of smoking and alcohol, imaging examination findings, pathologic diagnosis, albumin, creatinine, calcium, magnesium, hemoglobin (Hb), hematocrit, platelet count, activated partial thromboplastin time, international normalized ratio, fibrinogen concentration and blood transfusion. Univariate and multivariate analyses were performed to identify risk factors for greater IBL during removal of intracranial meningioma. A total of 530 patients were included in our study. Univariate analysis revealed that sex (p = 0.004), two-dimensional (2D) tumor area (p < 0.001), sinus involvement (p = 0.014), World Health Organization grade (p = 0.015), preoperative albumin level (p = 0.032), preoperative Hb level (p = 0.001) and preoperative platelet count (p = 0.004) were significantly associated with greater IBL. Multivariate analysis revealed that greater 2D tumor area (p < 0.001), higher preoperative albumin concentration (p = 0.029) and higher preoperative platelet count (p = 0.03) were independent risk factors for greater IBL in resection of intracranial meningioma. Larger tumor size, higher preoperative albumin concentration and higher preoperative platelet count were identified as independent risk factors for greater IBL in resection of intracranial meningioma.

Significance of Early Postoperative Magnetic Resonance Imaging following Intracranial Meningioma Resection.

The significance of early postoperative magnetic resonance imaging (MRI) for meningioma resection has not yet been evaluated. We retrospectively reviewed patients with intracranial meningiomas resected at our institute between 2011 and 2021. Early postoperative MRI with contrast enhancement was routinely performed within 48 h after surgery while first follow-up MRI was performed approximately after 6 months. MRI findings were reviewed, and the risk factors for postoperative infarction and early recurrence were analyzed. Among the 245 resections performed, early postoperative MRI was performed in 200 cases. Postoperative radiological and symptomatic infarctions occurred in 54 (27%) and 17 patients (9%), respectively. Diameter > 5 cm (p = 0.015) and skull base location (p = 0.010) were independent risk factors for radiological infarctions. Follow-up postoperative MRI performed in 180 patients (90%) detected early recurrence in 24 patients (13%). Non-gross total resection was an independent risk factor for early recurrence (p < 0.0001). Additionally, early recurrence after gross total resection occurred significantly more frequently in meningiomas with dural sinus involvement than in those without (8.3% vs. 0%, p = 0.018). Thus, early postoperative MRI may enable the timely assessment of postoperative neurological deficits, especially after large skull base meningioma resections along with accurate detection of early recurrence, which is critical for meningiomas with dural sinus involvement.

Circular multiple burr hole for surgical removal of an extra and intracranial meningioma (technical note)

Introduction. Intracranial meningiomas are the most common primary central nervous system tumors and are mostly benign, arising from the meninges surrounding the brain, nerves, and vessels. An obstacle to the surgical resection of meningiomas is the risk of injury to the superior sagittal sinus and the resulting compromise to the integrity of the venous drainage. This article describes a circular multiple trepanation technique, which can be used to safely perform resection of extracranial and intracranial meningiomas, aiming to reach the largest possible tumor area, since patient prognosis is directly proportional to tumor resection.Surgical technique. The first step is to make a horseshoe incision, then drill burr holes, forming a circumference around the bone meningioma. The next step is to connect the orifices, incising the dura mater affected by the tumor along the periphery of the extracranial meningioma. Subsequently, the bone and the dura mater are elevated. Thus, the bone and dural part are separated from the intradural part, which is, in turn, removed later. Results. The circular multiple trepanation technique was performed and a gross total resection of the extracranial and intracranial meningioma (Simpson grade I) was achieved. The postoperative period showed positive results, with an improvement in the patient’s eye disorder and interruption of generalized tonic‑clonic seizures.Conclusion. The circular multiple trepanation approach for treating extracranial and intracranial meningiomas described in this note is performed safely and effectively, with good patient prognosis. Although it is a recognized option, it has been insufficiently described, and it is therefore important to expand the knowledge and proper use of this technique among neurosurgeons.

Associations of race and socioeconomic status with outcomes after intracranial meningioma resection: a systematic review and meta-analysis.

Social determinants of health broadly affect healthcare access and outcomes. Studies report that minorities and low socioeconomic status (SES) patients undergoing intracranial meningioma resection demonstrate worse outcomes and higher mortality rates. This systematic review and meta-analysis summarizes the available research reporting racial and SES disparities in intracranial meningioma resection outcomes. A systematic review was conducted using PRISMA guidelines and included peer-reviewed, English-language articles from the United States between 2000 and 2022 that reported racial and SES disparities in meningioma outcomes. Outcomes included overall survival (OS), extent of resection (EOR), hospitalization costs, length of stay (LOS), 30-day readmission, recurrence, and receipt of surgery and adjuvant radiotherapy. A quantitative meta-analysis was performed only on survival outcomes by race. All other variables were summarized as a systematic review. 633 articles were identified; 19 studies met inclusion criteria. Black or low SES patients were more likely to have increased hospitalization costs, rates of 30-day readmission, LOS, recurrence and less likely to undergo surgery, gross total resection, and adjuvant radiotherapy for their tumors. Six studies were used for the quantitative meta-analysis of race and OS. Compared to White patients, Black patients had significantly worse survival outcomes, and Asian patients had significantly better survival outcomes. Disparities in outcomes exist for patients who undergo surgery for meningioma, such that Black and low SES patients have worse outcomes. The literature is quite sparse and contains confounding relationships not often accounted for appropriately. Further studies are needed to help understand these disparities to improve outcomes.

