OBJECTIVE:Spinal meningiomas (SMs) are common primary spinal tumors for which surgery is considered the first-line treatment when safe and feasible. The ability to extrapolate the tumor grade from preoperative imaging may significantly inform early patient expectation-setting regarding recurrence. Building on radiomics studies in cranial meningiomas, the authors aimed to construct a benchmark radiomics model to preoperatively identify the histological grade of SMs. METHODS:Institutional surgical records from May 2012 to November 2025 were queried for pathology-confirmed meningiomas below the foramen magnum, with preoperative contrast-enhanced imaging available for segmentation. SMs were classified as low-grade (WHO grade 1) and high-grade (WHO grade 2 tumors and grade 1 tumors with atypia). Tumors were manually segmented, and features were extracted using the PyRadiomics software package. An ensemble model of k-nearest neighbors, random forest, and support vector machine classifiers was trained using nested cross-validation on a subset of 10 features to differentiate tumor grades. Clinical data for the cohort were also extracted, and disease control in an adjunctive clinical series was assessed. RESULTS:Seventy-four patients were included in radiomics analysis, with an area under the receiver operating characteristic curve of 0.879 and a mean F1 score of 0.748. The model's top 5 features were all texture features that differed significantly (p < 0.05) across low- and high-grade SMs. These included measures of tumor textural and contrast-enhancement heterogeneity, with overlap with features reported in radiomics models for histological grading of intracranial meningiomas. Fifty-five patients with a median radiographic follow-up of 22.2 (range 1.9-86.4) months remained for clinical analysis after exclusion of patients with less than 1 month of follow-up and syndromic meningiomas. Four recurrences occurred at a median of 20.8 (range 1.8-41.8) months. High-grade tumor pathology did not significantly impact progression-free survival (p = 0.682, log-rank test; Cox regression high vs low grade hazard ratio [HR] 0.62, 95% CI 0.06-6.11, p = 0.685). Subtotal resection was associated with poorer progression-free survival than gross-total resection (p = 0.004, log-rank test; Cox regression subtotal vs gross-total resection HR 10.62, 95% CI 1.46-77.05, p = 0.019). These findings remain contextualized within a relatively limited follow-up window and small recurrence event count, suggesting a need to characterize the interplay between tumor grade and extent of resection as drivers of local disease control in SMs. CONCLUSIONS:A preoperative radiomics model can stratify high-grade SMs using open-source tools applied to single-institution data.
OBJECTIVE:The objective was to evaluate the Superior Sagittal Sinus Involvement Grading (SSIG) system as an imaging-based surgical stratification framework for parasagittal meningiomas adjacent to the superior sagittal sinus (SSS) and to assess its relationship with established sinus invasion grading, venous sinus patency, and operative strategy. METHODS:In this single-center retrospective cohort study, the authors included 62 consecutive parasagittal meningioma resections performed by a single surgeon. SSIG grade was assigned primarily on contrast-enhanced coronal MRI, with CT/MR venography used when available to evaluate sinus patency and collateral venous drainage. Operative variables, resection strategy, and clinicopathological factors were compared across SSIG and Sindou grades, and postoperative complications were compared between low- and high-involvement SSIG groups. RESULTS:SSIG correlated significantly with Sindou grade (rs = 0.790, τb = 0.702, both p < 0.001), and among patients with available venous imaging, it also correlated with the venous sinus involvement grade (rs = 0.742, τb = 0.665, both p < 0.001). With increasing SSIG grade, operative time, intraoperative blood loss, and intraoperative fluid administration increased (p = 0.012, p = 0.008, and p = 0.007, respectively). Compared with the low-involvement group (SSIG grades 1, 2, and 4a), the high-involvement group (SSIG grades 3, 4b, and 5) was less likely to achieve Simpson grade I resection and more likely to adopt Simpson grades II-III strategies (66.7% vs 13.6%, p < 0.001; OR 12.667). Surgery-related complication rates did not differ significantly between groups. The mean follow-up was 13.3 ± 7.9 months, with no radiographic recurrence or progression at last follow-up. CONCLUSIONS:SSIG characterizes parasagittal meningiomas by integrating sinus invasion, venous patency, falcine extension, and parasagittal convexity involvement on preoperative imaging. This surgically oriented framework may help anticipate operative exposure, sinus handling, and resection strategy. Its predictive value for complications and long-term oncological outcomes requires validation in larger cohorts with longer follow-up.
