Early Postoperative Complications in Meningioma: Predictive Factors and Impact on Outcome

Incidence and Risk Factors of Surgical Site Infection After Cranial Surgery for Patients with Brain Tumors: A Systematic Review and Meta-analysis

BACKGROUND

Surgical site infections after craniotomy (SSI-CRANs) are a serious adverse event given the proximity of the wound to the central nervous system. SSI-CRANs are associated with substantial patient morbidity and mortality. Despite the importance and recognition of this event in other surgical fields, there is a paucity of evidence in the neurosurgical literature devoted to SSI-CRAN specifically in patients after brain tumor surgery.

METHODS

Systematic searches of Medline, Embase, and Cochrane Central were undertaken. The primary outcome was the incidence of SSI-CRAN at 30 and 90 days. Secondary outcomes were risk factors for SSI-CRAN.

RESULTS

Thirty-seven studies reporting 91,907 patients with brain tumors who underwent cranial surgery were included in the meta-analysis. Pooled incidence of SSI-CRAN at 30 and 90 days was 4.03% (95% CI: 2.94%-5.28%, I2 = 97.3) and 6.17% (95% CI: 3.16%-10.07%, I2 = 97.3), respectively. Specifically, incidence of SSI-CRAN following surgery for posterior fossa tumors was the highest at 9.67% (95% CI: 5.98%-14.09%, I2 = 75.5). Overall pooled incidence of readmission within 30 days and reoperation due to SSI-CRAN were 13.9% (95% CI: 12.5%-15.5%, I2 = 0.0) and 16.3% (95% CI: 5.4%-31.3%, I2 = 72.9), respectively. Risk factors for SSI-CRAN included reintervention (risk ratio [RR] 1.58, 95% CI: 1.22-2.04, I2 = 0.0), previous radiotherapy (RR 1.69, 95% CI: 1.20-2.38, I2 = 0.0), longer duration of operation (mean difference 64.18, 95% CI: 3.96-124.40 minutes, I2 = 90.3) and cerebrospinal fluid (CSF) leaks (RR 14.26, 95% CI: 2.14-94.90, I2 = 73.2).

CONCLUSIONS

SSI-CRAN affects up to 1 in 14 patients with brain tumors. High-risk groups include those with reintervention, previous radiotherapy, longer duration of operation, and CSF leaks. Further prospective studies should focus on bundles of care that will reduce SSI-CRAN.

Individuals' perceptions of health and well-being in the context of stereotactic radiosurgery for benign brain tumour: A longitudinal qualitative investigation

BACKGROUND AND OBJECTIVES

Treatment-related outcomes after Gamma Knife Stereotactic Radiosurgery (GKSRS) for benign brain tumour are well-established; yet patient reported outcomes have been largely overlooked. This study explored individuals' perspectives of their health and well-being prior to and following GKSRS.

METHOD

Twenty adults (65% female) aged 24-71 years with benign brain tumour were recruited from a major metropolitan hospital and assessed approximately one week prior to, two weeks after, and at three months following GKSRS. They completed telephone-based interviews focusing on general health, symptoms, and well-being. Interviews were transcribed and analysed using thematic analysis.

RESULTS

Three major themes characterized individuals' perceptions of their health and well-being. "Understanding my Illness and Treatment" reflected individuals' efforts to make sense of their illness and symptoms to reduce ambiguity and increase sense of control. "Experiencing Gamma Knife" related to expectations of the procedure, outcomes, daily impacts, and emotional reactions. "Adjusting one's Mindset and Coping" characterised how peoples' approaches to coping with their illness were altered over time.

CONCLUSIONS

Coping and adjustment is highly individualistic in the context of GKSRS. Over time, most individuals were able to make sense of their illness, adjust their mindset and utilize behavioural strategies and support systems to cope with the long-term effects.

Intracranial intricacies: Comprehensive analysis of rare skull base meningiomas-A single-center case series

This study paper's main goal is to report rare cases of skull base meningiomas that exemplify the complexities of diagnosis, therapy, and postoperative care. By describing these rare cases, we hope to advance knowledge of the clinical signs, difficulties, and prognoses of skull base meningiomas in a challenging anatomical setting. In the posterior cranial fossa, our investigation reveals a unique example of skull base meningioma that involved numerous cranial nerves and complex vasculature. A variety of visual abnormalities were present in the patient's clinical presentations, highlighting the wide range of symptoms that these tumors might cause depending on their precise positions. These cases highlight the critical importance of preoperative imaging, including high-resolution MRI and angiography, as well as the diagnostic difficulties these tumors pertain. By reporting these instances, our research adds to the body of knowledge about skull base meningiomas and offers insightful information about the nuances of their therapies. Our findings highlight the importance of individualized treatment plans, interdisciplinary cooperation, and the demand for continued study to better comprehend these convoluted tumors. Such studies are essential for advancing our knowledge of these enigmatic tumors, guiding clinical judgment, and eventually improving patient outcomes. These findings are important because they can fill information gaps, improve treatment plans, and encourage additional research in neuro-oncology.

Abstract

This study presents a series of three rare cases of skull base meningiomas, emphasizing the complexities in diagnosis, treatment, and postoperative care. The patients' clinical presentations and imaging highlighted the diverse symptoms and challenges associated with these tumors, found in intricate anatomical locations. The cases underscore the crucial role of preoperative high-resolution imaging and angiography in diagnostic accuracy. Surgical intervention, guided by a multidisciplinary approach, is pivotal in managing these demanding cases. Histopathological examinations confirmed atypical meningiomas. The postoperative phases involved meticulous care to ensure optimal recovery and functional outcomes. Our findings contribute to the understanding of skull base meningiomas, emphasizing the need for personalized treatment plans and ongoing research to improve patient outcomes in neuro-oncology.