Clinical tool for prognostication of discharge outcomes following craniotomy for meningioma

BackgroundPatients' comorbidities might affect the immediate postoperative morbidity and discharge disposition after surgical resection of intracranial meningioma. ObjectiveTo study the impact of comorbidities on outcomes and provide a web-based application to predict time to favorable discharge. MethodsA retrospective review of the prospectively collected national inpatient sample (NIS) database was conducted for the years 2009–2013. Time to favorable discharge was defined as hospital length of stay (LOS). A favorable discharge was defined as a discharge to home and a non-home discharge destination was defined as an unfavorable discharge. Cox proportional hazards model was built. Full model for time to discharge and separate reduced models were built. ResultsOf 10,757 patients who underwent surgery for meningioma, 6554 (60%) had a favorable discharge. The median hospital LOS was 3 days (interquartile range [IQR] 2–5). In the full model, several clinical and socioeconomic factors were associated with a higher likelihood of unfavorable discharge. In the reduced model, 13 modifiable comorbidities were negatively associated with a favorable discharge except for drug abuse and obesity, which are not associated with discharge. Both models accurately predicted time to favorable discharge (c-index:0.68–0.71). ConclusionWe developed a web application using robust prognostic model that accurately predicts time to favorable discharge after surgery for meningioma. Using this tool will allow physicians to calculate individual patient discharge probabilities based on their individual comorbidities and provide an opportunity to timely risk stratify and address some of the modifiable factors prior to surgery.

Letter: Frailty-Based Prehabilitation for Patients Undergoing Intracranial Meningioma Resection.

To the Editor: Intracranial meningioma resection (IMR) carries significant morbidity and mortality despite being a benign tumor and less aggressive than malignant brain tumors.1,2 In recent years, moving beyond chronological age, baseline frailty status has been identified as a more robust predictor of postoperative outcomes of IMR.3-8 Frail patients undergoing IMR have been reported to have increased incidence of postoperative complications, increased length of hospital stay, and nonhome discharge destination.3-8 Cole et al3 reported that frail patients undergoing resection of intracranial meningiomas were approximately 11 times more likely to develop postoperative adverse events. Frailty affects how the body responds to the alteration of homeostasis during surgery,9 and frailty-based prehabilitation of patients at risk can lead to improved outcomes. Although this association has been extensively demonstrated using various frailty indices and preoperative risk stratification tools in spine surgery patients,10,11 frailty-based prehabilitation remains yet to be implemented for brain tumor resection patients in general and for IMR in particular. This remains relevant for IMR as most of these patients (apart from high-grade meningiomas with obstructive symptoms) do not require emergent/urgent surgery and can undergo frailty-based prehabilitation for improved outcomes (Figure).FIGURE.: A graphical representation of frailty-directed prehabilitation measures to improve postoperative outcomes.Several studies have reported on worse postoperative outcomes predicted by poor preoperative frailty status assessed by using different indices (Table), including the Risk Analysis Index (RAI) and the Modified Frailty Index (MFI).12,13 RAI is a robust frailty score based on 11 variables that captures the true phenotypic manifestation of frailty—sex, age, cancer diagnosis (excluding melanoma), unintentional weight loss, renal failure, congestive heart failure, poor appetite, shortness of breath at rest, residence defined as not independent living, cognitive deterioration, and activities of daily living (ADL) defined as functional status. Each component of RAI has significance in frailty assessment and serves as a guide to prehabilitation. For instance, interventions such as smoking cessation and inspiratory muscle training target shortness of breath and have been shown to reduce the overall LOS after elective surgical procedures.14 Exercise and physical therapy helps reduce functional dependence before surgery.15 Other frailty-specific interventions that have proven efficacy in enhancing postoperative outcomes include nutritional rehabilitation to target poor appetite and cognitive behavioral therapy in patients with excessive fear or cognitive deterioration.11 The 5-factor MFI assigns 1 point each based on the presence of diabetes mellitus, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and dependent functional status.13 It is largely made up on comorbid conditions that may not capture true frailty, thus compromising its effectiveness in determining prehabilitative measures. RAI has proven to be a better predictor of outcomes after surgery and could be a more useful tool during prehabilitation measures.16 TABLE. - Predictive Ability of Preoperative Frailty Score on Postoperative Outcomes of IMR Author Year FI Outcomes OR (95% CI) Thommen et al 6 2022 RAI Major complications 2.94 (1.39-6.20) Clavien IV complications 3.99 (1.68-9.46) LOS 15.73 (7.45-33.24) Nonhome discharge destination 13.61 (6.40-28.94) Cole et al 3 2022 mFI-5 Mortality 11.17 (3.45-36.19) Major complications 4.15 (2.46-6.99) Unplanned readmission 4.37 (2.68-7.12) Unplanned reoperation 2.31 (1.17-4.55) Extended LOS 4.28 (2.74-6.68) Nonhome discharge 9.34 (6.03-14.47) Dicpinigaitis et al 4 2021 mFI-11 LOS (1.20, 1.10-1.32) Life-threatening complications/mortality (1.40, 1.17- 1.68) Theriault et al 5 2020 mFI-11 Nonhome discharge 0.131 (0.022-0.773) Readmission 0.131 (0.022-0.773) Taricotti et al 7 2022 FI Early (14.752, 1.463-148.777) and late (35.457, 25.210-41.318) postoperative functional deterioration Ikawa et al 8 2022 mFI-5 Worsening Barthel Index score 1.4 (1.1-1.7) In-hospital mortality 5.0 (2.2-11.1) Complications 1.7 (1.4-2.0) FI, Frailty Index; IMR, intracranial meningioma resection; LOS, length of stay; OR, odds ratio; RAI, Risk Analysis Index. A recent study by our group has shown RAI's robust predictive ability for brain tumor resection outcomes including IMR,6 thus raising the possibility of using RAI-based prehabilitaion for IMR patients. Emphasizing on preoperative rehabilitation measures for IMR could improve a patient's physiological reserve and reduce postoperative adverse events.7 Unlike malignant tumors, intracranial meningiomas are associated with lower rates of mortality and recurrence.17 We believe that the less urgent need to proceed with surgical resection in patients harboring these tumors could allow for preoperative optimization of a patient's physiological reserve. This would guide clinical decision-making by allowing for a tailored approach to improving a patient's ability to cope with surgery.

