Surgical 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.

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.

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.

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 &amp;lt; 0.0001), and increased postoperative Hb (SMD: 0.46; CI95% = -0.15 to 1.07; p &amp;lt; 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.

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.

Risk factors analysis and a nomogram model establishment for late postoperative seizures in patients with meningioma

BackgroundPostoperative seizures (Sz) following surgical resection of intracranial meningiomas negatively impacts the quality of life of patients. However, there is still unclear with respect to the risk factors of and long-term freedom to Sz in patients with meningiomas. This study aimed to identify independent predictors and develop a nomogram model of late postoperative Sz to optimize postoperative surveillance. MethodsWe retrospectively analyzed 318 meningioma patients who underwent surgical resection at the Subei People’s Hospital of Jiangsu province from January 2014 to December 2018. Then, clinical data were collected for further analysis and nomogram construction. ResultsIn our cohort, 62 patients (19.50%) experienced preoperative Sz, 12 patients (3.77%) experienced early postoperative Sz, and 56 patients (17.61%) experienced late preoperative Sz. Multivariate logistic regression analysis revealed that preoperative Sz, convexity location, tumor maximal size ≥3.5 cm, medical/surgical complications and tumor recurrence/progression were independent predictors of late postoperative Sz. A nomogram was developed by employing these five significant predictive factors. Statistical analysis showed that this model had a good discrimination performance. Among 32 patients who had more than one year follow up period form first late postoperative Sz, 17 (53.13%) patients experienced good Sz control. The probability of Sz freedom in the 2-year follow-up was roughly 75.2% among patients with preoperative Sz, and 84.8% among patients without preoperative Sz. ConclusionsThis nomogram model will be useful to assist clinicians to assess late postoperative Sz occurrence, identify high-risk patients early and schedule AEDs treatment, but further external validations are needed.

Can CT and MRI features differentiate benign from malignant meningiomas?

To highlight magnetic resonance imaging (MRI) and computed tomography (CT) characteristics in distinguishing benign from high-grade meningiomas (World Health Organization [WHO] grade II and III) preoperatively. Seventy-one patient who underwent surgical resection of intracranial meningiomas at American University of Beirut Medical Center between 2008 and 2017 were evaluated for various CT and MRI features. The correlation between imaging findings, histopathological grading, and operative reports was analysed via univariate and multivariate logistic regression analysis. MRI specificity and sensitivity in detecting meningioma brain invasion as compared to operative reports post-resection was detected. Univariate analysis results showed a significant correlation between high-grade meningiomas and several MRI features including tumour size and volume (p=0.002,0.02), heterogeneous enhancement (p<0.0001), presence of intra-tumoural necrosis (p<0.0001), ill-defined margin (p=0.003), bone erosion (p=0.004), brain invasion (p=0.001), and a higher rate of recurrence (p=0.007) Only brain invasion and presence of intra-tumoural necrosis were significantly correlated with the high-grade meningioma in multivariate analysis. Hyperostosis of the adjacent skull was the only significant CT feature predicting the presence of low-grade meningioma. MRI showed 79% specificity and 20% sensitivity, 92% negative predictive value and 7% positive predictive value in detecting meningioma brain invasion. MRI has a promising role in predicting meningioma grade prior to resection, which can directly impact patients' management protocols regarding surgical planning and complications.

Comparison of machine learning classifiers for differentiation of grade 1 from higher gradings in meningioma: A multicenter radiomics study

Background and purposeAdvanced imaging analysis for the prediction of tumor biology and modelling of clinically relevant parameters using computed imaging features is part of the emerging field of radiomics research. Here we test the hypothesis that a machine learning approach can distinguish grade 1 from higher gradings in meningioma patients using radiomics features derived from a heterogenous multicenter dataset of multi-paramedic MRI. MethodsA total of 138 patients from 5 international centers that underwent MRI prior to surgical resection of intracranial meningiomas were included. Segmentation was performed manually on co-registered multi-parametric MR images using apparent diffusion coefficient (ADC) maps, T1-weighted (T1), post-contrast T1-weighted (T1c), subtraction maps (Sub, T1c – T1), T2-weighted fluid-attenuated inversion recovery (FLAIR) and T2-weighted (T2) images. Feature selection was performed and using cross-validation to separate training from testing data, four machine learning classifiers were scored on combinations of MRI modalities: random forest (RF), extreme gradient boosting (XGBoost), support vector machine (SVM) and multilayer perceptron (MLP). ResultsThe best AUC of 0.97 (1.0 and 0.97 for sensitivity and specificity) was observed for the combination of ADC, ADC of the peritumoral edema, T1, T1c, Sub and FLAIR-derived features using only 16 of the 10,914 possible features and XGBoost. ConclusionsMachine learning using radiomics features derived from multi-parametric MRI is capable of high AUC scores with high sensitivity and specificity in classifying meningiomas between low and higher gradings despite heterogeneous protocols across different centers. Feature selection can be performed effectively even when extracting a large amount of data for radiomics fingerprinting.

