Simpson Grade Research Articles

The Evolution of Endoscopic Endonasal Approach for Olfactory Groove Meningiomas.

There is controversy over the choice of optimal approach for olfactory groove meningiomas (OGM). The endoscopic endonasal approach (EEA) is one of the most recently described corridors, which provides direct access to the tumor base. To detail the evolution of the endoscopic endonasal technique over the past 2 decades and demonstrate the impact of this evolution on patient outcomes. This is a retrospective study based on a prospectively maintained database of consecutive cases of OGM operated on at our institution via EEA. For analysis, the whole cohort has been divided into 3 equal "eras" according to the time period during which the surgery happened, creating early, middle, and contemporary groups. Seventy-five patients were included, 25 in each group. The rate of postoperative cerebrospinal fluid leak significantly decreased over time (28%, 32%, and 8% in the early, middle, and contemporary groups, respectively, P = .020). The rate of postoperative encephalomalacia was significantly lower in more recent groups (24%, 16%, and 0% in the early, middle, and contemporary groups, respectively, P = .029), as was the time to resolution of postoperative brain edema (103.9 months, 87.3 months, and 16.8 months in the early, middle, and contemporary groups, respectively, P = .020). The endoscopic endonasal approach for OGM significantly evolved over time, achieving lower cerebrospinal fluid leak rates while providing a high rate of Simpson grade 1 resection. Technical improvements minimized the frontal lobe impact. Current data support EEA as a safe and effective corridor to treat OGM.

Ga68]-DOTATATE/MRI-Guided Fractionated Stereotactic Radiosurgery for Residual/Recurrent Atypical Meningiomas – Local Control and Salvage Requirements in a Single Institution Series

<h3>Purpose/Objective(s)</h3> The NCI-sponsored phase III NRG protocol BN-003 randomizing completely resected atypical meningiomas to observation or fractionated radiotherapy to the resection bed requires clinical equipoise to ethically randomize patients between the two arms. A radiographically complete resection, required for protocol eligibility, may be Simpson Grade 1, 2, or 3, which differ in excision completeness and thus in risk of recurrence. Meningiomas express high levels of somatostatin receptor 2A, which avidly binds [68Ga]-DOTATATE, a PET tracer that permits differentiation of postoperative scar tissue from residual/recurrent meningioma. We hypothesized that using [68Ga]-DOTATATE PET/MRI would permit the radiosurgical treatment of patients with atypical (WHO Grade 2) meningiomas not completely removed at surgery, thereby sparing normal brain high-dose irradiation and shortening treatment from six weeks to one. We prospectively accrued patients with residual/recurrent atypical meningiomas at our institution and subsequently investigated their local control (LC) and salvage requirements after treatment with fractionated stereotactic radiosurgery (fSRS) that incorporated [68Ga]-DOTATATE PET/MRI in the planning process. <h3>Materials/Methods</h3> We approached patients with pathologically confirmed atypical meningioma for an Institutional Review Board approved prospective trial of [68Ga]-DOTATATE PET/MRI imaging. fSRS (35 Gy in 5 fractions) was offered to patients with positive findings. 20 tumors in 19 patients were treated. Patients were scheduled for follow-up MRI and [Ga68]-DOTATATE PET scanning per protocol on an at least semi-annual basis. Not all patients have yet presented for follow-up imaging. LC duration was calculated from the first day of fSRS until the most recent MRI. No patients were lost to follow-up. <h3>Results</h3> 20 fSRS sessions were delivered, LC was achieved at fSRS sites in all patients. Median follow-up is 15.9 months (range: 0-35.7, SD 11.1). One patient progressed remote from the original site of disease and was managed with [Lu177]-DOTATATE and salvage SRS to a new nodular focus. Two patients had surgical bed recurrences, one of which was managed with salvage re-resection (now WHO Grade III), followed by fractionated radiotherapy; the other is pending salvage fSRS. Overall, 16/19 patients (84%) have experienced progression-free survival to date after [Ga68]-DOTATATE PET/MRI guided fSRS of residual/recurrent atypical meningioma. No unusual toxicities were reported by patients in follow-up, and no patients required treatment for radiation injury. <h3>Conclusion</h3> [Ga68]-DOTATATE PET/MRI can assist with radiation management of residual/recurrent atypical meningiomas through improving the ability to discern what volumes of tissue require aggressive focal treatment, and what volumes are at low risk and can be spared treatment. Further follow-up will help clarify the value of this approach.