A nomogram for predicting the risk of major postoperative complications for patients with meningioma

PURPOSE

To identify risk factors for major postoperative complications in meningioma patients and to construct and validate a nomogram that identify patients at high risk of these complications.

METHODS

The medical records of meningioma patients who underwent surgical resection in our hospital from January 2018 to December 2020 were collected. The patients were divided into a training set (815 cases from the main campus in 2018 and 2019) and a validation set (300 cases from two other campuses in 2020). Major postoperative complications were defined as any new neurological deficits and complications classified as Clavien-Dindo Grading (CDG) II or higher. Univariate and multivariate analyses were conducted using the training set to identify independent risk factors. A nomogram was constructed based on these results. And then validated the nomogram through bootstrap re-sampling in both the training and validation sets. The concordance index (C-index) and the area under the curve (AUC) were used to assess the discriminative ability of the nomogram. The Hosmer-Lemeshow test was performed to evaluate the goodness-of-fit. The optimal cutoff point for the nomogram was calculated using Youden's index.

RESULTS

In the training set, 135 cases (16.56%) experienced major postoperative complications. The independent risk factors identified were male sex, recurrent tumors, American Society of Anesthesiologists (ASA) class III-IV, preoperative Karnofsky Performance Scale (KPS) score < 80, preoperative serum albumin < 35 g/L, tumor in the skull base or central sulcus area, subtotal tumor resection (STR), allogeneic blood transfusion, and larger tumor size. A nomogram was constructed based on these risk factors. It demonstrated good predictive performance, with a C-index of 0.919 for the training set and 0.872 for the validation set. The area under the curve (AUC) > 0.7 indicated satisfactory discriminative ability. The Hosmer-Lemeshow test showed no significant deviation from the predicted probabilities. And the cutoff for nomogram total points was about 200 (specificity 0.881 and sensitivity 0.834).

CONCLUSIONS

The constructed nomogram demonstrated robust predictive performance for major postoperative complications in meningioma patients. This model can be used by surgeons as a reference in clinical decision-making.

Uncovering the molecular landscape of meningiomas and the impact of perioperative steroids on patient survival

BACKGROUND

The current literature on meningioma reveals a gap in knowledge regarding the impact of genetic factors on patient survival. Furthermore, there is a lack of data on the relationship between the perioperative use of corticosteroids and patient survival in meningioma patients. Our study aims to overcome these gaps by investigating the correlation between genetic factors and overall survival and the effect of postoperative corticosteroids and other clinical characteristics on patient outcomes in meningioma patients.

METHODS

A retrospective analysis of the medical records of 85 newly diagnosed meningioma patients treated from 2016 to 2017 with follow-up until December 2022 was performed.

RESULTS

NF2 mutations occurred in 60% of tumors, AKT1 mutations in 8.2%, and TRAF7 mutations in 3.6%. Most tumors in the parasagittal region had the NF2 mutation. On the other hand, almost all tumors in the sphenoid ridge area did not have the NF2 mutation. AKT-1-mutated meningiomas had more frequent peritumoral edema. Patients who received steroids perioperatively had worse overall survival (OS) than those without steroids (p = 0.034). Moreover, preoperative peri-meningioma edema also was associated with worse OS (p < 0.003). Contrarily, NF2 mutations did not influence survival.

CONCLUSIONS

The combination of clinical, pathomorphological, and genetic data allows us to characterize the tumor better and assess its prognosis. Corticosteroids perioperatively and peri-meningioma edema were associated with shorter OS, according to our study. Glucocorticoids should be used judiciously for the shortest time required to achieve symptomatic relief.

Role of risk factors, scoring systems, and prognostic models in predicting the functional outcome in meningioma surgery: multicentric study of 552 skull base meningiomas

Despite the importance of functional outcome, only a few scoring systems exist to predict neurologic outcome in meningioma surgery. Therefore, our study aims to identify preoperative risk factors and develop the receiver operating characteristics (ROC) models estimating the risk of a new postoperative neurologic deficit and a decrease in Karnofsky performance status (KPS). A multicentric study was conducted in a cohort of 552 consecutive patients with skull base meningiomas who underwent surgical resection from 2014 to 2019. Data were gathered from clinical, surgical, and pathology records as well as radiological diagnostics. The preoperative predictive factors of functional outcome (neurologic deficit, decrease in KPS) were analyzed in univariate and multivariate stepwise selection analyses. Permanent neurologic deficits were present in 73 (13.2%) patients and a postoperative decrease in KPS in 84 (15.2%). Surgery-related mortality was 1.3%. A ROC model was developed to estimate the probability of a new neurologic deficit (area 0.74; SE 0.0284; 95% Wald confidence limits (0.69; 0.80)) based on meningioma location and diameter. Consequently, a ROC model was developed to predict the probability of a postoperative decrease in KPS (area 0.80; SE 0.0289; 95% Wald confidence limits (0.74; 0.85)) based on the patient's age, meningioma location, diameter, presence of hyperostosis, and dural tail. To ensure an evidence-based therapeutic approach, treatment should be founded on known risk factors, scoring systems, and predictive models. We propose ROC models predicting the functional outcome of skull base meningioma resection based on the age of the patient, meningioma size, and location and the presence of hyperostosis and dural tail.