Meningioma risk stratification has historically been defined by the Simpson grade of resection and the histological grade of tumor tissue. Recent scientific advances have elucidated the molecular architecture of meningioma, and multiple groups have developed molecular classification systems that refine meningioma risk stratification. Reported meningioma molecular classification systems use DNA methylation or gene expression profiling, copy number alterations, DNA mutations, or multiple molecular and histological variables combined into individual models. While the details of meningioma molecular classification systems may vary, concordance is observed across unsupervised systems that are not trained on clinical outcomes, suggesting conserved tumor biology. Moreover, some molecular classification systems outperform the WHO grade in risk stratification and can identify meningiomas that may benefit from radiotherapy or targeted therapies. According to this emerging paradigm, patients with molecular high-risk meningioma may be guided toward postoperative radiotherapy or targeted therapies. In contrast, patients with molecular low-risk meningioma may be followed with serial postoperative imaging in the right clinical context. Practical and logistical barriers must be overcome to implement meningioma molecular classification into clinical practice, and prospective randomized trials are needed to validate emerging molecular risk stratification systems and define the subsets of patients who might benefit the most from their use. In the interim, clinicians are increasingly recognizing the value of meningioma molecular classification and are already implementing these approaches into the postoperative management of patients with meningioma.
OBJECTIVE:Hyperostosing spheno-orbital meningiomas (SOMs) infiltrate bone and cause bone overgrowth leading to progressive visual and cosmetic deformities. DOTA0-Tyr3-octreotate (DOTATATE) is a somatostatin receptor-targeted PET ligand that enables highly sensitive identification of meningiomas. This ligand is useful in defining the extent of bone infiltration by the meningioma, which can be difficult to detect on standard CT and MRI. In this study, the authors aimed to provide a pragmatic technical framework for integrating molecular imaging, navigation, and patient-specific reconstruction in the management of complex SOMs by reporting their experience designing custom spheno-orbital implants based on DOTATATE-PET for skull and orbital reconstruction, as well as to report patient outcomes. METHODS:Four patients with SOMs who underwent cranio-orbital resection and rigid orbital reconstruction with custom polyetheretherketone patient-specific implants (PSIs) at a single center between 2023 and 2025 were retrospectively reviewed. Three patients had DOTATATE-PET/CT data available, and all had undergone CT and MRI to delineate tumor extent and guide implant design. All surgical procedures involved a multidisciplinary neurosurgery-oculoplastics team. The exophthalmos index was measured pre- and postoperatively. RESULTS:All patients underwent tumor resection with a single PSI for skull and orbital reconstruction. Gross-total resection was achieved in 1 patient. Radiotracer-defined transosseous tumor involvement extended beyond the structural hyperostosis seen on CT and MRI and directly informed both the planned bony resection and PSI design. Visual outcomes stabilized or improved in all patients; 1 pediatric patient with neurofibromatosis type 2 (NF2) had persistent poor vision despite decompression due to significant tumor involvement at the orbital apex. The exophthalmos index improved in all patients, with a return to normal globe position in 3 patients and persistent proptosis due to intraorbital residual tumor in 1 patient. One patient developed transient diplopia and a pseudomeningocele, which resolved with conservative management. There were no enophthalmos or implant-related complications. CONCLUSIONS:Integrating DOTATATE-PET with custom cranio-orbital PSIs allows single implant reconstruction of combined skull and orbital defects after resection of hyperostosing SOMs. DOTATATE-PET is useful for defining transosseous tumor extent and informing implant design. By enlarging the orbital volume with the implant compared with the contralateral normal side, excellent correction of proptosis can be achieved.
OBJECTIVE:The authors aimed to systematically investigate the expression and subcellular localization of estrogen receptors ERα and GPER in meningioma and to evaluate the functional impact of estradiol on cell viability in common meningioma cell lines and primary patient-derived cultures. METHODS:Tissue microarrays (TMAs) representing 120 patients (82 female, median age at diagnosis 57 years) with meningiomas (564 regions of interest) were analyzed using quantitative digital image analysis (QuPath) to evaluate nuclear and cytoplasmic receptor density. Subcellular localization was validated via immunofluorescence in meningeal and meningioma cell lines. Functional responsiveness to 17β-estradiol (E2) was assessed using in vitro cell viability assays with common meningioma cell lines Ben-Men-1, CH157-MN, IOMM-Lee, human meningeal cells, and primary cultured dura. RESULTS:GPER was ubiquitously expressed across the cohort, exhibiting both cytoplasmic and nuclear localization, whereas ERα detection was comparatively limited. Multivariable linear regression analysis identified the anatomical location as a significant independent predictor of GPER expression. Non-skull base tumors demonstrated higher GPER staining intensity compared with that of skull base tumors (nuclear, p = 0.013; cytoplasmic, p = 0.011). GPER staining intensity also varied across genomic alteration subgroups, with lower intensity observed in the TRAF7 ± other subgroup compared with NF2/22q-loss tumors. In vitro experiments revealed a biphasic response to E2 in which low-dose exposure (1-10 pM) was frequently associated with reduced viability, whereas higher concentrations (10-100 nM) increased cell viability. These effects varied across cell lines, with the NF2-loss CH157-MN meningioma cell line demonstrating the most pronounced increase in viability at 100 nM (adjusted p = 0.0002). CONCLUSIONS:These findings provide a systematic protein-level characterization of estrogen receptor expression in meningioma, identify GPER as a predominant receptor with expression patterns associated with tumor location and genomic subgroup, and lay the foundation for future mechanistic and translational studies.
