Huge meningiomas: a review of 93 cases

Massive cystic falcine meningioma presented with slight symptoms: a case report

Introduction and importance

Meningiomas are the most common intracranial tumors while their presence with cysts is relatively low. In general, large ones usually present with severe symptoms and have a high recurrence rate even after total resection which is also difficult.

Case presentation

The authors present a case of an elderly patient with a large Falcine meningioma associated with peritumoral cysts. The patient presented with mild symptoms despite the tumor's significant size. Imaging studies revealed a large mass in the falcine region with peritumoral cysts. The patient underwent surgical resection of the tumor, which was completed without complications.

Clinical discussion

The atypical presentation of this large Falcine meningioma with peritumoral cysts highlights the variability in clinical manifestations of these tumors. Despite the tumor's size and the presence of peritumoral cysts, the patient experienced mild symptoms and recovered after relatively easy surgery challenging conventional expectations.

Conclusion

The successful outcome of this case demonstrates that even large meningiomas can present with mild symptoms. Medical practitioners should not always link the tumor size to the severity of symptoms, recurrence rate, and complexity of surgery.

Recurrence and Mortality Rate in a 42 Patient Cohort of Giant Meningiomas

BACKGROUND

Giant meningiomas may show special features in terms of biological behavior and management. We aimed to research recurrence and mortality of giant meningiomas.

METHODS

Medical files of patients with meningioma with at least 1 dimension of ≥5 cm in any plane in radiological investigations between December 2012 and January 2022 were retrospectively reviewed. Tumor dimensions were measured on magnetic resonance images except 1. All patients except two underwent clinical follow-up at a mean of 27.19 ± 29.87 (range, 4-112) months.

RESULTS

There were 42 patients, 26 (61.9%) women and 16 (38.1%) men who ranged in age from 31 to 85 (mean, 60.31 ± 14.86) years. Headache (57.1%) was the most common symptom. The mean tumor size was 70.14 ± 19.03 (range, 50-152) mm. Tumors were most located at the frontal convexity (40.5%). Simpson grade I resection was achieved in 19% of the cases. The tumors were World Health Organization grade 1 in 74% and grade 2 in 26% of the cases. Major complications developed in 26.1% of the patients. Recurrence happened in 5 (11.9%) cases. The number of World Health Organization grade 2 tumors (P = 0.013; P < 0.05) and tumor size (P = 0.006; P < 0.01) were significantly higher in the recurrent cases. Mortality was % 11.9 and statistically significantly higher in the recurrence group (P = 0.025; P < 0.05).

CONCLUSIONS

Giant intracranial meningiomas are challenging because of surgical experience, tumor size, peritumoral edema, blood supply, anatomical changes, and limited visibility. They have a high risk of recurrence and mortality.

Widening the Operative Corridor-Evaluating the Transcortical Approach to Giant Falcine Meningiomas

BACKGROUND

Giant falcine meningiomas are surgically complex as they are deep in location, concealed by normal brain parenchyma, in close proximity to various neurovascular structures, and frequently involve the falx bilaterally. Although classically accessed using a bifrontal craniotomy and interhemispheric approach, little data exist on alternative operative corridors for these challenging tumors. We evaluated perioperative and long-term outcomes in patients undergoing transcortical resection of giant bilateral falcine meningiomas.

METHODS

From 2013 to 2022, fourteen patients with giant bilateral falcine meningiomas treated via a transcortical approach at our institution were identified. Perioperative and long-term outcomes were evaluated to determine predictors of adverse events. Corticectomy depth was also analyzed to determine if it correlated with increased postoperative seizure rates.

RESULTS

57.1% of cases were WHO grade 2 meningiomas. Average tumor volume was 77.8 ± 46.5 cm3 and near/gross total resection was achieved in 78.6% of patients. No patient developed a venous infarct or had seizures in the 6 months after surgery. Average corticectomy depth was 0.83 ± 0.71 cm and increasing corticectomy depth did not correlate with higher risk of postoperative seizures (P = 0.44). Increasing extent of tumor resection correlated with lower tumor grade (P = 0.011) and only 1 patient required repeat resection during a median follow-period of 24.9 months.