Effect of systolic blood pressure fluctuations during resuscitation on postoperative complications following meningioma surgery: A retrospective observation study

It is unclear whether blood pressure variability in the post-anesthesia care unit is associated with postoperative complications. This study aims to characterize the impact of blood pressure fluctuations on postoperative complications and postoperative length of stay after meningioma surgery. Adult meningioma patients undergoing general anesthesia were retrospectively recruited. The principal exposure was blood pressure variability in the post-anesthesia care unit, calculated by noninvasive blood pressure measurements. The primary outcome was major postoperative complications, defined as II or higher in the Clavien-Dindo classification grades. Secondary outcomes included healthcare resource utilization parameters among patients. Multivariable logistic regression was used and adjusted for potential confounding variables. Data sensitivity analyses were performed via different variable transformations and propensity score matching analyses. A total of 578 patients qualified for the study, and 161 (27.9%) cases experienced postoperative complications. The multivariable analysis found that increased systolic blood pressure variability in the post-anesthesia care unit was associated with postoperative complications (adjusted odds ratio [aOR] = 1.15; 95% confidence interval [CI], 1.09-1.22, P < .001) and prolonged postoperative length of stay (adjusted regression coefficients [β] = 1.86; 95% CI, 0.58-3.13, P = .004). Patients with postoperative complications had a higher frequency of intensive care admission (44.1% vs 15.3%), major postoperative interventions (6.6% vs 0%), and 30-day readmission (5.0% vs 0.7%). Systolic blood pressure fluctuations during resuscitation have an independent impact on postoperative complications and postoperative length of stay following meningioma surgery.

Can Currently Suggested Quality Indicators Be Transferred to Meningioma Surgery?-A Single-Center Pilot Study

BACKGROUND

 Risk stratification based on standardized quality measures has become crucial in neurosurgery. Contemporary quality indicators have often been developed for a wide range of neurosurgical procedures collectively. The accuracy of tumor-inherent characteristics of patients diagnosed with meningioma remains questionable. The objective of this study was the analysis of currently applied quality indicators in meningioma surgery and the identification of potential new measures.

METHODS

 Data of 133 patients who were operated on due to intracranial meningiomas were subjected to a retrospective analysis. The primary outcomes of interest were classical quality indicators such as the 30-day readmission, 30-day reoperation, 30-day mortality, 30-day nosocomial infection, and the 30-day surgical site infection rate. Uni- and multivariate analyses were performed. The occurrence of a new postoperative neurologic deficit was analyzed as a potential new quality indicator.

RESULTS

 The overall unplanned readmission rate was 3.8%; 13 patients were reoperated within 30 days (9.8%). The 30-day nosocomial infection and surgical site infection rates were 6.8 and 1.5%, respectively. A postoperative new neurologic deficit or neurologic deterioration as a currently assessed quality feature was observed in 12 patients (9.2%). The edema volume on preoperative scans proved to have a significant impact on the occurrence of a new postoperative neurologic deficit (p = 0.023).

CONCLUSIONS

 Classical quality indicators in neurosurgery have proved to correlate with considerable deterioration of the patient's health in meningioma surgery and thus should be taken into consideration for application in meningioma patients. The occurrence of a new postoperative neurologic deficit is common and procedure specific. Thus, this should be elucidated for application as a complementary quality indicator in meningioma surgery.

Preoperative frailty measured by risk analysis index predicts complications and poor discharge outcomes after Brain Tumor Resection in a large multi-center analysis

PURPOSE

To evaluate the independent effect of frailty, as measured by the Risk Analysis Index-Administrative (RAI-A) for postoperative complications and discharge outcomes following brain tumor resection (BTR) in a large multi-center analysis.

METHODS

Patients undergoing BTR were queried from the National Surgical Quality Improvement Program (NSIQP) for the years 2015 to 2019. Multivariable logistic regression was performed to evaluate the independent associations between frailty tools (age, 5-factor modified frailty score [mFI-5], and RAI-A) on postoperative complications and discharge outcomes.

RESULTS

We identified 30,951 patients who underwent craniotomy for BTR; the median age of our study sample was 59 (IQR 47-68) years old and 47.8% of patients were male. Overall, increasing RAI-A score, in an overall stepwise fashion, was associated with increasing risk of adverse outcomes including in-hospital mortality, non-routine discharge, major complications, Clavien-Dindo Grade IV complication, and extended length of stay. Multivariable regression analysis (adjusting for age, sex, BMI, non-elective surgery status, race, and ethnicity) demonstrated that RAI-A was an independent predictor for worse BTR outcomes. The RAI-A tiers 41-45 (1.2% cohort) and > 45 (0.3% cohort) were ~ 4 (Odds Ratio [OR]: 4.3, 95% CI: 2.1-8.9) and ~ 9 (OR: 9.5, 95% CI: 3.9-22.9) times more likely to have in-hospital mortality compared to RAI-A 0-20 (34% cohort).

CONCLUSIONS AND RELEVANCE

Increasing preoperative frailty as measured by the RAI-A score is independently associated with increased risk of complications and adverse discharge outcomes after BTR. The RAI-A may help providers present better preoperative risk assessment for patients and families weighing the risks and benefits of potential BTR.

Brain infarction following meningioma surgery-incidence, risk factors, and impact on function, seizure risk, and patient-reported quality of life

In this study, we seek to explore the incidence of and potential risk factors for postoperative infarctions after meningioma surgery, in addition to the possible association with new neurological deficits, seizures, and health-related quality of life (HRQoL). A single-center cohort study was conducted, where all patients operated for an intracranial meningioma at our institution between 2007 and 2020 were screened for inclusion. Clinical data were prospectively collected in a local tumor registry, and HRQoL was assessed using both generic and disease-specific instruments. In total, 327 meningioma operations were included, and early postoperative MRIs showed peritumoral infarctions in 114 (34.9%). Median infarction volume was 4.5 ml (interquartile range 2.0-9.5) and 43 (37.7%) of the infarctions were rim-shaped, 44 (38.6%) were sector-shaped, 25 (21.9%) were a combination of rim- and sector-shaped, and two (1.8%) were remote infarctions. Permanent neurological deficits were seen in 22 patients (6.7%) and deficits were associated with infarctions (p < 0.001). There was no difference in frequency of registered postoperative epilepsy between patients with versus without infarctions. Patients with infarctions reported more future uncertainty; otherwise, there were no significant differences in disease specific HRQoL between patients with versus without infarctions. In this study, we found that peritumoral infarctions after meningioma resection are common. Most patients with permanent neurological deficits had infarctions. Yet, most infarctions were small, and although sometimes symptomatic on individual level, infarctions did not lead to significant deterioration of HRQoL on group level.