Meningiomas are the most common primary intracranial tumor and demonstrate marked heterogeneity in clinical behavior, ranging from indolent lesions cured by surgery to tumors characterized by early recurrence, treatment resistance, and neurological morbidity. The current WHO classification system, based predominantly on histopathological features with limited incorporation of molecular alterations, remains the global standard for grading. However, accumulating evidence indicates that WHO grade alone incompletely captures biological aggressiveness and risk of progression. Over the past decade, integrative molecular investigations, including genomic, transcriptomic, epigenetic, and copy number-based analyses, have generated multiple independent classification schemas that more accurately stratify recurrence risk and clinical outcomes. Although these systems are not yet standardized or incorporated into formal WHO criteria, they consistently identify biologically distinct meningioma subgroups with clinically meaningful prognostic implications. This review synthesizes the current molecular classification landscape with a specific focus on its relevance to neurosurgical practice. We summarize key findings from single-omic and integrative studies, compare emerging schemas with traditional histopathological grading, and discuss how molecular risk stratification may influence surgical decision-making, surveillance strategies, and adjuvant therapy considerations. As molecular diagnostics become increasingly accessible, neurosurgeons will be confronted with this information in routine practice. A practical understanding of the strengths, limitations, and clinical implications for molecular diagnostics will be essential for optimizing the management of patients with aggressive meningiomas.
OBJECTIVE:Postoperative radiotherapy is an effective treatment for meningiomas; however, treatment response varies among patients. In addition, practical methods for predicting tumor recurrence after radiotherapy have not been well established. Minichromosome maintenance protein 2 (MCM2), a key regulator of DNA replication licensing, was recently implicated in highly proliferative molecular subtypes of meningioma. In this study, the authors evaluated whether MCM2 immunohistochemical expression predicts response to radiotherapy in patients with meningiomas. METHODS:The authors retrospectively analyzed the records of patients with WHO grade 1-3 meningiomas treated with resection followed by radiotherapy at a single institution between July 2003 and November 2023. The MCM2 labeling index was assessed immunohistochemically, and patients were stratified into MCM2-high and -low groups using a cutoff of 35%. Progression-free survival (PFS) was defined as the interval from the completion of radiation therapy to postoperative radiological tumor recurrence or regrowth. Patients who showed no progression were censored at their last follow-up. PFS was estimated using Kaplan-Meier analysis and subsequently evaluated with Cox proportional hazards models. To further investigate the biological mechanisms associated with MCM2 expression, comprehensive transcriptomic analyses, including gene set enrichment analysis, was performed to elucidate the molecular processes that occur within MCM2-high tumors. RESULTS:The study population included 15 men (42%) and 21 women (58%), with a mean age of 63 years. Ten tumors (28%) were classified as MCM2-high meningiomas and 26 (72%) as MCM2-low meningiomas. High MCM2 expression was significantly associated with WHO grades 2-3 histology and higher Ki-67 labeling indices. During a median follow-up of 2.52 years, tumor progression after radiotherapy occurred in 47% of the patients. High MCM2 expression (HR 8.34, p = 0.03) was significantly associated with shorter PFS and remained an independent predictor of recurrence after adjustment for WHO grade, tumor size, and Ki-67 labeling index. Transcriptomic analyses of MCM2-high tumors revealed upregulation of cell proliferation-related pathways, accompanied by increased signaling through the E2F8-CHEK1 axis associated with radiation resistance and suppression of the TNF-α signaling pathway implicated in radiosensitivity. CONCLUSIONS:In meningiomas, high MCM2 expression is associated with early recurrence following radiotherapy. The study findings suggest that this association is driven by diverse biological mechanisms related to cell cycle regulation and radioresistance. Immunohistochemical assessment of MCM2 expression may serve as a practical and accessible biomarker for risk stratification and may support the future development of individualized postoperative radiotherapy strategies.