CONCLUSIONS

The transcortical approach is a safe alternative corridor for accessing giant, falcine meningiomas, and postoperative seizures were not found to correlate with increasing corticectomy depth. Further prospective studies are necessary to determine the best approach to these surgically complex lesions.

Surgical Therapy of Non-Skull Base Meningiomas

In a previous chapter, the surgical management of skull base meningiomas were discussed. However, the most common meningiomas that are diagnosed and operated on are non-skull base tumors located in the parasagittal/parafalcine region and convexity, and more rarely along the tentorium, and in an intraventricular location. These tumors present their own unique set of challenges given their unique anatomy and tend to be more biologically aggressive compared to skull base meningiomas, thereby reinforcing the importance of obtaining a gross total resection if possible, in order to delay recurrence. In this chapter we will cover the surgical management of non-skull base meningiomas with technical considerations for tumors located in each of the anatomical areas listed above.

Surgical Challenges of Meningiomas with Extracranial Invasion: A Clinical Study

Objective: Meningiomas are mostly benign tumors located intracranially and intradurally, but they can rarely show extradural and extracranial growth. Surgical treatment of extracranial meningiomas is specifically challenging. In this study, we present an illustrated surgical series to convey our experience in treating meningiomas with extracranial extension. Methods: We retrospectively reviewed 11 patients with meningioma who underwent surgery between 2008 and 2020. In these patients, both intracranial and extracranial components were confirmed both radiologically and intraoperatively. Results: The patients were 7 males and 4 females with a mean age of 55.4 years. Most presented with facial disfigurement or asymmetrical growth of their skull. The most common symptom at presentation was headache. The most common location of meningiomas was the frontal region and that of extracranial growth was the paranasal sinuses and parietal bone invasion. We recognized two distinct modalities of bone destruction: hyperostosis (n=3) and osteolysis (n=8). Pathological study revealed atypical features in 6 patients. Preop embolization was attempted in 4 patients and proved difficult. Proper embolization was achieved only in one patient. The most commonly encountered surgical challenges were large calvarial and cranial base defects due to bone erosion, dural defects, and managing the superior sagittal sinus with parietal tumors. Excessive blood was of a particular concern and was managed by simple scalp clips, intraoperative transfusion, and conservative approach for tumor extensions into paranasal sinuses. No perioperative mortality occurred. Postoperative CSF fistulas beneath the scalp were common complications but conservatively managed with pressure wrapping. No cranial base CSF fistula developed. Calvarial reconstruction was performed with PMMA cement where needed. Conclusions: Meningiomas with extracranial extension are surgically challenging but treatable tumors. It contains fine neurosurgical trics in its treatment and follow-up.

The Surgical Risk Factors of Giant Intracranial Meningiomas: A Multi-Centric Retrospective Analysis of Large Case Serie

Giant intracranial meningiomas (GIMs) are a subgroup of meningiomas with huge dimensions with a maximum diameter of more than 5 cm. The mechanisms by which a meningioma can grow to be defined as a “giant” are unknown, and the biological, radiological profile and the different outcomes are poorly investigated. We performed a multi-centric retrospective study of a series of surgically treated patients suffering from intracranial meningioma. All the patients were assigned on the grounds of the preoperative imaging to giant and medium/large meningioma groups with a cut-off of 5 cm. We investigated whether the presence of large diameter and peritumoral brain edema (PBE) on radiological diagnosis indicates different mortality rates, grading, characteristics, and outcomes in a multi-variate analysis. We found a higher risk of developing complications for GIMs (29.9% versus 14.8%; p < 0.01). The direct proportional relationship between PBE volume and tumor volume was present only in the medium/large group (Pearson correlation with p < 0.01) and not in the GIM group (p = 0.47). In conclusion, GIMs have a higher risk of developing complications in the postoperative phase than medium/large meningioma without higher risk of mortality and recurrence.

Retrospective Analysis and Comparison of 48 Intracranial Meningioma Cases As Two Groups According to Their Size

Objective

This study aims to examine the possible demographic, clinical, and surgical differences between giant and smaller meningiomas.