Five-year cause-specific survival after meningioma surgery. A nationwide population-based study

BACKGROUND

Survival after meningioma surgery is often reported with inadequate allowance for competing causes of death.

METHODS

We processed the French administrative medical database (Système National des Données de Santé: SNDS), to retrieve appropriate cases of surgically treated meningioma. Cause-specific survival in meningioma-related death was analyzed with the Fine & Gray (F&G) and cause-specific (CS) Cox models to identify associated factors.

RESULTS

Five-year cumulative incidence was 2.85% for meningioma-related death and 6.3% for unrelated death (P<0.001). In the adjusted F&G and cause-specific Cox regression models for meningioma-related death, gender, age at surgery, co-morbidities, neurofibromatosis type 2, tumor insertion, tumor grade, cerebrospinal fluid (CSF) shunt insertion, preoperative embolization and need for redo surgery for recurrence emerged as independent prognostic factors of cause-specific survival (CSS) in meningioma-related death.

CONCLUSION

At 5 years, the risk of meningioma-unrelated death was 2.21-fold greater than the risk of dying from the meningioma disease. Five-year CSS after meningioma surgery was greater in younger adults with benign spinal meningioma with low comorbidity. Those with malignant cranial tumor requiring preoperative embolization or CSF shunting for associated hydrocephalus and with severely degraded overall health status showed a significantly increased risk of meningioma-related death. Redo surgery for recurrence failed to improve the risk of meningioma-related death. We recommend the use of net survival methods such as CSS in meningioma studies where unrelated mortality is predominant, as this approach results in more accurate estimates of disease risk and associated predictors.

Long-term risk of shunt failure after brain tumor surgery

Long-term risks and survival times of ventriculoperitoneal (VP) shunts implanted due to hydrocephalus (HC) after craniotomy for brain tumors are largely unknown. The aim of this study was to establish the overall VP shunt survival rates during a decade after shunt insertion and to determine risks of shunt failure after brain tumor surgery in the long-term period. In this population-based cohort from a well-defined geographical region, all adult patients (> 18 years) from 2004 to 2013 who underwent craniotomies for intracranial tumors leading to VP shunt dependency were included. Our brain tumor database was cross-linked to procedure codes for shunt surgery (codes AAF) to extract brain tumor patients who became VP shunt dependent after craniotomy. The VP shunt survival time, i.e. the shunt longevity, was calculated from the day of shunt insertion after brain tumor surgery until the day of its failure. A total of 4174 patients underwent craniotomies, of whom 85 became VP shunt dependent (2%) afterwards. Twenty-eight patients (33%) had one or more shunt failures during their long-term follow-up, yielding 1-, 5-, and 10-year shunt success rates of 77%, 71%, and 67%, respectively. Patient age, sex, tumor location, primary/repeat craniotomy, placement of external ventricular drainage (EVD), ventricular entry, post-craniotomy hemorrhage, post-shunting meningitis/infection, and multiple shunt revisions were not statistically significant risk factors for shunt failure. Median shunt longevity was 457.5 days and 21.5 days for those with and without pre-craniotomy HC, respectively (p < 0.01). This study can serve as benchmark for future studies.

Preoperative risk factors associated with new focal neurological deficit and other major adverse events in first-time intracranial meningioma neurosurgery

BACKGROUND

Neurosurgical resection is the mainstay of meningioma treatment. Adverse event (AE) rates of meningioma resections are significant, but preoperative risk factors for major AEs in patients undergoing first-time meningioma surgery are largely unknown. The aim of this study was to explore major AEs and identify preoperative risk factors in patients undergoing first-time meningioma surgery.

METHODS

Data on all meningioma resections performed at the University Hospital Zurich from 1 January 2013 to 31 December 2018 were collected in a prospective registry. All AEs that occurred within 3 months of surgery were documented in detail and classified as "minor" or "major." Statistical analysis included initial individual bivariate analyses of all preoperative factors and the occurrence of major AEs. Statistically significant variables were then included in a logistic regression model to identify predictors.

RESULTS

Three hundred forty-five patients were included in the study. Mean age was 58.1 years, and 77.1% of patients were female. The overall major AE rate was 20.6%; the most common of which was a new focal neurological deficit (12.8% of patients). Six preoperative factors showed a significant association with the occurrence of major AEs in bivariate analysis. All variables included in the logistic regression model showed increased odds of occurrence of major AE, but only tumor complexity as measured by the Milan Complexity Scale was a statistically significant predictor, with a score of 4 or more having twice the odds of major AEs (OR: 2.00, 95% CI: 1.15-3.48).

CONCLUSION

High tumor complexity is an independent predictor of the occurrence of major AEs following meningioma resection. Preoperative assessment of tumor complexity using the Milan Complexity Scale is warranted and can aid communication with patients about AE rates and surgical decision-making.