Long-Term Follow-Up, Treatment Strategies, Functional Outcome, and Health-Related Quality of Life after Surgery for WHO Grade 2 and 3 Intracranial Meningiomas.

Simple SummaryMeningiomas are the most common group of primary intracranial tumors. While the majority are classified as WHO grade 1, WHO grade 2 and 3 meningiomas have poorer outcomes, even after gross total resection, and often require supplementary treatment. Long-term follow-up data regarding the progression-free survival (PFS) and overall survival (OS) for grade 2 and 3 tumors are scarce, and data evaluating the routine use of supplementary radiotherapy and radiosurgery have been inconclusive. Furthermore, few studies have reported data on the health-related quality of life (HRQoL), anxiety, and depression for these patients. In this population-based cohort study, we reviewed 51 cases of WHO grade 2 and 3 meningiomas. We found that the median OS was 13 years for grade 2 and 1.4 years for grade 3 meningiomas. Meningioma was the cause of death in 93% of the patients who passed away. The surviving patients showed HRQoL measures comparable to that of the general population, with the exception of significantly more anxiety and depression. All patients who worked preoperatively returned to work after their treatment.Progression-free survival (PFS) and overall survival (OS) for WHO grade 2 and 3 intracranial meningiomas are poorly described, and long-term results and data evaluating the routine use of supplementary fractionated radiotherapy (RT) or stereotactic radiosurgery (SRS) has been inconclusive. The aim of this study was to determine the long-term PFS and OS at a center that does not employ routine adjuvant RT. For this purpose, a retrospective population-based cohort study was conducted of all WHO grade 2 and 3 meningiomas surgically treated between 2005 and 2013. The cohort was uniformly defined according to the WHO 2007 criteria to allow comparisons to previously published reports. Patient records were reviewed, and patients were then prospectively contacted for structured quality-of-life assessments. In total, 51 consecutive patients were included, of whom 43 were WHO grade 2 and 8 were grade 3. A Simpson grade 1–2 resection was achieved in 62%. The median PFS was 31 months for grade 2 tumors, and 3.4 months for grade 3. The median OS was 13 years for grade 2, and 1.4 years for grade 3. The MIB-1-index was significantly associated with an increased risk for recurrence (p = 0.018, OR 1.12). The median PFS was significantly shorter for high-risk tumors compared to the low-risk group (10 vs. 46 months; p = 0.018). The surviving meningioma patients showed HRQoL measures comparable to that of the general population, with the exception of significantly more anxiety and depression. All patients who worked before surgery returned to work after their treatment. In conclusion, we confirm dismal prognoses in patients with grade 2 and 3 meningiomas, with tumor-related deaths resulting in severely reduced OS. However, the cohort was heterogenous, and a large subgroup of both grade 2 and 3 meningiomas was alive at 10 years follow-up, suggesting that a cure is possible. In addition, fractionated radiotherapy and chemotherapy had little benefit when introduced for recurrent and progressive diseases.

Parasagittal meningiomas: surgical treatment outcomes

Purpose: to improve the outcomes of surgical treatment of parasagittal meningioma patients by implementing a differentiated approach to the choice of surgical intervention, given the preoperative assessment of patency of the superior sagittal sinus (SSS) and collateral venous circulation. Materials and methods. Analysis of short-term and long-term outcomes of surgical treatment of 199 patients in the Department of Neurosurgery № 2, Mechnikov Dnipropetrovsk Regional Clinical Hospital was carried out. In the first follow-up period (2000 to 2012), the data were obtained retrospectively (95 cases). In the second follow-up period (2013 to 2021), the data were obtained prospectively (104 cases). The patients were assigned to the groups according to a differentiated approach (implemented in 2013) to the choice of surgical treatment tactics based on preoperative angiographic data (selective cerebral angiography and CT angiography). Results. In the first follow-up period, the completeness of surgical resection according to Simpson Grading Scale was: type I, 23 (24.2%) cases; type II, 37 (38.9%) cases; type III, 13 (13.7%) cases; type IV, 22 23.2%) cases. 53.7% of patients had intraoperative or postoperative complications. Among patients with tumors of the middle third of the SSS, 21 (41.2%) had their neurological status improved postoperatively. Mortality rate was 4.2%. 14 (14.7%) patients had further parasagittal meningioma growth after its removal grade II–IV according to Simpson Scale. In the second follow-up period, the completeness of surgical intervention according to Simpson Scale was: type I, 74 (71.2%) cases; type II, 26 (25%) cases; type III, 2 (1.9%) cases; type IV, 2 (1.9%) cases. 19.2% of patients had intraoperative or postoperative complications. Among the patients with tumors of the middle third of the SSS, 46 (79.3%) patients had postoperative improvement of neurological status. No lethal outcome was reported. 3 (2.9%) patients had further parasagittal meningioma growth after radical surgical removal according to Simpson grade II. Conclusions. Adequate analysis of instrumental methods of brain study using cerebral vasculature study, application of neuronavigation station (with brain MRI and/or CT angiography data available) and new microsurgical techniques contributed to the completeness of surgery and minimally invasive removal of parasagittal meningioma with reduced intraoperative and postoperative complications, which affected the immediate and long-term treatment outcomes.