OBJECTIVE:Jugular foramen meningiomas are challenging because of their deep, neurovascularly crowded location and multicompartment extension; hyperostosis and rigid dural attachment further narrow the corridor and increase the risk of lower cranial nerve morbidity, causing dysphagia and airway complications that may rarely require tracheostomy. This study aimed to describe a contemporary function-first workflow integrating compartment-based anatomy, venous sinus status, preoperative embolization, and continuous vagus nerve monitoring and its relation to clinically actionable recovery endpoints. METHODS:The authors retrospectively reviewed 26 consecutive patients who underwent primary surgery for jugular foramen meningiomas (2014-2025). Tumors were classified as intradural + intrajugular (IJ) or intradural + intrajugular + extracranial extension (IJE). Retrosigmoid, suprajugular, or transjugular approaches were selected by tumor extension and sigmoid-jugular venous status. Selective embolization and continuous vagus nerve monitoring were used when feasible. Outcomes included extubation timing, time to oral intake, 1-year swallowing/voice severity, extent of resection, and salvage stereotactic radiosurgery (SRS) for progression/regrowth. RESULTS:Twenty tumors were IJ and 6 were IJE. Selective embolization was performed in 16 patients (62%) without complications. Continuous vagus nerve monitoring was implemented in 16 patients (62%); lower preservation rates showed an exploratory association with worse 1-year swallowing. All patients were extubated immediately after surgery. Oral intake began by postoperative day ≤ 7 in 20 patients (77%); only 1 required > 14 days before resuming oral intake. At 1 year, swallowing and hoarseness remained worse in 54% and 46% of patients, respectively, but almost all cases were mild; the same patient had moderate dysphagia/hoarseness, and none required tracheostomy, gastrostomy, long-term tube feeding, or phonosurgery. Simpson grade IV comprised 69% of cases but predominantly reflected intrajugular/extracranial residual rather than persistent intradural disease. No patient without preoperative facial nerve palsy developed new palsy; serviceable hearing was preserved in 70%, and 38% with preoperative nonserviceable hearing improved to serviceable hearing. During a median 55.6-month follow-up, 3 patients (12%) underwent salvage SRS for regrowth; none required reoperation. CONCLUSIONS:A function-first workflow guided by anatomical compartment extension and intraoperative monitoring can support rapid recovery and durable functional independence in jugular foramen meningiomas. The IJE phenotype identifies a higher-risk subgroup for delayed oral intake and postoperative subjective dysphagia/hoarseness, while continuous vagus nerve monitoring may provide actionable insights to calibrate surgical aggressiveness and support function-prioritized acceptance of intrajugular/extracranial residual with close surveillance and salvage SRS when needed.
OBJECTIVE:Gross-total resection is the primary surgical objective in meningioma management; however, predicting resectability preoperatively remains challenging, particularly for meningiomas located in the skull base that exhibit complex anatomical relationships. There is a lack of validated reproducible models that integrate known anatomical factors for surgery; similarly, the value of radiomics as a stand-alone predictor is still unclear. The aim of this study was to develop a machine learning model that combines clinical and radiomic features to estimate early postoperative residual meningioma. METHODS:This retrospective multicenter study included 369 patients who underwent meningioma resection from 2020 to 2024 and had available preoperative contrast-enhanced T1-weighted MRI. Patient data from 3 centers (n = 307) were used to develop the model using leave-one-center-out cross-validation, and an independent cohort (n = 62) was used for external validation. Radiomic features were derived from manually segmented meningiomas, filtered for reproducibility, and integrated with 6 predefined clinical variables. The clinical-only, radiomics-only, and combined models were trained using 4 machine learning classifiers. Model performance was assessed through cross-validation, independent external validation, and receiver operating characteristic analysis. Formal incremental benefit analyses were performed on the common overlap external subset, with predictions available for all compared models. RESULTS:Residual meningioma occurred in 23.5% of patients in the development cohort and 14.5% in the external cohort. Lesion location and venous sinus involvement were significantly associated with residual status. Following the feature selection, 2 stable radiomic texture features were retained. In external validation, the combined radiomics-clinical k-nearest neighbors model achieved the highest area under the curve (0.821), with sensitivity of 0.889, specificity of 0.706, and accuracy of 0.733. Clinical variables provided most of the predictive value, whereas radiomic features provided only limited incremental value when added to the clinical model. Decision curve analysis revealed net benefit for the combined model within a narrow range of low thresholds. CONCLUSIONS:In this multicenter study, which included external validation, clinical variables provided most of the predictive value for postoperative residual meningioma. Radiomic features alone showed limited discrimination and only modest added value beyond clinical predictors. These combined models could serve as decision-support tools for preoperative risk assessment in meningioma surgery but are not yet suitable for routine stand-alone clinical use.