Materials and Methods

Forty-eight meningioma patients who were operated on in our clinic between 2016-2020 were included in our study. Fourteen meningiomas larger than 5 cm in diameter were defined as giant meningiomas and placed in group 1. Thirty-four remaining meningiomas, with sizes less than 5 cm, were placed in group 2. These patients were evaluated regarding age, sex, localization, symptoms and neurological findings, surgical results, histopathology, and postoperative results.

Results

The most common localization in group 1 was falcine-parasagittal, whereas in group 2 it was convexity. Simpson’s grade I resection rate in group 1 was 35.71%, while in group 2 this rate was 67.65%. In histopathological examination, transitional type meningiomas (35.71%) were the most common in group 1, whereas fibrous type meningiomas (32.35%) were seen the most in group 2. Group 1 Karnofsky Performance Scale score average was 75.71 preoperatively and 85.71 postoperatively. In group 2, the preoperative and postoperative average was 97.35 and 96.76, respectively. The comparative statistical analysis reflects that: A) Resection rates were significantly lower in the giant meningioma group. B) Similarly, Karnofsky Performance Scale scores were also lower than group 2. C) When statistical comparisons were made according to sex, age, localization, histopathological results, postoperative complications, and recurrence rates, no significant differences were observed.

Conclusion

The term “Giant Meningioma” is a type of distinction that is frequently made in the literature. However, the single major difference we see in our study was the surgical results. The general condition of patients before and after surgery may be more critical than others in giant meningiomas. Although surgical resection is the main form of treatment in giant meningiomas, the risks arising from the size of the tumor should be taken into account, and necessary plans should be made for a successful surgical intervention.

Surgical Management of Giant Intracranial Meningiomas

Objective

Giant intracranial meningiomas are a challenge for neurosurgeons because of their size and location in the cranium. Difficult tumor dissection and encasement of important neurovascular structures make them a horrible nightmare. The aims of this study are to present our giant intracranial meningioma series and to compare our experience using advanced surgical technology with the current literature.

Materials and Methods

The data of patients with the diagnosis of giant intracranial meningioma between 2014 and 2020 who underwent surgical treatment were retrospectively reviewed. The demographic, radiological, and surgical characteristics of patients were documented. The size and location of tumors as well as surgical technique were analyzed in detail.

Results

A total of 61 patients with intracranial meningioma underwent surgical treatment over a 7-year period, and 10 (16.4%) tumors were larger than 5 cm in diameter, which were classified as giant meningioma. Seven patients were male and 3 were female, with a mean age of 64.9 years. Four tumors were located at the skull base. Histological diagnosis was meningioma World Health Organization grade I in 7 patients and grade II in 3 patients. Simpson grade 1 resection was achieved in 6 patients and grade 2 resection in 4 patients. No mortality was observed.

Conclusion

Careful surgical planning should be made for giant intracranial meningiomas. Their location, adjacent neurovascular structures, and vascular supply affect the resection level of these giant tumors. Simpson grade 1 resection is seldom possible for skull base meningiomas.

The evolution of resistance and tolerance as cancer defences

Although there is a plethora of cancer associated-factors that can ultimately culminate in death (cachexia, organ impairment, metastases, opportunistic infections, etc.), the focal element of every terminal malignancy is the failure of our natural defences to control unlimited cell proliferation. The reasons why our defences apparently lack efficiency is a complex question, potentially indicating that, under Darwinian terms, solutions other than preventing cancer progression are also important contributors. In analogy with host-parasite systems, we propose to call this latter option ‘tolerance’ to cancer. Here, we argue that the ubiquity of oncogenic processes among metazoans is at least partially attributable to both the limitations of resistance mechanisms and to the evolution of tolerance to cancer. Deciphering the ecological contexts of alternative responses to the cancer burden is not a semantic question, but rather a focal point in understanding the evolutionary ecology of host-tumour relationships, the evolution of our defences, as well as why and when certain cancers are likely to be detrimental for survival.