Factors predicting complications, neurologic deterioration and mortality for patients with meningioma surgery: An observational study

Background: Meningiomas are the second most common intracranial neoplasm, contributing to 30% of all intracranial tumors. Clinical examination, anatomical pathology testing, CT, and MRI are required to confirm the meningioma diagnosis. Surgery is the therapy of choice for meningiomas. Understanding factors affecting the outcome of meningioma surgery is critical to predicting the outcome of meningioma surgery. Methods: A retrospective analytic method was conducted in this study, which included meningioma patients who underwent surgery at Dr. Soetomo General Academic Hospital between January 2014 and December 2020. The study incorporated secondary data in the form of medical records. Data collection was followed by binomial logistic regression analysis using SPSS IBM 25. Results: A total of 440 samples of patients with meningiomas were obtained through medical records. Post-operative hematoma (2.5%), postoperative infection (3.0%), neurologic deterioration (3.9%), and 30-day mortality (2.3%) were the postoperative complications reported. Emergency surgery was found to be a significant predictor of postoperative hematoma (p=0.025; OR=4.539; 95% CI: 1.211-17.006), postoperative infection (p=0.015; OR=4.777; 95% CI: 1.362-16.751), neurologic deterioration (p=0.022; OR=5,151; 95% CI: 1,271-20,882), and 30-day mortality (p=0.002; OR=17,874; 95% CI: 2,933-108,915). Simpson Grade IV (p=0.016; OR=33,524; 95% CI: 1.905-590.056) was a significant predictive factor for postoperative hematomas. Post-operative hematoma was a significant predictive factor for neurologic deterioration (p=0.000; OR=235,807; 95% CI: 38,058-1461,069) and 30-day mortality (p=0.001; OR=40,047; 95% CI: 4,985-321,699). Conclusions: Post-operative complications following meningioma surgery may result in high morbidity and mortality. The predictive factors for meningioma surgery complications were identified in this study. Knowledge of these factors may aid in preventing or predicting meningioma surgery complications.

Symptom burden and surgical outcome in non-skull base meningiomas.

PurposeNon-skull base meningiomas (NSBM) are a distinct entity and frequently present with focal neurological deficits. This study was designed to analyze functional and oncological outcome following microsurgical tumor resection in patients with NSBM.Patients and methodsAn analysis of 300 patients that underwent NSBM resection between 2003 and 2013 was performed. Assessment measures for functional outcome were Karnofsky Performance Scale (KPS), Medical Research Council - Neurological Performance Scale (MRC-NPS), and improvement rates of focal deficits and seizures. The extent of resection; recurrence-free survival (RFS) and tumor-specific survival (TSS) were also determined.ResultsImpaired KPS and MRC-NPS were present in 73.3% and 45.7%, respectively. Focal neurological deficits were recorded in 123 patients (41.0%), with hemiparesis (21.7%) and aphasia (9.3%) the most prevalent form of impairment. Most meningiomas were localized at the convexity (64.0%), followed by falcine tumors (20.3%). Both KPI and MRC-NPS scores were significantly improved by surgical resection. Postoperative improvement rates of 96.6%, 89.3%, 72.3%, 57.9%, and 27.3% were observed for aphasia, epilepsy, hemiparesis, cranial nerve, and visual field deficits, respectively. Long-term improvement was achieved in 83.2%, 89.3%, 80.0%, 68.4% and 54.6% of patients, respectively. Gross total resection (GTR) over subtotal resection (STR) significantly improved preoperative seizures and visual field deficits and correlated with reduced risk of new postoperative hemiparesis. Poor Simpson grade was the only significant prognostic factor in multivariate analysis for long-term functional deficit, which occurred in 7.3%. Median RFS was 45.9 months (6.0 - 151.5 months), while median TSS was 53.7 months (3.1 – 153.2 months). Both WHO grade (p= 0.001) and Simpson classification (p= 0.014 and p= 0.031) were independent significant prognostic factors for decreased RFS and TSS by multivariate analysis, respectively. Furthermore, tumor diameter > 50 mm (p= 0.039) significantly correlated with decreased TSS in multivariate analysis.ConclusionSurgical resection significantly and stably improves neurological deficits in patients with NSBM.