Impact of a cell cycle and an extracellular matrix remodeling transcriptional signature on tumor progression and correlation with EZH2 expression in meningioma.

The authors searched for genetic and transcriptional signatures associated with tumor progression and recurrence in their cohort of patients with meningiomas, combining the analysis of targeted exome, NF2-LOH, transcriptome, and protein expressions. The authors included 91 patients who underwent resection of intracranial meningioma at their institution between June 2000 and November 2007. The search of somatic mutations was performed by Next Generation Sequencing through a customized panel and multiplex ligation-dependent probe amplification for NF2 loss of heterozygosity. The transcriptomic profile was analyzed by QuantSeq 3' mRNA-Seq. The differentially expressed genes of interest were validated at the protein level analysis by immunohistochemistry. The transcriptomic analysis identified an upregulated set of genes related to metabolism and cell cycle and downregulated genes related to immune response and extracellular matrix remodeling in grade 2 (atypical) meningiomas, with a significant difference in recurrent compared with nonrecurrent cases. EZH2 nuclear positivity associated with grade 2, particularly with recurrent tumors and EZH2 gene expression level, correlated positively with the expression of genes related to cell cycle and negatively to genes related to immune response and regulation of cell motility. The authors identified modules of dysregulated genes in grade 2 meningiomas related to the activation of oxidative metabolism, cell division, cell motility due to extracellular remodeling, and immune evasion that were predictive of survival and exhibited significant correlations with EZH2 expression.

Association between preoperative hematologic markers and aggressive behavior in meningiomas

IntroductionMeningiomas have varying degrees of aggressive behavior. Some systemic hematologic makers are associated with malignancy, but their value in predicting aggressive meningioma behavior is not fully understood. ObjectiveTo evaluate the association between preoperative markers such as neutrophil-lymphocyte ratio (NLR), neutrophil-monocyte ratio (NMR), monocyte-lymphocyte ratio (MLR), platelet-lymphocyte ratio (PLR), and prognostic nutritional index (PNI), and diagnostic and prognostic factors including WHO grade, proliferation index, presence of edema on preoperative MRI, and tumor recurrence. MethodsA retrospective review of patients treated between 2000 and 2019 with a preoperative complete blood count (CBC) differential lab draw before intracranial meningioma resection was conducted. All preoperative steroid dosages were converted to dexamethasone equivalents. Primary outcomes included presence/absence of perilesional edema, WHO grade, Ki-67/MIB-index, and recurrence. Univariate and multivariable regression analyses were conducted. ResultsA total of 209 meningioma patients were included. Of these, 143 (68 %) were WHO grade I, 61 (29 %) grade II and 5 (2 %) were grade III. Recurrence was reported in 19 (9.1 %) tumors. No hematologic markers were associated with recurrence. In separate multivariable logistic analyses, no biomarkers were associated with perilesional edema or WHO grade. MLR was associated with higher MIB-index (p = 0.018, OR 6.57, 95 % CI 1.37–30.91). ConclusionMost hematologic markers were not associated with meningioma invasiveness, grade, proliferative index, or aggressiveness. Preoperative MLR was associated with high proliferation index in patients undergoing surgery for intracranial meningioma. Higher MLR could be a surrogate for meningioma proliferation and has potential to be used as an adjunct for risk-stratifying meningiomas.