OBJECTIVE:The aim of this study was to assess the clinical and radiographic changes in meningioma burden following cessation of depo-medroxyprogesterone acetate (dMPA) in patients with meningioma stabilization or shrinkage. METHODS:This retrospective case series included 3 patients with meningioma who did not undergo resection at the author's institution but who discontinued dMPA during tumor surveillance (2020-2025) and experienced tumor regression. Data collection included meningioma characteristics, previous pathology reports, tumor size across various follow-up time points, and clinical course. RESULTS:The mean cumulative duration of dMPA was 19.7 ± 2.5 years. Tumor regression was identified as early as 14 months after cessation of dMPA and persisted beyond 68 months after cessation. Patient A, with ≥ 20 tumors, demonstrated nearly 39% reduction in overall tumor burden across 45 months. Patient B demonstrated nearly 80% decrease in tumor burden across 68 months. Patient C demonstrated a 6% decrease in tumor burden, with near-complete resolution of 1 anterior skull-base tumor, within 14 months of dMPA cessation. CONCLUSIONS:The authors present 3 patients with previously diagnosed meningioma who were managed with active surveillance and dMPA cessation. After 12 months of follow-up, all patients demonstrated decreases in overall tumor burden. These results highlight an evolving understanding in the management of patients with possible progestin-associated meningioma in the setting of dMPA exposure.
OBJECTIVE:The methylation profile of meningiomas is a promising predictive tool that may improve risk stratification beyond WHO grading. This study aimed to evaluate the clinical relevance and real-world applicability of routine epigenetic testing in meningioma management. METHODS:The authors retrospectively analyzed patients who underwent meningioma resection between January 2021 and December 2023. Histopathological grading (WHO 2021) and methylation profiling (methylation class [MC]) with the MethylationEPIC v1.0 (850k) chip were performed by an independent neuropathologist. RESULTS:A total of 106 patients were included; 81 tumors (76%) were classified as WHO grade 1, 20 (19%) as grade 2, and 5 (5%) as grade 3. Epigenetically, 55 tumors (52%) were classified as benign, 18 (17%) as intermediate, and 2 (2%) as malignant; 31 (29%) could not be classified. Discordances between WHO grading and methylation profiling were observed in 18 of 74 cases. Tumor board decisions were made after a median of 8 days postoperatively, guided by WHO grading; however, the epigenetic report was only available after a median of 23 days. During follow-up, 20 patients experienced tumor progression. Progression was significantly associated with the MC (r = -0.4, p < 0.001) and tumor volume (r = 0.4, p = 0.0005), but not with WHO grading (r = 0.17, p = 0.084). However, the relatively high rate of unclassified tumors and delayed result availability limited the direct impact of MC profiling on immediate clinical decision-making. Interestingly, progression-free survival in MC-unclassified tumors mirrored that of the intermediate group. CONCLUSIONS:Methylation profiling demonstrates superior predictive accuracy for meningioma progression and complements WHO grading, especially in identifying malignant meningiomas. However, its current clinical utility is constrained by technical and logistical limitations. In real-world practice, epigenetic classification should therefore be considered a complementary tool rather than a replacement for established histopathological assessment.