What is the ideal grade of resection for parasagittal meningiomas with the invasion of superior sagittal sinus? Simpson I or Simpson II resection? A retrospective observational study.

Parasagittal meningioma (PSM) is a tumor located in the parasagittal angle which extends to and/ or invades the superior sagittal sinus (SSS). Surgical resection of the PSM, the standard treatment in such cases, poses a challenge for neurosurgery, particularly where there is an invasion of the SSS. This is due to the risk of complications through injury to the adjacent vascular structures. The objective of the study was to perform a comparative evaluation of the surgical techniques for total resection of the PSM (Simpson Grade [SG] I and SG II), which present the highest rates of success in terms of the following variables: mortality, recurrence, and postoperative complications. Fifty-six patients undergoing resection surgery for PSM with the invasion of the SSS were enrolled. The patients were divided into two groups: Group A, comprising 26 cases of patients subjected to SG I PSM resection surgery and Group B, with 31 cases of patients subjected to SG II PSM resection surgery, with preservation of the SSS. The results showed that Group B had lower rates of postoperative deficit (P = 0.026), zero mortality, and reduced recurrence. The use of complementary radiotherapy for atypical meningiomas (WHO II) in Group B was satisfactory in controlling the disease. The Simpson II, with preservation of the SSS, was better as it diminishes the vascular risks of surgery, reduces the frequency of severe postoperative deficit, and reduces mortality.

Individualized surgical treatment of giant tuberculum sellae meningioma: Unilateral subfrontal approach vs. endoscopic transsphenoidal approach.

Giant tuberculum sellae meningiomas (TSMs) are deeply located in the suprasellar region and extensively compressed or encased in the surrounding neurovascular structures, making gross total resection (GTR) without postoperative visual impairment challenging. The authors presented individualized unilateral subfrontal approach and endoscopic transsphenoidal approach (ETSA) in a series of patients and elaborated on their advantages and indications in resecting giant TSMs. A total of 38 patients with giant TSMs operated by a single surgeon between March 2012 and November 2021 were retrospectively reviewed. Patients underwent unilateral subfrontal approach and ETSA according to preoperative imaging characteristics. Tumor characteristics, surgical details, preoperative symptoms, and neurological outcomes of TSMs patients were collected and analyzed. In 31 patients operated with the unilateral subfrontal approach, total resection (Simpson grade I or II) was achieved in 27 patients (87.0%), while 6 patients (85.7%) achieved GTR in 7 patients using ETSA. The postoperative visual improvement was maintained in 22 (81.5%) and 5 patients (83.3%). Recurrence or progression was only observed in 2 (7.4%) patients operated with the unilateral subfrontal approach. There was no mortality in our series. Preoperative imaging and visual function are important for surgical approach selection. Maximum tumor resection and optic nerve protection can be achieved concurrently by taking advantage of these surgical approaches. The cerebral artery protection strategies and individualized surgical techniques provide great utility in improving a patient's quality of life.

Lateral supraorbital approach for resection of large and giant olfactory groove meningiomas: a single center experience

Background The lateral supraorbital approach (LSO) provides an optimal access corridor for various skull bases lesions, including olfactory groove meningiomas (OGMs). The aim of this study is to describe the authors’ experience with the management of large and giant OGMs utilizing the LSO approach and describe the technical nuances of the procedure. Methods A retrospective review of seven patients with large and giant OGMs managed with the LSO approach between 2013 and 2019 was performed. Radiographic and clinical data were recorded and analyzed. Results Seven patients with large and giant OGMs underwent surgical resection via the LSO approach. Six patients were female, with a median age of 56 years. Patients commonly presented with altered mentation, anosmia, and headaches. The average tumor volume was 120.6 ± 64.7 cm3 with five cases of vascular encasement. Simpson grade II resection was achieved in four patients while Simpson grade IV resection was achieved in three patients. The median length of stay was 2.0 days. The median preoperative Karnofsky Performance Scale (KPS) score was 70, improving to 100 at last postoperative follow-up visit. Two complications were encountered in the form of postoperative cerebrospinal fluid leak in one patient and a transient diplopia in another patient. Tumor recurrence/progression was identified in two patients during a median follow-up time of 65.5 months. Both cases have been managed with adjuvant radiosurgery. Conclusion The LSO approach is a safe and effective minimally invasive transcranial corridor for the management of OGMs that should be part of the armamentarium of skull base neurosurgeons.