Risk of seizures before and after neurosurgical treatment of intracranial meningiomas

ObjectiveTo identify variables associated with the development of pre- and postoperative seizures in patients who underwent surgical resection of intracranial meningiomas, in a patient cohort not routinely treated prophylactically with antiepileptic drugs (AED). Patients and methodsRetrospective cohort study of 295 patients that underwent resection of a supratentorial meningioma at Odense University Hospital in between 2007–2015. Multivariate logistic regression was used to identify variables significantly correlating with pre- and postoperative seizures. Retrospective chart review was used to identify the rates of seizure incidence in patients, and the effect of AED on them. ResultsThe presence of peritumoral edema (OR:18.00, 7.44–43.58) was identified as predictor of preoperative seizure, while headache (OR:0.43, 0.22–0.84) and neurological deficit (OR:0.18, 0.09–0.39) were associated with a reduced incidence of preoperative seizures. The rates of postoperative seizure were increased in meningiomas in the left side (OR:1.91, 1.11–3.29), and reduced for tumor location in the convexity/parasagittal/falx (OR:0.72, 0.59–0.88) as well as in the absence of postoperative complications (OR:0.19, 0.10–0.36). 24.4% of the patients experienced seizures preoperatively, and a complete seizure freedom was achieved in 63.9% of them. 75.6% of the patients did not experience seizures preoperatively, but 15.2% of them then developed seizures postoperatively. A total of 20.3% of the patients experienced seizures after surgery. Time to first seizure in patients that did not experience seizures preoperatively but developed seizures after surgery, was one week (47%). However, first time postoperative seizures were also observed within one month postoperative (21%) and three months after surgery (32%). AED had a treatment success rate of 98.2% in preoperative seizures, and 98.0% in postoperative seizures. ConclusionSeizures after supratentorial meningioma surgery is common also in patients with no seizures preoperatively and mainly occurs within the first three postoperative months. AED are effective in controlling seizures.

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OBJECTIVES/SPECIFIC AIMS: “Loss to follow up” is a common phenomenon and challenge in clinical medicine. Missed appointments are a well-documented source of waste in the health care system, and can lead to strained patient-physician relationships and inferior quality of care. Meningiomas are relatively common, benign tumors that arise from the dural coverings of the brain. Although complete surgical resection is considered curative, surgically excised meningiomas have a well-documented propensity to recur, necessitating continued imaging surveillance of postresection patients. A recent retrospective study at our institute demonstrated that 20% of postresection patients fail to return for follow up within a year of their surgery. Although social determinants of health have been associated with failure to follow up in this population, there has been no research identifying patient-reported barriers that result in loss to follow up in this patient population. The purpose of this study is to identify specific barriers that prevent patients from returning for surveillance. METHODS/STUDY POPULATION: We used an IRB approved, prospective brain tumor clinical database to identify patients who underwent surgical resection of intracranial meningioma at our institution between 2001 and 2013. “Loss to follow up” was defined as failure to attend follow-up appointments with neurosurgery, radiation oncology, or neuro-oncology within a year of the most recent assigned follow-up interval, as recorded in the electronic medical record. Structured interviews were conducted with patients who met study criteria and specific barriers to follow-up were elicited, transcribed, and coded. In 2 cases, a primary caregiver participated in all or portions of the interview with the patient. A general assessment of patient knowledge about meningioma and a screening for basic health literacy were also conducted. RESULTS/ANTICIPATED RESULTS: There were 80 patients in the brain tumor clinical database met chart review criteria for inclusion in the study. A total of 9 structured interviews were conducted; 1 interview was excluded from analysis for failure to meet study criteria. In total, 24 unique obstacles to follow up were recorded. These were stratified and grouped into 4 broad categories: 2 of 8 (25%) patients identified environmental factors, including distance to appointment and challenges with insurance coverage as barriers to follow up; 2 patients (25%) identified psychosocial factors, including poor communication with and distrust of their neurosurgeon as barriers to follow up; 2 (25%) patients identified health factors, including poor health and old age, as barriers to follow up; 6 patients identified healthcare systems factors as barriers to follow up, with 6 patients (75%) reporting seeing a non-specialist for follow up after surgery and 4 patients (50%) reporting not being told by their neurosurgeon that they would need continued follow up. Of those patients seen by non-specialists, only 1 reported any recent brain imaging by those providers. All patients had limited to no prior knowledge of meningiomas before their diagnosis. Four (50%) patients reported satisfaction with the level education about meningiomas they received from their physician. Of these patients, 3 (75%) correctly reported that meningiomas may recur following surgery. Of the patients who did not report satisfaction with physician counseling, 3 (75%) did not realize that meningiomas can recur. DISCUSSION/SIGNIFICANCE OF IMPACT: Healthcare system factors, including uncoordinated transition of postoperative care to non-neurosurgeons and uncertain postoperative surveillance schedules, represent that most common patient-identified barriers to follow up after meningioma resection. Improving transition of care from specialists to non-specialists, including designation of appropriate imaging surveillance schedules, as well as improving communication between specialists and patients about the need for continued follow up, represent clear points for intervention that could improve care for this patient population. In addition, consistent and clear counseling about meningioma and its disease course may reduce loss to follow up following meningioma resection. It is important to note, however, that the small sample size represents a significant limitation of the study.