OBJECTIVE:Anatomical location correlates with mutational and histopathological subtypes in meningiomas. However, the relationship between anatomical distribution and arm-level chromosomal copy number alterations (CNAs), central mediators of meningioma biology, has not been systematically characterized. METHODS:A total of 740 primary sporadic intracranial meningiomas (538 WHO grade I, 194 WHO grade II, 8 WHO grade III) were analyzed for anatomical location: anterior midline skull base (n = 100), lateral (supratentorial) skull base (n = 120), infratentorial skull base (n = 101), midline convexity (n = 157), lateral convexity (n = 201), infratentorial non-skull base (n = 54), and other (n = 7). Histopathological grade was extracted from the medical record. Chromosome arm-level CNAs were derived from whole-genome microarrays. Angiomatous meningiomas (n = 55) were excluded from cytogenetic analyses. Overall CNA burden was defined as the total number of chromosome arm gains and losses. High-risk CNA burden was quantified based on alterations previously associated with poor progression-free survival (PFS). Hierarchical and nonnegative matrix factorization (NMF) clustering analyses were applied to CNA profiles to identify genomic subgroups. RESULTS:WHO grade and molecularly Integrated Grade (IG) differed markedly across anatomical location (both p = 0.0001). Anterior midline skull base and infratentorial skull base meningiomas were predominantly IG 1/low grade, whereas supratentorial convexity meningiomas were enriched for IG 2 and 3/high-grade tumors. Proliferative index and CNA burden mirrored these patterns, with minimal overall and high-risk CNAs in anterior midline and infratentorial skull base tumors and higher-burden CNA profiles in supratentorial convexity and intraventricular meningiomas. Across all analyses, lateral (supratentorial) skull base meningiomas occupied an intermediate status, falling between lower-risk infratentorial skull base tumors and more aggressive supratentorial convexity tumors. Hierarchical clustering and NMF independently validated these findings by identifying similar genomic profiles between lateral (supratentorial) skull base and supratentorial convexity meningiomas. PFS analyses demonstrated that gross-total resection confers local disease control compared to subtotal resection, especially in biologically benign anatomical locations. CONCLUSIONS:Meningiomas exhibit a significant association between their anatomical origin and chromosomal alterations. These findings suggest that developmental factors may shape divergent cytogenetic trajectories and that anatomical context may serve as a proxy for guiding assessment of meningioma behavior.
The influence of progestins on meningioma growth has been known for a long time, but it is only recently, with the description of meningiomas associated with synthetic progestins, that the links between hormones and meningiomas have been analyzed in greater detail. This review looks back at the epidemiological, clinical, biological, and histopathological characteristics of progestin-associated meningiomas, outlining the pathological characteristics and clinical behavior of pregnancy-associated and progestin-associated meningiomas.
OBJECTIVE:Tentorial incisura meningiomas, particularly those arising from the middle incisural region (Yaşargil T2), are surgically challenging because of their deep location and compression of critical neurovascular structures. These lesions typically have supratentorial or infratentorial extension but can also extend across both compartments. Although approach selection is often guided by the dominant compartment of tumor extension, for lesions with supratentorial-dominant extension, the optimal approach remains controversial, and a standardized strategy has not been established. Authors of this study evaluated the feasibility and outcomes of the paramedian supracerebellar transtentorial (PST) approach for Yaşargil T2 tentorial incisura meningiomas with a supratentorial-dominant or combined extension. METHODS:The authors retrospectively reviewed data from consecutive patients with radiographic and intraoperative findings consistent with a Yaşargil T2 tentorial incisura lesion treated via the PST approach from September 2005 through December 2025. Patients were placed in a semisitting position whenever feasible and in a semilateral position when semisitting was contraindicated. Collected data included demographics, tumor extension patterns, extent of resection on postoperative MRI, neurological outcomes, histopathology, rate of recurrence, and follow-up. RESULTS:Six patients, 1 male and 5 female, with an overall mean age of 43 years, underwent resection via the PST approach. Four lesions had predominantly supratentorial extension, and 2 had combined supra- and infratentorial growth, with no cases of isolated infratentorial extension. Five patients had been placed in the semisitting position and 1 in a semilateral position because of a cardiac contraindication to the semisitting position. No new permanent neurological deficits were observed. Postoperative MRI showed Simpson grade I resection in all 6 patients. The mean follow-up was 8.6 years. Histopathological analysis revealed 3 WHO grade 1 meningiomas, 1 WHO grade 2 meningioma (clear cell), and 2 solitary fibrous tumors (meningioma mimics). These diagnoses were evaluated according to the 2021 WHO classification. CONCLUSIONS:In this consecutive series, the PST approach was a viable single-corridor strategy for Yaşargil T2 tentorial incisura lesions, including supratentorial-dominant tumors, achieving Simpson grade I resection with no permanent neurological deficits. By providing early devascularization at the tentorial attachment and a gravity-assisted, retractorless working corridor with favorable deep venous visualization, the PST approach challenges compartment dominance as the primary determinant of approach selection.