Predictors of postoperative seizure outcome in supratentorial meningioma.

Meningiomas are the most common primary intracranial tumor. Seizures are common sequelae of meningioma development. Meningioma patients with seizures can be effectively treated with resection, with reports of seizure freedom of 60%-90%. Still, many patients manifest persistent epilepsy. Determining factors associated with worsened seizure outcomes remains critical in improving the quality of life for these patients. The authors sought to identify clinical, radiological, and histological factors associated with worse seizure outcomes in patients with supratentorial meningioma and preoperative seizures. The authors retrospectively reviewed the charts of 384 patients who underwent meningioma resection from 2008 to 2020. The charts of patients with a documented history of preoperative seizures were further reviewed for clinical, radiological, operative, perioperative, histological, and postoperative factors associated with seizures. Engel class at last follow-up was retrospectively assigned by the authors and further grouped into favorable (class I) and worse (class II-IV) outcomes. Factors were subsequently compared by group using comparative statistics. Univariable and multivariable regression models were utilized to identify independent predictors of worse seizure outcome. Fifty-nine patients (15.4%) were found to have preoperative seizures, of whom 57 had sufficient postoperative data to determine Engel class outcome. Forty-two patients (74%) had Engel class I outcomes. The median follow-up was 17 months. Distinct margins on preoperative imaging (p = 0.012), Simpson grade I resection (p = 0.004), postresection ischemia (p = 0.019), WHO grade (p = 0.019), and recurrent disease (p = 0.015) were found to be the strongest predictors of Engel class outcome in univariable logistic regression. MIB-1 index (p = 0.001) and residual volume (p = 0.014) at last follow-up were found to be the strongest predictors of Engel class outcome in univariable generalized linear regression. Postresection ischemia (p = 0.012), WHO grade (p = 0.022), recurrent disease (p = 0.038), and MIB-1 index (p = 0.002) were found to be the strongest independent predictors of Engel class outcomes in multivariable analysis. Postresection ischemia, higher WHO grade, elevated MIB-1 index, and disease recurrence independently predict postresection seizure persistence in patients with supratentorial meningioma. Further understanding of the etiology of these markers may aid in elucidation of this complex disease process and guide management to prevent worse outcomes.

Increased MIB-1 Labeling Index Is Associated with Abducens Nerve Morbidity in Primary Sporadic Petroclival Meningioma Surgery: Beyond Location and Approach.

Abducens nerve palsy is a severe dysfunction after petroclival meningioma (PC MNG) surgery. The objective of this investigation was to analyze abducens nerve outcomes in patients who underwent the retrosigmoid approach in relation to the MIB-1 index. Thirty-two patients with primary sporadic PC MNG were retrospectively analyzed. Mean follow-up was 28.0 months. Analysis of the MIB-1 index was performed to evaluate the abducens nerve outcome. An optimal MIB-1 index cut-off value (<4/≥4) in the association with postoperative CN VI palsy was determined by ROC analysis (AUC: 0.74, 95% CI: 0.57–0.92). A new-onset CN VI palsy was present in 7 cases (21.88%) and was significantly associated with an increased MIB-1 index (≥4%, p = 0.025) and a peritumoral edema in the brachium pontis (p = 0.047) which might be caused by the increased growth rate. Tumor volume, cavernous sinus infiltration, auditory canal invasion, and Simpson grading were not associated with new CN VI deficits. Six (85.7%) of the 7 patients with both an increased MIB-1 index (≥4%) and new abducens nerve palsy still had a CN VI deficit at the 12-month follow-up. A peritumoral edema caused by a highly proliferative PC MNG with an elevated MIB-1 index (≥4%) is associated with postoperative abducens nerve deficits.

Preoperative tumor embolization prolongs time to recurrence of meningiomas: a retrospective propensity-matched analysis

BackgroundMeningiomas are often embolized preoperatively to reduce intraoperative blood loss and facilitate tumor resection. However, the procedure is controversial and its effects have not yet been reported. We evaluated preoperative...