Clinical features and surgical management of intracranial meningiomas in the elderly.

Meningioma accounts for ~25% of all primary intracranial neoplasms and the incidence increases with age. Prvios population-based studies demonstrated that the annual incidence of intracranial meningiomas was 1.2-3.1/100,000 population. In particular, the incidence of this disease among the elderly is high. Recently, increased life expectancy and greater use of diagnostic radiological imaging led to an increased incidence in the diagnosis of intracranial meningiomas, both symptomatic and asymptomatic, in the elderly. Thus, neurosurgeons may be increasingly confronted with the management of intracranial meningiomas in the elderly. In practice, it is often difficult for physicians to determine whether traditional surgical resection is the optimal management strategy for intracranial meningiomas in the elderly. However, reported clinical studies about the outcome of surgical resection of intracranial meningiomas in the elderly are limited. Increased risk of mortality and morbidity associated with surgical treatment for intracranial meningiomas in the elderly compared with younger patients have been controversial. In the present study, the clinical features of intracranial meningiomas in 70 consecutive intracranial meningioma patients that underwent surgical treatment at the affiliated hospital of University of Occupational and Environmental Health between 2007 and 2013 were assessed. In addition, patient selection and surgical management of intracranial meningioma in elderly patients was discussed. Preoperative factors, including symptoms, tumor location, tumor size, Karnofsky Performance Scale (KPS) score and American Society of Anesthesiology (ASA) score, and postoperative factors, including pathological diagnosis, tumor proliferation index (Ki-67), resection rate (Simpson grade), length of hospital stay and discharge destination were retrospectively analyzed in patients aged ≥75 years (n=16; elderly group) and <75 years (n=54; younger group). Outcomes were assessed 6 months after surgery. Multivariate logistic regression revealed that tumor resection rate (Simpson grade III-V) was an important predictor of surgical complications (odds ratio, 5.662; 95% confidence interval, 1.323-24.236; P=0.0194). Perioperative morbidity was not correlated with age (>75 years), tumor location, tumor size, KPS score or ASA score. Thus, the present study indicated that age is not associated with surgical outcome in elderly meningioma patients. Regardless of patient age, the decision to perform surgical resection should be made on an individual basis wherein tumor characteristics and the general health of the patient are considered.