Clinical Outcomes Following Re-Operations for Intracranial Meningioma

The outcomes following re-operation for meningioma are poorly described. The aim of this study was to identify risk factors for a performance status outcome following a second operation for a recurrent meningioma. A retrospective, comparative cohort study was conducted. The primary outcome measure was World Health Organization performance. Secondary outcomes were complications, and overall and progression free survival (OS and PFS respectively). Baseline clinical characteristics, tumor details, and operation details were collected. Multivariable binary logistic regression was used to identify risk factors for performance status outcome following a second operation. Between 1988 and 2018, 712 patients had surgery for intracranial meningiomas, 56 (7.9%) of which underwent a second operation for recurrence. Fifteen patients (26.8%) had worsened performance status after the second operation compared to three (5.4%) after the primary procedure (p = 0.002). An increased number of post-operative complications following the second operation was associated with a poorer performance status following that procedure (odds ratio 2.2 [95% CI 1.1-4.6]). The second operation complication rates were higher than after the first surgery (46.4%, n = 26 versus 32.1%, n = 18, p = 0.069). The median OS was 312.0 months (95% CI 257.8-366.2). The median PFS following the first operation was 35.0 months (95% CI 28.9-41.1). Following the second operation, the median PFS was 68.0 months (95% CI 49.1-86.9). The patients undergoing a second operation for meningioma had higher rates of post-operative complications, which is associated with poorer clinical outcomes. The decisions surrounding second operations must be balanced against the surgical risks and should take patient goals into consideration.

Long-Term Follow-Up and Predictors of Functional Outcome after Surgery for Spinal Meningiomas: A Population-Based Cohort Study

Simple Summary

Spinal meningiomas are the most common adult primary intradural spinal tumors. While mostly benign, they may give rise to spinal cord compression with acute or chronic neurologic dysfunction. The primary treatment is surgical resection. Previous studies, limited by small sample sizes and short follow-up times, report that histopathological grade, tumor localization and size affect outcomes following surgery. In this population-based cohort study, we retrospectively reviewed 129 cases of surgically treated spinal meningiomas to assess postoperative complications, long-term clinical and radiological outcomes, predictors of neurological improvement and potential differences between elderly and non-elderly patients. Our median follow-up time was 8.2 years. We found that surgery was associated with significant neurological improvement. There was no significant difference in postoperative complications, tumor control or neurological improvement between elderly and non-elderly. Shorter time from diagnosis to surgery, larger tumor size and spinal cord compression predicted postoperative outcomes.

Abstract

Spinal meningiomas are the most common adult primary spinal tumor, constituting 24–45% of spinal intradural tumors and 2% of all meningiomas. The aim of this study was to assess postoperative complications, long-term outcomes, predictors of functional improvement and differences between elderly (≥70 years) and non-elderly (18–69 years) patients surgically treated for spinal meningiomas. Variables were retrospectively collected from patient charts and magnetic resonance images. Baseline comparisons, paired testing and regression analyses were used. In conclusion, 129 patients were included, with a median follow-up time of 8.2 years. Motor deficit was the most common presenting symptom (66%). The median time between diagnosis and surgery was 1.3 months. A postoperative complication occurred in 10 (7.8%) and tumor growth or recurrence in 6 (4.7%) patients. Surgery was associated with significant improvement of motor and sensory deficit, gait disturbance, bladder dysfunction and pain. Time to surgery, tumor area and the degree of spinal cord compression significantly predicted postoperative improvement in a modified McCormick scale (mMCs) in the univariable regression analysis, and spinal cord compression showed independent risk association in multivariable analysis. There was no difference in improvement, complications or tumor control between elderly and non-elderly patients. We concluded that surgery of spinal meningiomas was associated with significant long-term neurological improvement, which could be predicted by time to surgery, tumor size and spinal cord compression.

Predicting Discharge Disposition Following Meningioma Resection Using a Multi-Institutional Natural Language Processing Model

BACKGROUND

Machine learning (ML)-based predictive models are increasingly common in neurosurgery, but typically require large databases of discrete variables for training. Natural language processing (NLP) can extract meaningful data from unstructured text.

OBJECTIVE

To present an NLP model that predicts nonhome discharge and a point-of-care implementation.

METHODS

We retrospectively collected age, preoperative notes, and radiology reports from 595 adults who underwent meningioma resection in an academic center from 1995 to 2015. A total of 32 algorithms were trained with the data; the 3 best performing algorithms were combined to form an ensemble. Predictive ability, assessed by area under the receiver operating characteristic curve (AUC) and calibration, was compared to a previously published model utilizing 52 neurosurgeon-selected variables. We then built a multi-institutional model by incorporating notes from 693 patients at another center into algorithm training. Permutation importance was used to analyze the relative importance of each input to model performance. Word clouds and non-negative matrix factorization were used to analyze predictive features of text.

RESULTS

The single-institution NLP model predicted nonhome discharge with AUC of 0.80 (95% CI = 0.74-0.86) on internal and 0.76 on holdout validation compared to AUC of 0.77 (95% CI = 0.73-0.81) and 0.74 for the 52-variable ensemble. The multi-institutional model performed similarly well with AUC = 0.78 (95% CI = 0.74-0.81) on internal and 0.76 on holdout validation. Preoperative notes most influenced predictions. The model is available at http://nlp-home.insds.org.

CONCLUSION

ML and NLP are underutilized in neurosurgery. Here, we construct a multi-institutional NLP model that predicts nonhome discharge.