Endoscopic Contralateral Interhemispheric Transfalcine Keyhole Approach for Large Falcine Meningiomas

Falcine meningioma is usually approached ipsilaterally, and the technique for tumor removal has traditionally been performed under microscopy. We report a surgical procedure for large falcine meningioma by an endoscopic contralateral interhemispheric transfalcine keyhole approach. The study period was from September 2019 to March 2021. Study participants were patients with World Health Organization grade I meningioma showing falx attachment, excluding neurofibromatosis, who underwent initial surgery at our institution. The surgical procedure begins with a small contralateral craniotomy of about 3cm, followed by insertion of an endoscope. The tumor attachment to the falx is excised, exposing the tumor. Internal decompression is performed, and the lesion is dissected from the surrounding brain before removal through the falx. An endoscopic contralateral interhemispheric transfalcine keyhole approach was used to resect 4 cases of large falcine meningioma. The mean operation time was 265minutes (range: 216-294minutes), achieving Simpson grade I removal in all cases. No evidence of cerebral infarction, cerebral edema, or new neurological complaints related to impaired venous return was seen using this surgical method. In the case of falcine meningioma, the endoscopic keyhole contralateral technique allows detachment of the tumor from the falx and safe manipulation in a minor field of view. In addition, because the craniotomy is smaller and the operation time is shorter, this procedure offers a less-invasive approach for the patient. This technique is thus, in our opinion, quite advantageous.

Adjuvant Radiotherapy Versus Surveillance for Grade 2 Intracranial Meningiomas: A Multi-Institutional Propensity Score-Matched Study.

PurposeWe aimed to compare the outcomes of adjuvant radiotherapy (ART) and surveillance in patients with grade 2 meningiomas (MNG2) who underwent surgical resection.Materials and MethodsData from four hospitals, in which patients aged ≥18 years underwent Simpson grade 1−4 surgical resection for newly diagnosed MNG2 between 1998 and 2018, were examined in this multicenter retrospective cohort study. Patients receiving ART with conventional fractionation were compared with those undergoing surveillance. Progression-free survival (PFS), progression/recurrence (P/R) were evaluated.ResultsThis study included 518 patients, 158 of whom received ART. The median follow-up duration was 64.9 months. In the total cohort, ART was independently associated with significantly improved PFS (HR, 0.35; 95% CI, 0.23–0.55; P<0.001) and P/R (HR, 0.30; 95% CI, 0.18–0.48; P<0.001). In the propensity score-matched cohort (n=143 in each group), the 5-year PFS rates were 80.8% and 57.7% (P=0.004), and the 5-year P/R rates were 16.5% and 40.0% (P=0.002) in the ART and surveillance groups, respectively. After gross total resection, the 5-year PFS (85.0% vs. 64.7%; P=0.020) and P/R rates (15.2% vs. 32.0%; P=0.035) were significantly better in the ART group than in the surveillance group. A model for P/R was developed using recursive partitioning analysis with surgical extent, tumor size, and Ki-67 index. ART reduced the risk of P/R in the low- (P=0.069), intermediate- (P=0.044), and high-risk groups (P<0.001). Local control was also significantly enhanced by ART among all the risk groups (all P<0.05).ConclusionsART significantly improved PFS and P/R in patients with MNG2, irrespective of the surgical extent, and can be recommended after gross total resection. A prognostic model may guide decision-making for the use of ART.

Functional Outcome after Spinal Meningioma Surgery.

A multicenter cross-sectional analytical retrospective study. To assess functional outcome (FO) after a spinal meningioma (SM) surgery. All studies report functional improvement after SM removal. We performed an analytical retrospective cohort study at five different institutions. All patients with a diagnosis of SM were included in this study, including those with recurrent tumors. Meningiomas of the foramen magnum were excluded. Useful histopathological characteristics were separately extracted. Surgical resection was evaluated according to the Simpson grading scale. Patient outcomes and clinical states were assessed with the help of their medical records using four different scales: the modified Ranawat score, the Nurick scale, the Prolo score, the Frankel grade, and the Eastern Cooperative Oncology Group-World Health Organization- Zubrod score. Between 1991 and 2018, 417 patients were identified, of which 85.8% were female. The median age at surgery was 67.2 years (interquartile range [IQR], 56.7-76.5). The lesion was located in the thoracic region in 77.9% of the patients, cervical region in 16.8%, and lumbar region in 4.1%. Surgical resection was complete in 95.5% of the cases. Only 0.96% of the patients died within the first postoperative month. Neurological status, which improved in 76.9% of the patients, was unchanged in 17.5% and even worsened in 4.4%. Functional status was assessed using the Ranawat score and Nurick scale, with scores of 1 (IQR, 0-2) (i.e., hyperreflexia and asymptomatic; mean, 1.3±1.3) and 1 (IQR, 0-2) (i.e., signs of spinal cord disease, but no difficulty in walking; mean, 1.2±1.4), respectively. Approximately 10.1% of the patients were not ambulant at the last neurosurgical follow-up visit. Older age at surgery was not significantly associated with a chair-bound status (p =0.427). This large series confirms the favorable FO after spinal meningioma surgery even in the case of seriously impaired preoperative status. A validated scale is needed to assess the factors predicting a worsening of the functional status and guide the management of patients.

