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Background: Our purpose was to determine the utility of [68Ga]-DOTATATE PET/MRI in meningioma response assessment following radiosurgery., Methods: Patients with meningioma prospectively underwent postoperative DOTATATE PET/MRI. Co-registered PET and gadolinium-enhanced T1-weighted MRI were employed for radiosurgery planning. Follow-up DOTATATE PET/MRI was performed at 6-12 months post-radiosurgery. Maximum absolute standardized uptake value (SUV) and SUV ratio (SUVRSSS) referencing superior sagittal sinus (SSS) blood pool were obtained. Size change was determined by Response Assessment in Neuro-Oncology (RANO) criteria. Association of SUVRSSS change magnitude and progression-free survival (PFS) was evaluated using Cox regression., Results: Twenty-seven patients with 64 tumors (26% World Health Organization [WHO]-1, 41% WHO-2, 26% WHO-3, and 7% WHO-unknown) were prospectively followed post stereotactic radiosurgery (SRS) or stereotactic body radiotherapy (SBRT; mean dose: 30 Gy, modal dose 35 Gy, mean of 5 fractions). Post-irradiation SUV and SUVRSSS decreased by 37.4% and 44.4%, respectively (P < .0001). Size product decreased by 8.9%, thus failing to reach the 25% significance threshold as determined by RANO guidelines. Mean follow-up time was 26 months (range: 6-44). Overall mean PFS was 83% and 100%/100%/54% in WHO-1/-2/-3 subcohorts, respectively, at 34 months. At maximum follow-up (42-44 months), PFS was 100%/83%/54% in WHO-1/-2/-3 subcohorts, respectively. Cox regression analyses revealed a hazard ratio of 0.48 for 10-unit reduction in SUVRSSS in the SRS cohort., Conclusions: DOTATATE PET SUV and SUVRSSS demonstrated marked, significant decrease post-radiosurgery. Lesion size decrease was statistically significant; however, it was not clinically significant by RANO criteria. DOTATATE PET/MR thus represents a promising imaging biomarker for response assessment in meningiomas treated with radiosurgery., Clinicaltrials.gov Identifier: NCT04081701., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Neuro-Oncology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Objective: Surgical resection is the mainstay of treatment for WHO grade 2 meningioma. Fractionated radiation therapy (RT) is frequently used after surgery, though many centers utilize stereotactic radiosurgery (SRS) for recurrence or progression. Herein, we report disease control outcomes from an institutional cohort with adjuvant fractionated RT versus salvage SRS., Methods: We identified 32 patients from an institutional database with WHO grade 2 meningioma and residual/recurrent tumor treated with either SRS or fractionated RT. Patients were treated between 2007 and 2021 and had at least 1 year of follow-up. Kaplan-Meier estimators were used to determine gross tumor control (GTC) and intracranial control (IC). Univariate Cox proportional hazards models using biologically effective dose (BED) as a continuous parameter were used to assess for dose responses., Results: With a median follow-up of 5.5 years, 13 patients (41%) received SRS to a recurrent or progressive nodule, 2 (6%) fractionated RT to a recurrent or progressive nodule, and 17 (53%) adjuvant fractionated RT following subtotal resection. Five-year GTC was higher with fractionated RT versus SRS (82% vs. 38%, P = 0.03). Five-year IC was also better with fractionated RT versus SRS (82% vs. 11%, P < 0.001). On univariate analysis, increasing BED 10 was significantly associated with better GTC (P = 0.039); increasing BED 3 was not (P = 0.82)., Conclusions: In this patient cohort, GTC and IC were significantly higher in patients treated with adjuvant fractionated RT compared with salvage SRS. Increasing BED 10 was associated with better GTC. Fractionated RT may provide a better therapeutic ratio than SRS for grade 2 meningiomas., (Published by Elsevier Inc.)