Factors Associated with Recurrence of Intracranial Meningiomas After Surgical Resection: A Retrospective Single-Center Study

Summary Background Meningioma is one of the most common primary brain neoplasms with poor outcomes. The present study was aimed to determine clinical and surgical characteristics of intracranial meningiomas associated with tumor recurrence and complications. Methods A total of 138 patients undergoing surgical resection of intracranial meningiomas between Jan 2003 and Dec 2014 were included and followed for the period of at least 12 months. The demographic and clinical characteristics possibly associated with tumor recurrence were assessed, including age, gender, clinical symptoms, pathology data, tumor parameters, preoperative and postoperative Karnofsky Performance Scale (KPS), complications and recurrence rate. Results One hundred and twenty one lesions were benign (classified as Grade I) and 17 were atypical/malignant (classified as Grade II/III). The patients were of a mean age of 60.5 years and a mean follow-up duration of 36.8 months (range, 16.3–62.9 months). The 1, 3, 5-year recurrence/tumor enlargement rates were 3.4%, 7.2%, and 15.7%, respectively. In multivariate analysis, symptoms of disturbance of consciousness and palpable cranial mass were associated with increased recurrence/tumor enlargement. In addition, patients with Simpson grade IV were more likely to have recurrence/tumor enlargement. Conclusion The pattern of intracranial meningioma in this series is typical to other studies. Presenting symptoms is suggested to be predictive of recurrence.

Extent of T1+C Intensity Is a Predictor of Blood Loss in Resection of Meningioma.

Surgery for meningioma is associated with significant blood loss. Preoperative embolization has been associated with reduction of blood loss and has been noted to decrease intensity on T1+ contrast sequences. We investigate potential relationships between blood loss and the extent of T1+ contrast intensity. Forty-two patients who underwent surgical resection of intracranial meningioma were retrospectively reviewed from August 2009 to May 2016. Clinical data were extracted (age, gender, location of meningioma, grade of meningioma, need for blood transfusion during surgery, preoperative and postoperative hematocrit level, estimated blood loss [EBL], and duration of surgery). Using OsiriX MD, the tumor volume, sinus involvement, peritumoral edema, extent of resection, and T1 index (average T1+C intensity across the tumor normalized to value at basilar artery) were assessed. With EBL, univariate analysis for gender, tumor volume, and T1 index showed correlations with Pvalue <0.1. A logistic regression to predict EBL <300 mL and ≥300 mL using the 3 variables yielded T1 index (odds ratio [OR], 31.22; 95% confidence interval [CI], 1.14-855.65), gender (OR, 0.17; 95% CI, 0.03-0.96), and tumor volume (OR,1.05; 95% CI, 1.00-1.10) as significant predictors (all P< 0.05). With duration for surgery, gender, tumor volume, need for blood transfusion, and preoperative hematocrit exhibited P value <0.05; multivariate analysis did not show a significant model. Along with gender and tumor volume, extent of T1+C intensity is also an independent predictor of EBL. This finding may be helpful for surgical management of meningioma.

Detailed anatomy knowledge: first step to approach petroclival meningiomas through the petrous apex. Anatomy lab experience and surgical series.

Petroclival meningiomas are a challenge for neurosurgeons due to the complex anatomy of the region that is rich of vessels and nerves. A perfect and detailed knowledge of the anatomy is very demanding in neurosurgery, especially in skull base surgery. The authors describe the microsurgical anatomy to perform an anterior petrosectomy based on their anatomical and surgical experience and perform a literature review. The temporal bone is the most complex and fascinating bone of skull base. The apex is located in the angle between the greater wing of the sphenoid and the occipital bone. Removing the petrous apex exposes the clivus. The approach directed through the temporal bone in this anatomical area is referred to as an anterior petrosectomy. The area that must be drilled is the rhomboid fossa that is defined by the Kawase, premeatal, and postmeatal triangles. In Division of Neurosurgery - University of Turin, 130 patients, from August 2013 to September 2015, underwent surgical resection of intracranial meningiomas. In this group, we have operated 7 PCMs and 5 of these were approached performing an anterior petrosectomy with good results. In our conclusions, we feel that this surgery require an advanced knowledge of human anatomy and a specialized training in interpretation of radiological and microsurgical anatomy both in the dissection lab and in the operating room.