Surgical Management of Falcotentorial Junction Tumors: A Case Series Report.

ObjectiveThe surgical strategy for falcotentorial junction tumors remains complex. Different approaches are selected according to the location and growth pattern of the tumor and the operator’s experience. This report reviews our single-institution experience in the surgical management of falcotentorial junction tumors.MethodsWe retrospectively reviewed the clinical and imaging data, surgical strategy, and follow-up outcomes of 49 patients treated from 2007 to 2020.ResultAll 49 patients (12 male, 37 female, mean age: 56.3 ± 11.3 years) underwent safe tumor resection. The most common complaints were headache (43%), dizziness (39%), and unstable gait (16%). Thirty percent of the tumors showed calcification, and the computed tomography scans revealed hydrocephalus in 36% of the patients. On magnetic resonance imaging, 43% of the tumors were unilateral. According to the Asari classification, the tumors were divided into inferior (16%), superior (29%), anterior (22%), and posterior (33%) types. The occipital interhemispheric approach (88%) and supracerebellar–infratentorial approach (10%) were primarily used to reach the tumors. The pathology examination results revealed that 85.7% of the tumors were meningioma and 14.3% were hemangiopericytoma. Of the 49 patients, 15 achieved a Simpson grade I resection, and 29 achieved a Simpson grade II resection. The follow-up rate was 77.6% (38/45); 94.7% of patients (36/38) achieved a favorable outcome, and 9 experienced tumor recurrences.ConclusionSurgical approach selection depends on the growth characteristics of the tumor and the degree of venous or sinus involvement. The occipital interhemispheric approach is the most commonly used and safest approach for falcotentorial junction tumors with multiple brain pressure control assistance techniques.

Simplifying the Surgical Strategy for Excising Medial Sphenoid Wing Meningiomas: A Stepwise Approach.

Medial sphenoid wing meningiomas constitute 15%-20% of all intracranial meningiomas. These lesions have a propensity to encase the vessels of the circle of Willis and the surrounding cranial nerves. Thus, radical excision is a difficult proposition. In this paper, we analyzed our series of sphenoid wing meningiomas. We describe our surgical strategy, which was based on zone-wise dissection of the tumor. We describe the complications and outcomes of surgery. This case series is a retrospective analysis of a single surgeon series of medial sphenoid wing meningiomas operated over a 13-year period. Clinical, radiographic, and outcome variables were studied. The surgical videos were analyzed in detail. The meningioma and its extensions were divided into several zones and a zone-wise strategy for tumor excision was evolved. Twenty-four patients with medial sphenoid wing meningiomas were operated. In 14 patients, Simpson grade 3 excision could be achieved; 5 patients had Simpson grade 4 and 1 patient, grade 5 excision. Four (of 24 patients, 16.7%) had vessel injuries. Medial sphenoid wing meningiomas are difficult lesions to excise radically. Close follow-up of residual lesions (especially if attached to the basal dura) is warranted. Additional modalities of treatment like radiosurgery may be required in case of any progression and for higher-grade lesions.