Objective: 11 C-Methionine positron emission tomography (MET-PET) is used for stereotactic radiotherapy planning in meningioma patients. The role of MET-PET during subsequent follow-up (FU) is unclear. We analyzed the uptake of 11 C-Methionine before and after stereotactic radiotherapy (SRT) in patients with a complex meningioma and investigated if there was a difference between patients with progressive disease (PD) and stable disease (SD) during FU., Methods: This retrospective study investigates 62 MET-PETs in 29 complex meningioma patients. Standardized uptake value (SUV) max and SUV peak tumor-to-normal ratios (T/N-ratios) were calculated, comparing the tumor region with both the mirroring intracranial area and the right frontal gray matter. The difference in 11 C-Methionine uptake pre- and post-SRT was analyzed, as well as the change in uptake between PD or SD., Results: Median (IQR) FU duration was 67 months (50.5-91.0). The uptake of 11 C-Methionine in meningiomas remained increased after SRT. Neither a statistically significant difference between MET-PETs before and after SRT was encountered, nor a significant difference in one of the four T/N-ratios between patients with SD versus PD with median (IQR) SUV max T/N R front 2.65 (2.13-3.68) vs 2.97 (1.55-3.54) [p = 0.66]; SUV max T/N mirror 2.92 (2.19-3.71) vs 2.95 (1.74-3.60) [p = 0.61]; SUV peak T/N R front 2.35 (1.64-3.40) vs 2.25 (1.44-3.74) [p = 0.80]; SUV peak T/N mirror 2.38 (1.91-3.36) vs 2.35 (1.56-3.72) [p = 0.95]., Conclusions: Our data do not support use of MET-PET during FU of complex intracranial meningiomas after SRT. MET-PET could not differentiate between progressive or stable disease., (© 2024. The Author(s).)

Background: Intraventricular meningioma (IVM) is a rare subtype of intracranial meningioma, accounting for 9.8 to 14% of all intraventricular tumors. Currently, there is no clear consensus on which patients with IVM should receive conservative treatment, surgery, or stereotactic radiosurgery (SRS). This research aims to analyze the outcomes, including survival and recurrence rates of patients who undergo SRS for IVM as a primary or adjuvant treatment., Methods: A systematic search was conducted in Scopus, Web of Science, PubMed, and Embase till June 5th 2023. Screening and data extraction were performed by two independent authors. Random-effect meta-analysis was performed to determine the tumor control proportion of IVM cases treated with SRS. Individual patient data (IPD) meta-analysis was performed for the progression-free survival (PFS) of the patients in the follow-up time. All analyses were performed using the R programming language., Results: Out of the overall 132 records, 14 were included in our study, of which only 7 had enough data for the meta-analysis. The tumor control proportion was 0.92 (95% CI, 0.69-0.98) in patients who underwent SRS for primary IVM. The overall tumor control in both primary and adjuvant cases was 0.87 (95% CI, 0.34-0.99). the heterogeneity was not significant in both meta-analyses (P = 0.73 and P = 0.92, respectively). Post-SRS perifocal edema occurred in 16 out of 71 cases (0.16; 95% CI, 0.03-0.56), with no significant heterogeneity (P = 0.32). IPD meta-analysis showed a PFS of 94.70% in a 2-year follow-up. Log-rank test showed better PFS in primary SRS compared to adjuvant SRS (P < 0.01)., Conclusions: According to this study, patients with IVM can achieve high rates of tumor control with a low risk of complications when treated with SRS, regardless of whether they have received prior treatment. Although SRS could be a promising first-line treatment option for asymptomatic IVM, its efficacy in symptomatic patients and its comparison with resection require further investigation., (© 2024. The Author(s).)

Background: Radiosurgery plays an important role as a treatment modality for intracranial meningiomas. Perfusion MR imaging can be performed by using arterial spin-labeling (ASL) which is a relatively new and advanced technique., Objectives: To assess the changes in perfusion parameters on ASL perfusion MRI in intracranial meningioma after radiosurgery and correlate with histopathological grade of meningioma., Materials and Methods: In this Prospective study done at the our institute over a period of 20 months (Jan 2016-Aug 2017), patients with intracranial meningiomas had perfusion MRI with ASL sequence on GE Optima 450W®, 1.5T MRI (GE Medical Systems) prior to GKT and at 6 months after GKT were included in the study., Results: Twenty-seven patients were included in this study. Mean cerebral blood flow (CBF) was higher in angiomatous meningiomas. Though mean values of average CBF, maximum, minimum, and SD derived from the ASL MR perfusion were relatively higher in post GKT group as compared to those obtained in pre-GKT but it was not clinically significant. Mean baseline volume of whole cohort was 5.71 cm3 and decreased significantly post GKT in a follow up of 6 months to 5.59 cm3 (P value 0.0018). On comparing volumes of primary and secondary group, volumes were not found be significantly decreased in primary group (P value = 0.1361), 0.1361), but significantly reduced in secondary group (7.13 vs 7.034 cm3) (P value of = 0.0038)., Conclusion: Our preliminary observations support ASL as a sensitive MRI sequence for the evaluation of meningioma perfusion patterns., (Copyright © 2024 Copyright: © 2024 Neurology India, Neurological Society of India.)