OBJECTIVE:Hyperspectral imaging (HSI) is an emerging intraoperative, noninvasive, contrast agent-free imaging modality that enables quantitative assessment of tissue composition. The present study aimed to investigate whether HSI-derived tissue parameters correlate with WHO grade and molecular markers of aggressiveness in cranial meningiomas. METHODS:In this prospective study, intraoperative in vivo HSI was performed using the TIVITA tissue system, capturing spectral signatures between 500 and 1000 nm. Quantitative tissue parameters included tissue oxygen saturation (StO2), near-infrared perfusion index, organ hemoglobin index (OHI), and tissue water index (TWI). HSI parameters were correlated with histopathological WHO grade and molecular alterations, including CDKN2A/B deletion, TERT promoter mutation, and 1p/22q loss. Group differences were analyzed using one-way ANOVA, and diagnostic performance was assessed using receiver operating characteristic (ROC) analysis. RESULTS:Forty-six meningiomas were included, comprising WHO grade 1 (n = 35) and WHO grade 2-3 (n = 11) tumors. TWI was significantly higher in WHO grade 2-3 meningiomas compared with WHO grade 1 tumors (mean 0.49 [SD 0.12] vs 0.38 [SD 0.17], p = 0.048). ROC analysis demonstrated an area under the ROC curve (AUC) of 0.71 (95% CI 0.56-0.86, p = 0.036) for TWI in discriminating higher-grade disease. A TWI cutoff ≥ 0.367 identified all WHO grade 2-3 meningiomas with 100% sensitivity and 100% negative predictive value. In a molecular subgroup (n = 15), OHI appeared higher in tumors with homozygous CDKN2A/B deletion than in nondeleted tumors (mean 0.77 [SD 0.04] vs 0.62 [SD 0.10]). However, only 3 CDKN2A/B-deleted cases were available, and these findings should be considered descriptive. ROC analysis yielded an AUC of 0.89 (95% CI 0.71-1.00). An OHI cutoff ≥ 0.712 identified all three CDKN2A/B-deleted tumors (100% sensitivity), with 83.3% specificity and 86.7% accuracy. CONCLUSIONS:The present investigation demonstrated that HSI-derived tissue water and hemoglobin metrics provide biologically meaningful information in meningiomas. Low tissue water content appeared to rule out higher-grade diseases in this first subset cohort, while elevated hemoglobin showed a potential association with CDKN2A/B deletion in a small exploratory subgroup. These findings support the potential of HSI as a real-time noninvasive tool for intraoperative risk stratification and should be evaluated in large-scale studies. German Clinical Trials Register no. DRKS00036771 (www.drks.de).
OBJECTIVE:As the population ages, meningiomas are increasingly encountered in older patients, yet longitudinal functional outcomes following surgery across age groups remain incompletely characterized. This study evaluated age-related differences in clinical and tumor characteristics, functional trajectory, and surgical outcomes. METHODS:This was a retrospective cohort study of 396 consecutive patients who underwent surgery for intracranial meningiomas at a single academic center between January 2023 and September 2025. Patients were stratified into 5 age groups (< 65, 65-69, 70-74, 75-79, and ≥ 80 years). Neurological deficits and Karnofsky Performance Status (KPS) were assessed preoperatively, at discharge, and at last follow-up. Logistic regression analyses identified predictors of prolonged length of stay (LOS) (> 5 days) and poor functional outcome at discharge (KPS < 80). RESULTS:Older patients presented with greater comorbidity burden, larger tumors, and lower preoperative KPS (all p < 0.05), while gross-total resection was achieved at comparable rates across all age groups (p = 0.504). A clinically meaningful inflection point was observed around age 75 years, with KPS < 80 at discharge rising from 7.4% and 9.7% in the < 65-year and 70- to 74-year subgroups and to 36.2% and 57.1% in the 75- to 79-year and ≥ 80-year subgroups (p < 0.001), and median LOS increased from 4 days in the younger groups to 9 and 7 days in the 75- to 79-year and ≥ 80-year groups (p < 0.001). However, recovery rates among patients who experienced functional decline at discharge were comparable across age strata. On multivariable analysis, independent predictors of prolonged LOS were age ≥ 75 years (OR 2.31, p = 0.019), diabetes mellitus (OR 2.85, p = 0.004), posterior fossa location (OR 2.1, p = 0.008), tumor diameter (OR 1.33, p < 0.001), postoperative edema (OR 2.58, p = 0.015), and neurosurgical complications (OR 3.18, p = 0.002). Independent predictors of poor functional outcome at discharge were age ≥ 75 years (OR 5.84, p < 0.001), lower preoperative KPS (OR 2.8, p < 0.001), posterior fossa location (OR 3.72, p = 0.003), neurosurgical complications (OR 3.56, p = 0.008), and recurrent meningioma (OR 2.89, p = 0.025). Among 70 endoscopic endonasal approach patients, higher preoperative deficit burden and subtotal resection rates were observed compared to open craniotomy, though overall functional outcomes were comparable. CONCLUSIONS:Surgical risk in meningioma resection increases from age 75 years onwards, yet recovery capacity following initial functional decline remains similar across all age groups. Preoperative functional status, tumor location, comorbidity burden, and recurrence history should guide surgical decision-making rather than age alone.