Functional outcome and quality of life after meningioma surgery: a systematic review

Assessment of long-term functional outcomes after meningioma surgery is important. We systematically reviewed the literature on health-related quality of life (HrQoL) and functional disability (FD) of patients after surgery for intracranial meningiomas. Using PRISMA 2015 guidelines, we screened 289 abstracts and 43 titles were retained for full-paper screening. 15 articles did not present enough data to meet the inclusion criteria and 7 articles failed to assess functional assessment and HrQoL. Twenty-two articles were included in our review. HrQol was assessed in N = 18 publications, most frequently using SF-36 (N = 10), followed by EQ5D-5L (N = 4), EORTC-QLQ (N = 4), and the FACT questionnaire (N = 2). The assessment of FD was reported in N = 11 publications, mostly using the KPS (N = 8). The Barthel index was used in N = 2 publications. Follow-up was reported in N = 12 publications, ranging from 6 months to 9 years. Scientific publications assessing long-term postoperative HrQol and FD in patients undergoing meningioma surgery are scarce and the data are heterogeneously reported, using various scales and follow-up protocols. Efforts should be undertaken to uniformly assess long-term post-operative functional outcomes in meningioma patients.

Foramen magnum meningiomas: a systematic review and meta-analysis

Foramen magnum meningiomas (FMMs) account for 1.8–3.2% of all meningiomas. With this systematic review and meta-analysis, our goal is to detail epidemiology, clinical features, surgical aspects, and outcomes of this rare pathology. Using PRISMA 2015 guidelines, we reviewed case series, mixed series, or retrospective observational cohorts with description of surgical technique, patient and lesion characteristics, and pre- and postoperative clinical status. A meta-analysis was performed to search for correlations between meningioma characteristics and rate of gross total resection (GTR). We considered 33 retrospective studies or case series, including 1053 patients, mostly females (53.8%), with a mean age of 52 years. The mean follow-up was of 51 months (range 0–258 months). 65.6% of meningiomas were anterior, and the mean diameter was of 29 mm, treated with different surgical approaches. Postoperatively, 17.2% suffered complications (both surgery- and non-surgery-related) and 2.5% had a recurrence. The Karnofsky performance score improved in average after surgical treatment (75 vs. 81, p < 0.001). Our meta-analysis shows significant rates of GTR in cohorts with a majority of posterior and laterally located FMM (p = 0.025) and with a mean tumor less than 25 mm (p < 0.05). FMM is a rare and challenging pathology whose treatment should be multidisciplinary, focusing on quality of life. Surgery still remains the gold standard and aim at maximal resection with neurological function preservation. Adjuvant therapies are needed in case of subtotal removal, non-grade I lesions, or recurrence. Specific risk factors for recurrence, other than Simpson grading, need further research.

A nationwide population-based study on overall survival after meningioma surgery

BACKGROUND

There are very few nationwide studies on meningioma outcome, the most common primary intracranial tumour.

METHODS

We processed the French Système National des Données de Santé (SNDS) database using an algorithm combining the type of surgical procedure and the International Classification of Diseases to retrieve all cases of meningiomas operated between 2007 and 2017. A survival analysis was performed.

RESULTS

This nationwide study found 28 773 patients of which 75 % were female. Median age at surgery was 59 years, IQR[49-68]. Cranial convexity (24.4 %) and middle skull base (21.7 %) were the most common locations. 91.3 % of the tumours were benign and 2.6 % malignant.7.5 % of the patients underwent redo surgery, 9.1 % radiotherapy (RT) and 3.2 % stereotactic radiosurgery for recurrence. Median follow-up was 5.3 years 95 % CI [5.24-5.35]. 0.64 % of the patients died within a month of surgery and 2.1 % within a year. Overall survival (OS) rates at 5 and 10 years respectively were: 92.6 %, 95 %CI[92.3, 93] and 85 %, 95 %CI[84.3, 85.8]. In the multivariable analysis, female gender (HR = 0.64, 95 %CI[0.59, 0.69], p < 0.001), older age at surgery (HR= 1.07, 95 %CI[1.06, 1.07], p < 0.001), type 2 neurofibromatosis (HR= 3.89, 95 %CI[2.62, 5.76], p < 0.001), parasagittal (HR= 1.2, 95 %CI[1.05, 1.37], p = 0.00944) or falx cerebri location (HR= 1.18, 95 %CI[1.01, 1.37], p = 0.0343), atypical or (HR= 1.34, 95 %CI[1.15, 1.56], p < 0.001) malignant histology (HR= 2.34, 95 %CI[2.01, 2.73], p < 0.001), redo surgery (HR=1.81, 95 %CI[1.6, 2.04], p < 0.001), progressing meningioma (HR=1.34, 95 %CI[1.05, 1.71], p = 0.0175) or RT for recurrence (HR=2.17, 95 %CI[1.95, 2.4], p < 0.001) were established as independent prognostic factors of the OS.

CONCLUSION

In this registry-based study, OS after meningioma surgery is good and is even better in women, younger adults and those with convexity and benign tumour. We also found that NF2 patients and those required redo surgery or additional treatment for uncontrolled meningioma disease are further at risk of death.

Clinical Outcome and Recurrence After Meningioma Surgery: An Experience from a Developing Country, Nepal

BACKGROUND

Meningioma is the most common primary brain tumor, constituting more than half of all benign central nervous system tumors. This study aims to analyze the clinical outcome and recurrence after surgery of intracranial meningioma in Nepal.

METHODS

This is a retrospective study of newly diagnosed intracranial meningioma patients operated at Nepal Mediciti Hospital between 2007 and 2019. Demographics; clinical, radiologic, and perioperative details; histopathology; and clinical outcome variables were reviewed. Association of independent variables with primary outcome variables: modified Rankin Scale (favorable [≤ 3] vs. unfavorable [>3]) and recurrence was analyzed. Logistic regression model was designed to calculate adjusted odds ratio with 95% confidence interval (CI).