Most meningiomas are benign, slow growing tumors, which rarely progress to a higher grade. The incidence rate of malignant progression is estimated to be 2.98/1000 patient-year. However, non-skull base location is a significant risk factor for progression. The median time to malignant progression is 4.3 years; however, the cumulative rate of progression approaches a plateau after 10 years. Although radiosurgery does not appear to increase the incidence rate(0.5/1000 patient-year), exact comparisons have been difficult because of differences in study populations. The median time to progression is 7.0 years from initial diagnosis and 5.0 years from radiosurgery. The cumulative rate appears to increase even after 10 years. The risk of malignant transformation after radiotherapy may increase in patients with tumor-prone syndromes, with some controversies regarding patients with neurofibromatosis type 2. Although short term follow-up in patients with meningioma suggests that radiosurgery is safe, there is uncertainty regarding its use in pediatric patients, and those with tumor-prone syndromes.

Objective: Parasagittal meningiomas (PM) are treated with primary microsurgery, radiosurgery (SRS), or surgery with adjuvant radiation. We investigated predictors of tumor progression requiring salvage surgery or radiation treatment. We sought to determine whether primary treatment modality, or radiologic, histologic, and clinical variables were associated with tumor progression requiring salvage treatment., Methods: Retrospective study of 109 consecutive patients with PMs treated with primary surgery, radiation (RT), or surgery plus adjuvant RT (2000-2017) and minimum 5 years follow-up. Patient, radiologic, histologic, and treatment data were analyzed using standard statistical methods., Results: Median follow up was 8.5 years. Primary treatment for PM was surgery in 76 patients, radiation in 16 patients, and surgery plus adjuvant radiation in 17 patients. Forty percent of parasagittal meningiomas in our cohort required some form of salvage treatment. On univariate analysis, brain invasion (OR: 6.93, p < 0.01), WHO grade 2/3 (OR: 4.54, p < 0.01), peritumoral edema (OR: 2.81, p = 0.01), sagittal sinus invasion (OR: 6.36, p < 0.01), sagittal sinus occlusion (OR: 4.86, p < 0.01), and non-spherical shape (OR: 3.89, p < 0.01) were significantly associated with receiving salvage treatment. On multivariate analysis, superior sagittal sinus invasion (OR: 8.22, p = 0.01) and WHO grade 2&3 (OR: 7.58, p < 0.01) were independently associated with receiving salvage treatment. There was no difference in time to salvage therapy (p = 0.11) or time to progression (p = 0.43) between patients receiving primary surgery alone, RT alone, or surgery plus adjuvant RT. Patients who had initial surgery were more likely to have peritumoral edema on preoperative imaging (p = 0.01). Median tumor volume was 19.0 cm 3 in patients receiving primary surgery, 5.3 cm 3 for RT, and 24.4 cm 3 for surgery plus adjuvant RT (p < 0.01)., Conclusion: Superior sagittal sinus invasion and WHO grade 2/3 are independently associated with PM progression requiring salvage therapy regardless of extent of resection or primary treatment modality. Parasagittal meningiomas have a high rate of recurrence with 80.0% of patients with WHO grade 2/3 tumors with sinus invasion requiring salvage treatment whereas only 13.6% of the WHO grade 1 tumors without sinus invasion required salvage treatment. This information is useful when counseling patients about disease management and setting expectations., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Background: Meningiomas arising from or adjacent to the optic nerve sheath meningioma (ONSM) are management challenges because of their risk of visual loss. Stereotactic radiosurgery (SRS) is a minimally invasive modality that can be added as adjuvant treatment for patients whose tumor has progressed or recurred after initial resection., Methods: The authors retrospectively reviewed 2,030 meningioma patients who underwent SRS between 1987 and 2022. In total, 7 patients (4 females; median age = 49) were found with tumors originating from the optic nerve sheath. None of the patients had tumors that engulfed the optic nerve as such tumors typically undergo fractionated radiation therapy (FRT) to preserve vision. The clinical history, visual function, and radiographic and neurological findings were characterized. Outcome measures included visual status, tumor control, and the need for additional management., Results: All patients underwent either initial gross total (n = 1) or partial surgical resection (n = 6) before SRS. Two patients with progressive tumor growth also had SRS after failing additional fractionated radiation after surgery (54 Gy, 30 fractions for both patients). The median time between the date of surgery and the SRS procedure date was 38 months. The Leksell Gamma Knife was used to deliver a margin dose of 12 Gy (range: 8-14 Gy) to a median cumulative tumor volume of 3.3 cc (range: 1.2-18 cc). The median maximal optic nerve radiation dose was 6.5 Gy (range: 1.9-8.1 Gy). After SRS, the median follow-up time was 130 months (range: 26-169 months). Two patients showed local tumor progression at 20 and 55 months after SRS. Four had stable visual function, 2 experienced improved visual acuity, and 1 patient had visual deterioration., Conclusions: Meningiomas arising from (but not engulfing the optic nerve) represent management quandaries after failed initial surgical removal. In this experience, salvage SRS was associated with tumor control and vision preservation in 5 of 7 patients. Additional experience with this strategy may further define the role of SRS both as a salvage and primary option., (Copyright © 2023 by North American Neuro-Ophthalmology Society.)