Fast-Growing Meningioma in a Woman Undergoing Fertility Treatments

Meningiomas have long been known to be associated with sexual hormones. We discuss here the case of a woman with a huge meningioma that rapidly grew over the course of a couple years while the patient was simultaneously taking fertility treatments. There is substantial evidence suggesting that fertility treatments can fuel the growth of meningiomas. The potential risks should be considered in women with a previous or family history of meningiomas who plan to undergo fertility treatment. These patients need to be evaluated and a screening imaging of brain MRI (Magnetic Resonant Imaging) should be offered in the middle or toward the end of such a treatment to control and prevent complications of these meningiomas.

Meningiomatosis restricted to the left cerebral hemisphere with acute clinical deterioration: Case presentation and discussion of treatment options

BACKGROUND

True multiple meningiomas are defined as meningiomas occurring at several intracranial locations simultaneously without the presence of neurofibromatosis. Though the prognosis does not differ from benign solitary meningiomas, the simultaneous occurrence of different grades of malignancy has been reported in one-third of patients with multiple meningiomas. Due to its rarity, unclear etiology, and questions related to proper management, we are presenting our case of meningiomatosis and discuss possible pathophysiological mechanisms.

CASE DESCRIPTION

We illustrate the case of a 55-year-old female with multiple meningothelial meningeomas exclusively located in the left cerebral hemisphere. The patient presented with acute vigilance decrement, aphasia, and vomiting. Further deterioration with sopor and nondirectional movements required oral intubation. Emergent magnetic resonance imaging (MRI) with MR-angiography disclosed a massive midline shift to the right due to widespread, plaque-like lesions suspicious for meningeomatosis, purely restricted to the left cerebral hemisphere. Emergency partial tumor resection was performed. Postoperative computed tomography (CT) scan showed markedly reduction of cerebral edema and midline shift. After tapering the sedation a right-sided hemiparesis resolved within 2 weeks, leaving the patient neurologically intact.

CONCLUSION

Although multiple meningeomas are reported frequently, the presence of meningeomatosis purely restricted to one cerebral hemisphere is very rare. As with other accessible and symptomatic lesions, the treatment of choice is complete resection with clean margins to avoid local recurrence. In case of widespread distribution a step-by-step resection with the option of postoperative radiation of tumor remnants may be an option.

Biological and demographic profile of meningiomas in a cohort of Egyptian patients: impact on tumor recurrence

Objective. This work was designed to study the biological and demographic characteristics of meningiomas and their impact on tumor recurrence in Egyptian patients. Material and Methods. A cohort of 265 Egyptian patients with meningioma was studied. Immunohistochemistry for VEGF, Ki67, PR, CD20, and CD3 was performed. Statistical analysis was used to detect independent predictors of recurrence. Results. Adults represented 98.9% of cases, with female preponderance (M : F ratio = 1 : 2.4). Histologically, 78.10% of cases were grade I, 19.20% were grade II, and 2.60% were grade III. Transitional variant was the most common (43.40%). VEGF expression (38.50% of cases) correlated positively with perifocal edema, tumor size, and proliferative index (PI). PR expression (64.5% of cases) correlated inversely with the PI (mean 3.75). Lymphocytic aggregates were detected in 7.20% of cases, with a mean CD20 : CD3 ratio of 1 : 10.1. In a multivariate analysis, only tumor size, PR expression and necrosis predicted recurrence independently. Using ROC curve, size was the best predictor of tumor recurrence with a cut-off point of >6 cm and an excellent negative predictive value (97.6%). Conclusions. Meningiomas in our region showed some distinctive clinicopathological and demographic criteria. Tumor size was found to be the best recurrence predictor factor of meningioma.

Is sagittal sinus resection in falcine meningiomas a factor of bad surgical outcome?

OBJECTIVE

Meningiomas arising purely from the falx below the longitudinal sinus represents a surgical challenge for the neurosurgeon. The authors discuss the new aspects of surgical details that may avoid complications and determine the prognosis.