The incidence of postoperative thromboembolic complications following surgical resection of intracranial meningioma. A retrospective study of a large single center patient cohort

BackgroundPatients with meningiomas carry an increased risk for postoperative venous thromboembolic complications (VTE) including deep venous thrombosis (DVT) and pulmonary embolism (PE). ObjectiveIn the present retrospective study we investigated the incidence of VTE and the risk factors involved, in a large cohort of patients surgically treated for an intracranial meningioma at our institution. MethodsDuring the period from January 1997 to January 2009, 581 consecutive patients underwent craniotomy for intracranial meningioma. All patients received low-molecular weight heparins as thromboembolism prophylaxis. Patient demographics and tumor characteristics were gathered via retrospective chart review. Postoperative VTE and hemorrhages were noted. Backward stepwise logistic regression was used to determine the risk factors. Results80.6% of meningiomas were WHO grade 1; 15.1% WHO grade 2; 4.3% WHO grade 3. Postoperative VTE were observed in 41 patients (7.2%). Of these, DVT was seen in 20 (3.5%) and PE in 26 patients (4.6%). The thromboembolic complication appeared on average 21.1±29.2 days post surgery. The 90-day mortality rate after VTE was 11.2% (23.1% for PE and 5.0% for DVT). Postoperative hemorrhages requiring surgical treatment were found in 2.9% of patients. Risk factors for VTE were body mass index (p=0.015) for DVT; weight (p=0.001) and bedridden postoperatively (p=0.001) for PE; and weight (p=0.004) and bedridden postoperatively (p=0.003) for VTE in general. There was no relation between tumor grade and thromboembolic complications. ConclusionThe major risk factors for postoperative VTE found in our single center study are patient weight and a bedridden status postoperatively. Prophylactic intervention for this potentially fatal complication should be evaluated against the relative lower risk of postoperative hemorrhages.

Craniotomy for resection of meningioma in the elderly: a multicentre, prospective analysis from the National Surgical Quality Improvement Program

ObjectWhether there is an increased surgical risk in elderly patients who undergo craniotomy for meningioma resection remains a point of controversy. Utilising multicentre, prospective data from the National Surgical Quality...

Effect of preoperative embolization on resection of intracranial meningioma: Local experience

Background/Aim: Preoperative devascularization of intracranial meningioma by endovascular embolization has been performed in many institutes over the past 30 years. Advancement in microsurgical techniques and endovascular technology during the period may have offset or magnified the benefit of the procedure. The aim of the present study was to evaluate the effect of preoperative embolization on surgical resection of intracranial meningiomas.Methods: The results of preoperative embolization followed by surgical resection of intrancranial meningiomas at a local neurosurgical unit in Kwong Wah Hospital (KWH) were compared to the results of surgical resection of intracranial meningiomas without preoperative embolization at another local neurosurgical unit in Princess Margaret Hospital (PMH) between 1 January 2000 and 30 June 2003.Results: For convexity meningioma, there was no statistically significant difference in intraoperative blood loss, units of blood transfused or operation time between the embolized group and the non‐embolized group. For parasagittal and sphenoid wing meningioma, although the mean tumour volume was larger in the embolized group, there was less intraoperative blood loss and units of blood transfused, and shorter operation time in the embolized group as compared with the non‐embolized group.Conclusion: There was no significant effect of preoperative embolization on surgical resection of convexity meningiomas. However, the procedure appeared to be a useful adjunct to surgical resection of parasagittal and sphenoid wing meningiomas.

Intracranial meningiomas in the aged: surgical outcome in the era of computed tomography.

Seventy-five patients older than 60 years of age underwent surgical resection of intracranial meningiomas during a 10-year period at a single institution. All patients had a computed tomographic scan preoperatively, and all were followed for at least 3 months postoperatively. There were 50 patients 61 to 70 years of age (Group A), and 25 patients older than 70 years (Group B). Sixteen patients (21%) were asymptomatic, and no patient was severely disabled preoperatively. Operative morbidity and mortality and outcome at 3 months were assessed and correlated with age, preoperative neurological status, and tumor size and location. Operative mortality was 6.6% (6% in Group A; 8% in Group B). Perioperative morbidity (including medical and surgical complications and worsening in neurological status) was 48% (46% in Group A; 52% in Group B). Neurological status 3 months after surgery was improved by at least one grade as compared to before surgery in 40% of patients (38% in Group A; 44% in Group B), unchanged in 29% (34% in Group A; 20% in Group B), and worsened in 31% (28% in Group A; 36% in Group B). While nearly half of the patients were asymptomatic 3 months after surgery, 11 patients (15%) had died or remained seriously disabled. Outcome at 3 months correlated significantly with low neurological grade preoperatively and with a tumor location over the cortical convexity. There was no significant correlation with age or tumor size. We conclude that resection of intracranial meningiomas is associated with significant morbidity and mortality in the elderly.(ABSTRACT TRUNCATED AT 250 WORDS)