Background: Gamma Knife Radiosurgery (GKRS) has established a role in treating various benign brain pathologies. The radiosurgery planning necessitates a proper understanding of radiation dose distribution in relation to the target lesion and surrounding eloquent area. The quality of a radiosurgery plan is determined by various planning parameters. Here, we have reviewed various GKRS planning parameters and analyzed their correlation with the morphology of treated brain lesions., Method: A total of 430 treatment plans (71 meningioma, 133 vestibular schwannoma/VS, 150 arteriovenous malformation/AVM, 76 pituitary adenoma/PA treated with GKRS between December 2013 and May 2023) were analyzed for target coverage (TC), conformity index (CI), homogeneity index (HI), and gradient index (GI)., Result: The values of CIPaddick and CILomax for PA were lower and differed significantly from meningioma, VS, and AVM. The value of HI for PA was higher and differed significantly when compared with meningioma, VS, and AVM. The values of HI for AVM were also significantly higher than VS and meningioma. The mean GI was 3.02, 2.92, 3.03, and 2.88 for meningioma, VS, AVM, and PA, respectively. The value of GI for meningioma and AVM was significantly higher when compared with the values for VS and PA. The mean TC was 0.94 for meningioma, 0.96 for VS, 0.95 for AVM, and 0.90 for PA. The value TC of PA was lower and differed significantly when compared with VS, AVM, and meningioma. Lesions with a volume of ≤1 cc had poor planning metrics as the spillage of radiation may be higher., Conclusion: The GKRS planning parameters depend on the size, shape, nature, and location of intracranial lesions. Therefore, each treatment plan needs to be evaluated thoroughly and a long-term follow-up is needed to establish their relation with clinical outcome., (Copyright © 2024 Copyright: © 2024 Journal of Cancer Research and Therapeutics.)

Purpose: To investigate the radiation-induced effects of Gamma Knife radiosurgery (GKRS) for sellar-parasellar tumors on optic pathways using DTI parameters within the first year after treatment., Methods: Twenty-five patients with sellar-parasellar tumors underwent MRI before and 3 months after GKRS, including T1WI, DTI, T2WI. Moreover, 21 patients underwent follow-up DTI 6-8 months after radiosurgery. ROIs were set on optic nerves, optic radiations, and control localizations; DTI parameters for each were calculated. Pre- and post-radiosurgery differences in DTI values were statistically compared and assessed with respect to tumor size changes., Results: Following GKRS, DTI parameters, notably ADC, FA, and RD, showed statistically significant changes in optic nerves and anterior optic radiations. DTI changes were more significant in the group of cases with tumor shrinkage. In this group, DTI of the anterior optic radiations further deteriorated 3 months post-GKRS, whereas acute changes in DTI parameters of the optic nerves resolved within 6-8 months. DTI of central and posterior optic radiations did not differ significantly following radiosurgery; 6-8 months after radiosurgery, visual function was stable in 14 (56%) patients and improved in 11 (44%), showing no correlation with tumor size changes or DTI parameters., Conclusion: White Matter (WM) injury in the optic pathways can be induced by Gamma Knife radiosurgery targeted to sellar and parasellar tumors. Following GKRS, microstructural abnormalities occurred in the optic radiations as well as the optic nerves within the first post-treatment year. Our findings could support modifications to radiosurgical treatment strategies to minimize the risk of permanent WM injury., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: Clear cell meningiomas (CCM) are an uncommon meningioma subtype marked by aggressive growth and high rates of recurrence despite initial resection. The present study evaluates the adjuvant benefit of stereotactic radiosurgery (SRS) for residual or recurrent tumors., Methods: After review of our prospectively maintained database, we identified 6 patients (3 female) with histologically confirmed Grade 2 CCMs. The median age of the patients at the time of SRS was 45 years. Five patients had undergone prior gross total surgical resection and 1 patient had subtotal resection before SRS. The median SRS treatment volume was 4.7 cc and the median radiosurgical margin dose was 13 Gy (range: 10-15 Gy)., Results: The median follow-up time was 35.5 months (range 6-168 months). Three patients achieved tumor control after the first SRS procedure. Three patients experienced tumor progression at 4, 22, and 32 months after initial SRS. Tumor control was obtained in 2 of these patients after additional SRS. One patient with multiple SRS procedures had suspected adverse radiation effect that was successfully treated with corticosteroids followed by bevacizumab., Conclusions: Tumor control was maintained in 5 of 6 patients after one or more SRS procedures. SRS should be considered for early intervention after surgical resection of CCM. To maximize the tumor control rate, patients with diagnosed CCM should be treated more generously and higher margin dose should be prescribed. Patients with CCM should be counselled that more than one SRS may be necessary to provide sustained tumor control., (Copyright © 2024. Published by Elsevier Inc.)