RESULTS

Of 233 patients, mean age was 47 years, female individuals were affected twice as much as male individuals. Location was supratentorial in 83.3%, 83.7% had tumor greater than 5 cm in size. Gross total resection (SM 0-III) was achieved in 85.4%. A total of 98.7% had grade I meningioma. Favorable outcome was found in 94.8%. Recurrence rate was 6.9%. Tumor size less than 3 cm (adjusted odds ratio [AOR] 0.024 95% CI 0.001-0.416, P = 0.010), gross total resection (AOR 19.737, 95% CI 4.69-83.063, P < 0.001), and comorbidity (AOR 0.202, 95% CI 0.052-0.785, P = 0.021) were significantly associated with favorable outcome whereas age (AOR 3.491, 95% CI 1.029-11.850, P = 0.045) and WHO grade (AOR 0.024, 95% CI 0.002-0.344, P = 0.006) were independently associated with recurrence. The complication and surgical mortality rates were 30% and 1.72%, respectively.

CONCLUSIONS

Tumor size, extent of resection, age, tumor grade, and medical comorbidities were significantly associated with postoperative outcome. We recommend a prospective study with standardized follow up protocol to assess the long-term outcome.

Analysis of the quality of meningioma education resources available on the Internet

Background

Meningiomas are the most common primary central nervous system tumors and patients face difficulty evaluating resources available online. The purpose of this study is to systematically evaluate the educational resources available for patients seeking meningioma information on the Internet.

Methods

A total of 127 meningioma websites were identified by inputting the term “meningioma” on Google and two meta-search engines. A structured rating tool developed by our research group was applied to top 100 websites to evaluate with respect to accountability, interactivity, readability, and content quality. Responses to general and personal patient questions were evaluated for promptness, accuracy, and completeness. The frequency of various social media account types was analyzed.

Results

Of 100 websites, only 38% disclosed authorship, and 32% cited sources. Sixty-two percent did not state date of creation or modification, and 32% provided last update less than 2 years ago. Websites most often discussed the definition (99%), symptoms (97%), and treatment (96%). Prevention (8%) and prognosis (47%) were most often not covered. Only 3% of websites demonstrated recommended reading level for general population. Of 84 websites contacted, 42 responded, 32 within 1 day.

Conclusions

Meningioma information is readily available online, but quality varies. Sites often lack markers for accountability, and content may be difficult to comprehend. Information on specific topics are often not available for patients. Physicians can direct meningioma patients to appropriate reliable online resources depicted in this study. Furthermore, future web developers can address the current gaps to design reliable online resources.

Cause-Specific Survival After Meningioma Surgery: A Nationwide Population-Based Competing Risk Study

BACKGROUND

Survival after meningioma surgery often is reported with inadequate allowance for competing causes of death.

METHODS

We processed the French Système National des Données de Santé database using an algorithm combining the type of surgical procedure and the International Classification of Diseases to retrieve appropriate cases of meningiomas. The cumulative incidence of meningioma-related death was the primary end point. A competing risk analysis was performed to identify factors associated with meningioma-specific death of patients who underwent meningioma surgery.

RESULTS

The risk of meningioma-related death at 1, 2, and 3 years respectively was 2.4%, 95% confidence interval [CI] 2-2.7; 3%, 95% CI 2.6-3.4; and 3.1%, 95% CI 2.7-3.6. In the adjusted Fine-Gray competing risk regression for meningioma cause-specific survival, age at surgery (subdistribution hazard ratio [SHR] 1.07, 95% CI 1.05-1.09, P < 0.001), mortality-related morbidity index (SHR 1.68, 95% CI 1.07-2.63, P = 0.025), expenditure-related morbidity index (SHR 1.06, 95% CI 1.03-1.09, P < 0.001), spinal location (SHR 0.2, 95% CI 0.08-0.47, P < 0.001), cerebrospinal fluid shunt (SHR 3.13, 95% CI 1.9-5.16, P < 0.001), grade (SHR 1.88, 95% CI 1.13-3.14, P = 0.015) redo surgery for recurrence (SHR 1.6, 95% CI 1.01-2.51, P = 0.043), and progressing meningioma (SHR 2.87, 95% CI 1.23-6.68, P = 0.015) were established as independent prognostic factors of meningioma-related death.

CONCLUSIONS

Cause-specific survival after meningioma surgery is greater in younger, low-comorbidity adults with spinal and benign meningioma. Those with an intracranial, progressing malignant tumor requiring cerebrospinal fluid shunting and having a severe global health-state have a significant increased risk of meningioma-related death. Redo surgery failed to improve the outcome. We recommend the use of competing risk model in meningioma studies in which unrelated mortality may be substantial, as this approach results in more accurate estimates of disease risk and associated predictors.

An Overview of Managements in Meningiomas

Meningioma is the most frequent primary tumor of the central nervous system. Important advances have been achieved in the treatment of meningioma in recent decades. Although most meningiomas are benign and have a good prognosis after surgery, clinicians often face challenges when the morphology of the tumor is complicated or the tumor is close to vital brain structures. At present, the longstanding treatment strategies of meningioma are mainly surgery and radiotherapy. The effectiveness of systemic therapy, such as chemotherapy or targeted therapy, has not been confirmed by big data series, and some clinical trials are still in progress. In this review, we summarize current treatment strategies and future research directions for meningiomas.

Acquired Personality Disturbances After Meningioma Resection Are Strongly Associated With Impaired Quality of Life

BACKGROUND

Some patients experience long-term declines in quality of life following meningioma resection, but associated factors are not well understood.

OBJECTIVE

To investigate whether long-term declines in quality of life (specifically impaired adaptive functioning) after meningioma resection are associated with specific personality disturbances that often develop with lesions in ventromedial prefrontal cortex (vmPFC).