MATERIALS AND METHODS

We retrospectively evaluated our surgical experience from June 2004 to January 2010. Seventy patients harboring falcine meningiomas were included and submitted for surgical resection. All historical records, office charts and images were reviewed in order to sample the most important data regarding epidemiology, clinical pictures, radiological findings and surgical results, as well as the main complications. The patients were divided into three main groups: anterior third 32 patients (Group A), middle third 15 patients (Group B), 23 patients in the posterior third of falx (Group C).

RESULTS

In Group A, total macroscopic resection was achieved in 31 out of 32 cases (96.87%). Twenty five patients had Rankin 0, five patients had Rankin 1-2, two patients had Rankin 6. In Group B (15 patients), 10 patients had gross resection and Rankin 0, four patients had Rankin 1-2 and one patient had Rankin 6. In Group C (23 patients), 20 patients were absolutely able, Rankin score 0, after six months postoperative period (83.3% had excellent results) and no mortality. Four cases had Rankin score 1 - 2 (16.6%). Ten cases (43.47%) had Simpson I resection and ten cases (43.47%) had Simpson II.

CONCLUSION

Despite larger lesion volumes, Group A meningiomas had a better outcome due to the position they were in, the tumor and surrounding structures. The preoperative preparation and surgical planning can preserve sagittal sinus; but in some cases, this is not possible. Sagittal sinus resection, as proven by this paper, is still a factor of bad surgical outcome. In the middle and posterior third, resection of sagittal sinus is a factor of a bad outcome, due to cerebral infartion.

LATERAL SUPRAORBITAL APPROACH APPLIED TO OLFACTORY GROOVE MENINGIOMAS

OBJECTIVE

The lateral supraorbital approach for safely and completely removing olfactory groove meningiomas was assessed.

METHODS

Between September 1997 and June 2008, a total of 656 meningiomas were operated on by the senior author (JH) at the Department of Neurosurgery, Helsinki University Central Hospital; 66 were olfactory meningiomas. We retrospectively analyze the clinical data, radiological findings, surgical treatment, histology, and outcome of all the olfactory groove meningioma patients and discuss the operative techniques used.

RESULTS

Sixty-six patients were operated on by the lateral supraorbital approach. The median preoperative Karnofsky Performance Scale score was 80 (range, 40–100). Three patients were redo cases in which the primary operation had been performed elsewhere. Seemingly complete tumor removal was achieved in 60 patients (91%); there was no surgical mortality. Postoperatively, 6 patients (9%) had cerebrospinal fluid leakage, 5 (8%) had new visual deficits, 4 (6%) had wound infections, 4 (6%) had cotton granulomas, and 1 (2%) had a postoperative hematoma. The median Karnofsky score at discharge was 80 (range, 40–100). Six patients had recurrent tumors; 3 underwent reoperations after an average of 21 months (range, 1–41 months); 1 was treated with radiosurgery, and 2 were only followed. During the median follow-up time of 45 months (range, 2–128 months), there were 4 recurrences (6%) diagnosed on average 32 months (range, 17–59 months) after surgery.

CONCLUSION

The lateral supraorbital approach can be used safely for olfactory groove meningiomas of all sizes with no mortality and relatively low morbidity. Surgical results and tumor recurrence with this fast and simple approach are similar to those obtained with more extensive, complex, and time-consuming approaches.

Problems in the management of intracranial meningiomas

Meningiomas account for approximately 15-20% of all brain tumors, and are the most common benign intracranial tumor. These neoplasms develop from cap cells in the arachnoidea; thus, they can be found anywhere that dura mater exists. Meningiomas are usually diagnosed in middle age, and are significantly more frequent in females than in males. Atypical and anaplastic malignant forms also exist. Some types of meningiomas are difficult to manage and require special considerations. The first-line therapy for meningioma is surgery aimed at total excision; however, limitations of surgery must be fully evaluated in order to achieve better results. Conventional radiotherapy and gamma-knife radiosurgery can be used as adjuvant therapeutic modalities under certain conditions. The issues that we consider important in the management of intracranial meningiomas can be discussed under the headings of diagnosis, surgery, multiplicity, pathology, and recurrence.