OBJECTIVE:Despite advancements in imaging studies, the preoperative prediction of the biological behavior and intraoperative consistency of intracranial meningiomas remains limited. This study evaluated the association of volumetric diffusion-based and texture-derived radiomic features extracted from routine MRI with histopathological aggressiveness and intraoperative tumor consistency. METHODS:Ninety-seven intracranial meningiomas resected at two tertiary centers were retrospectively analyzed. Volumetric segmentation was performed on contrast-enhanced T1-weighted MRI and coregistered to apparent diffusion coefficient (ADC) maps. Data on first-order diffusion metrics and selected texture features were collected. The associations between World Health Organization (WHO) grade and Ki-67 index were assessed using nonparametric tests and Spearman correlation analysis. Independent factors associated with intraoperative tumor consistency (Zada grades 1-5) were evaluated via multivariate ordinal logistic regression analysis that adjusted for tumor volume, skull base location, calcification status, and WHO grade. Secondary receiver operating characteristic (ROC) curve analyses were performed to differentiate solid (Zada grades 4-5) from soft (Zada grades 1-2) tumors. ROC analyses were performed within the study cohort and were intended as exploratory assessments of discriminative performance. RESULTS:The mean ADC (ADCmean) and the 10th percentile of the ADC decreased significantly with increasing WHO grade (p < 0.001). ADCmean had a moderate inverse correlation with the Ki-67 index (r = -0.42, p < 0.001) and intraoperative tumor consistency (r = -0.45, p < 0.001). In the multivariate analysis, the ADCmean remained independently associated with increasing tumor firmness. Each 0.1 × 10-3 mm2/sec increase corresponded to a 38% reduction in the odds of belonging to a higher consistency category (OR 0.62, 95% CI 0.51-0.74, p < 0.001). The ROC analysis showed good discrimination for solid tumors (area under the curve 0.847, 95% CI 0.742-0.953) and soft tumors (area under the curve 0.824, 95% CI 0.714-0.935). Texture features had weaker associations with intraoperative tumor consistency. CONCLUSIONS:Volumetric diffusion-derived metrics, particularly ADCmean, are associated with both histopathological aggressiveness and intraoperative tumor firmness in meningiomas. Diffusion imaging may reflect a graded microstructural continuum rather than a purely dichotomous property, providing complementary preoperative insights into surgical complexity.
Traumatic brain injury (TBI) is among the most emotionally demanding conditions encountered in neurosurgical and acute neurotrauma practice. Sudden neurological deterioration, unexpected death in young and previously healthy individuals, persistent prognostic uncertainty, and systemic resource constraints together create a uniquely intense emotional environment for clinicians involved in TBI care. While the psychosocial consequences of TBI for patients and caregivers have been extensively studied, the emotional burden borne by treating clinicians-particularly experiences of grief, moral distress, and moral injury-remains comparatively underexplored. This integrative narrative review synthesizes established conceptual frameworks of clinician grief, second-victim phenomena, burnout, and moral injury with the clinical realities of TBI management. Key emotional stressors intrinsic to neurotrauma care are identified, including rapid neurological deterioration, prognostic ambiguity, ethically complex decision-making, prolonged intensive care trajectories, exposure to family distress, and episodes of hostility or violence directed toward healthcare workers. Evidence from low- and middle-income countries highlights how high patient volumes, resource limitations, financial constraints, and medicolegal pressures amplify clinician distress and vulnerability to emotional exhaustion and moral injury. The authors further examine the psychological mechanisms underlying clinician responses to TBI care, including intrusive recollections, anticipatory anxiety, value dissonance, and the cumulative emotional residue that accrues across repeated high-stakes encounters. Finally, institutional and system-level strategies to mitigate these effects, including structured debriefing, peer-support programs, resilience-oriented training, transparent communication frameworks, and protections against workplace violence, are outlined. Recognizing clinician grief as an inherent component of TBI practice is essential for sustaining neurosurgeons' well-being, ethical decision-making, and long-term workforce resilience in high acuity neurotrauma systems.