METHODS

We studied 38 patients who underwent resection of meningioma, 18 of whom had vmPFC lesions and 20 with lesions elsewhere (non-vmPFC). A total of 30 personality characteristics were rated by spouse or family, and a neuropsychologist blindly rated adaptive functioning an average of 3.8 yr postresection. Relevant personality disturbance was defined by a priori process: the presence of "conjoint personality disturbance" required specific disturbances in at least 2 of 4 types of disturbance: executive disorders, disturbed social behavior, emotional dysregulation, and hypoemotionality.

RESULTS

Fourteen patients had impaired adaptive functioning: 12 had vmPFC lesions and 2 had non-vmPFC lesions. Fourteen patients had conjoint personality disturbance, and 12 of them had impaired adaptive functioning. By contrast, among the 24 patients who did not have conjoint personality disturbance, only 2 had impaired adaptive functioning. Mediation analysis showed that the association between vmPFC lesions and impaired adaptive functioning was mediated by the negative impact of acquired personality disturbance on adaptive functioning.

CONCLUSION

Anterior skull base meningiomas plus resection surgery may result in specific personality disturbances that are highly associated with impaired adaptive functioning at long-term follow-up. These patients may benefit from early counseling regarding potential personality changes and their implications for adaptive functioning.

Comparative clinical and genomic analysis of neurofibromatosis type 2-associated cranial and spinal meningiomas

Neurofibromatosis type 2 (NF2) is an autosomal dominant Mendelian tumor predisposition disorder caused by germline pathogenic variants in the tumor suppressor NF2. Meningiomas are the second most common neoplasm in NF2, often occurring in multiple intracranial and spinal locations within the same patient. In this prospective longitudinal study, we assessed volumes and growth rates of ten spinal and ten cranial benign meningiomas in seven NF2 patients that concluded with surgical resection and performed whole-exome sequencing and copy-number variant (CNV) analysis of the tumors. Our comparison of the volume and the growth rate of NF2-associated spinal and cranial meningiomas point to the differences in timing of tumor initiation and/or to the differences in tumor progression (e.g., non-linear, saltatory growth) at these two anatomical locations. Genomic investigation of these tumors revealed that somatic inactivation of NF2 is the principal and perhaps the only driver of tumor initiation; and that tumor progression likely occurs via accumulation of CNVs, rather than point mutations. Results of this study contribute to a better understanding of NF2-associated meningiomas clinical behavior and their genetic underpinnings.

Benefits of re-do surgery for recurrent intracranial meningiomas

Meningiomas are the most common intracranial extra-axial tumor. While the literature is abundant on the therapeutic management of meningioma recurrence after the initial surgery, the natural history of repeated recurrences is poorly described, as well as and their respective management. A partly retrospective, partly prospective review was conducted in a Norwegian cohort of 1469 consecutive cases of meningioma surgically treated, totaling 11 414 patient-years of follow-up. 114 recurrences (7.7%) were treated surgically with a risk a surgical retreatment of 1% per patient-year of follow-up. 36 patients were operated on 3 times or more. The time-to-retreatment (TTR) decreased significantly and steadily between surgeries, from 4.3 ± 4 years after the first surgery to 2.4 ± 2.9 years after the third surgery. The primary driver for recurrence was the WHO grade (OR 7.13 [4.40;11.55], p < 0.001 for the first recurrence and OR 4.13 [1.49;12.15], p 0.008 for the second), the second predictive factor being a skull base location (OR 2.76 [1.95;3.99] p < 0.001 and OR 0.24 [0.09;0.65], p0.006 respectively). The rates of postoperative hematomas and infections were not influenced by the number of surgeries, whereas the rate of postoperative neurological worsening increased from 3.9% to 16.6% and 13.9%, respectively, after the first, second, and third surgeries. We observed that the TTR decreased significantly between surgeries in patients requiring repeated resections, indicating that surgical treatment of recurrences does not reset the clock but is indeed a "race against time". This should be considered when assessing the benefit-to-risk ratio of patients undergoing repeated surgeries for a recurrent meningioma.

Benefits of re-do surgery for recurrent intracranial meningiomas

Meningiomas are the most common intracranial extra-axial tumor. While the literature is abundant on the therapeutic management of meningioma recurrence after the initial surgery, the natural history of repeated recurrences is poorly described, as well as and their respective management. A partly retrospective, partly prospective review was conducted in a Norwegian cohort of 1469 consecutive cases of meningioma surgically treated, totaling 11 414 patient-years of follow-up. 114 recurrences (7.7%) were treated surgically with a risk a surgical retreatment of 1% per patient-year of follow-up. 36 patients were operated on 3 times or more. The time-to-retreatment (TTR) decreased significantly and steadily between surgeries, from 4.3 ± 4 years after the first surgery to 2.4 ± 2.9 years after the third surgery. The primary driver for recurrence was the WHO grade (OR 7.13 [4.40;11.55], p < 0.001 for the first recurrence and OR 4.13 [1.49;12.15], p 0.008 for the second), the second predictive factor being a skull base location (OR 2.76 [1.95;3.99] p < 0.001 and OR 0.24 [0.09;0.65], p0.006 respectively). The rates of postoperative hematomas and infections were not influenced by the number of surgeries, whereas the rate of postoperative neurological worsening increased from 3.9% to 16.6% and 13.9%, respectively, after the first, second, and third surgeries. We observed that the TTR decreased significantly between surgeries in patients requiring repeated resections, indicating that surgical treatment of recurrences does not reset the clock but is indeed a “race against time”. This should be considered when assessing the benefit-to-risk ratio of patients undergoing repeated surgeries for a recurrent meningioma.