Sphenoid Wing Meningiomas with Secondary Cavernous Sinus Invasion: Surgical Results and Algorithm for Treatment at a Single Brazilian Center

Sphenoid wing meningiomas with cavernous sinus invasion (SWMCSI) are challenging tumors. The preservation of quality of life and cranial nerve function is one of the most relevant aspects of treating patients with SWMCSI. A retrospective study was conducted for surgery performed between 2008 and 2021, including 36 patients presenting with SWMCSI. The data from surgical intervention, Simpson grade of resection, tumor location, and morbimortality related to the surgery was reviewed. We examined the medical records, operative reports, radiologic examinations, and follow-up information. The group comprised 29 women and 7 men with an average age of 61 years (range, 31-87 years). The mean follow-up period was 75 months (range, 1-170 months). Simpson grade I and II resections were obtained in 80% of cases. The meningiomas were World Health Organization (WHO) grade 1 in 94% of cases, WHO grade 2 in 3%, and WHO grade 3 in 3%. The overall mortality was 5.5%. Permanent cranial nerve deficits occurred in 8% of cases, transient cranial nerve deficits in 22%, cerebrospinal fistula in 16.5%, and hemiparesis in 2.7%. The recurrence/regrowth rate was 14% during the follow-up period. The Karnofsky Performance Status 100 and 90 was 92%. The surgical treatment of symptomatic SWMCSI is an effective treatment modality with low morbimortality and good long-term control of the disease. Visual impairment is the most common abnormality, affecting preoperative and postoperative quality of life of patients with SWMCSI. Training in the microsurgical laboratory is essential for safe surgical approaches in this area.

The Simpson Grading: Is It Still Valid?

Simple SummarySince the initial publication of the Simpson Grade scale, the management paradigm for intracranial meningiomas has significantly evolved. The generalized application of the Simpson Grade in modern neurosurgery management of meningiomas is controversial. We conducted a review of the literature to determine the prognostic significance of the Simpson Grade and find it to be an antiquated grading scale with limited utility in the modern era. The Simpson Grade was introduced in the era of limited resources, outdated techniques, and rudimentary surgical and imaging technologies. With the advent of modern techniques including pre- and post-operative imaging, microsurgical and endoscopic techniques, advanced histopathology and molecular analysis and adjuvant radiotherapy, the utility of the Simpson Grade scale for prognostication of recurrence after meningioma resection has become less useful. While the extent of resection remains an important factor in reducing recurrence, a subjective naked-eye criteria to Grade extent of resection cannot be generalized to all meningiomas regardless of their location or biology. Achieving the highest Simpson Grade resection should not always be the goal of surgery. It is prudent to take advantage of all the tools in the neurosurgeons’ armamentarium to aim for maximal safe resection of meningiomas. The primary goal of this study was to review the literature highlighting the Simpson Grade and its association with recurrence in modern meningioma practice. A PubMed search was conducted using terms “Simpson”, “Grade”, “meningioma”, “recurrence”, “gross total resection”, “extent of resection” “human”. A separate search using the terms “intraoperative imaging”, “intraoperative MRI” and “meningioma” were conducted. All studies reporting prognostic value of Simpson Grades were retrospective in nature. Simpson Grade I, II and III can be defined as gross total resection and were associated with lower recurrence compared to Simpson Grade IV or subtotal resection. The volume of residual tumor, a factor not considered in the Simpson Grade, is also a useful predictor of recurrence. Subtotal resection followed by stereotactic radiosurgery has similar recurrence-free survival as gross total resection. In current modern meningioma surgery, the Simpson Grade is no longer relevant and should be replaced with a grading scale that relies on post-operative MRI imaging that assess GTR versus STR and then divides STR into > or <4–5 cm3, in combination with modern molecular-based techniques for recurrence risk stratification.

Meningioma Cell Invasion into DuraGen-Derived Dura Mater: A Case Report

Background: Dura mater infiltration is the main growth pattern of meningiomas. Local recurrence may occur in any type of meningioma, but it is more likely so in atypical meningiomas. Therefore, a wide resection of tumor cell-invaded dura mater is necessary to avoid recurrence. DuraGen® (an artificial dural substitute) can be used for dural reconstruction in meningiomas. Here, we report a rare case of a patient with atypical meningioma that invaded into the DuraGen®-derived mature dura mater. Case presentation: A 66-year-old female showed a three-time recurrence of atypical meningioma. Simpson grade I resection (en bloc tumor with autologous dura mater and DuraGen®-derived dura mater resection) was achieved at the 3rd recurrence. Collagen fibers running regularly and transversely were observed in the DuraGen®-derived dura mater resembling the autologous meningeal layer. Meningioma cell invasion, displayed by occasional EMA immunostaining, was observed in the DuraGen®-derived dura mater. Conclusions: This case indicates that meningioma cells may invade and survive in the DuraGen®-derived dura mater. Whether or not DuraGen® is not appropriate as a dural substitute remains unanswered. Further experiences are needed to validate these findings in large sample sizes.