Background and Objectives: Tectal plate gliomas (TPGs) are midbrain tumors that grow slowly and have a benign clinical course. Most TPGs are low-grade astrocytomas, but they can encompass various histological tumor types. Gamma Knife radiosurgery (GKRS) is being explored as a potentially safe and effective treatment option for TPGs, although research in this area is limited. This study aims to evaluate GKRS's efficacy and safety in patients with TPG and provide a comprehensive review of existing literature on the topic., Methods: This retrospective, single-center study included 48 patients with consecutive TPG who underwent GKRS between September 2005 and June 2022. Patients diagnosed with TPGs based on radiological or tissue-based criteria and who had a minimum follow-up period of 12 months were eligible for inclusion. The primary end points were local control and the absence of GKRS-associated or tumor-associated mortality and morbidity., Results: During a median follow-up of 28.5 months (range, 12-128), the radiological assessment showed tumor control in all cases, with 16.7% achieving a complete response and 68.8% achieving a partial response. Pseudoprogression occurred in 6.2% of cases, with onset ranging from 3 to 8 months. Clinical outcomes revealed no permanent neurological deterioration, with symptoms improving in 14.6% of patients and remaining stable in the others. One patient in the pseudoprogression group experienced transient Parinaud syndrome. One patient died during follow-up because of unrelated causes. The mean survival time after GKRS was 123.7 months. None of the clinical, radiological, or radiosurgical variables showed a correlation with partial/complete response, clinical improvement, or overall survival., Conclusion: There is limited research available on the management of TPGs, and this study presents the largest patient cohort treated with GKRS, along with a substantial follow-up duration. Despite its limitations, this study demonstrates the efficacy and low-risk profile of GKRS for TPGs., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Introduction: Resection of meningiomas (THMs) at the torcular Herophili poses challenges to surgeons due to complex regional anatomy. The current study aims to evaluate factors affecting the extent of resections, progression-free survival, and the role of radiation., Methods: We did a retrospective study of all the THM patients treated at our institute between May 1987 and June 2022. The demographic data, signs and symptoms, surgical notes, postoperative details, and radiotherapy were gathered retrospectively. Survival analysis was done with Kaplan-Meier tests along with predictors of the extent of resection as well as recurrence., Results: A total of 39 patients qualified to be included in the study, with 10 male patients (male:female 1:2.9) and an average age of 50.8 years. The average follow-up duration was 75.9 months. Simpson's grade 2 excision was achieved in 19 (48.7%) patients, followed by Simpson's grade 3 excision in 17 patients (43.6%). Progression-free survival in subtotal resection was 60 months, and 100 months in gross total resection. Statistically, the extent of the resection was determined by the involvement of sinuses/torcula and the number of quadrants involved around torcula. A total of 16 patients received radiosurgery for the residual or small reccurrence of the lesion. Follow-up revealed reccurrence in 5 cases., Conclusions: Torcular meningiomas are relatively uncommon, described in few reports, and represent a therapeutic dilemma. Though some experts recommend complete removal of tumor and reconstruction of the sinus, others suggest maximum safe resection, followed by radiosurgery. The present study reflects reasonable control of the residual lesion with radiosurgery after maximum safe resection., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Parafalcine and parasagittal (PFPS) are common locations for meningiomas. Surgical resection for these tumors, the first-line treatment, poses challenges due to their proximity to critical structures. This systematic review investigates the use of stereotactic radiosurgery (SRS) as a treatment for PFPS meningiomas, aiming to elucidate its safety and efficacy. The review adhered to PRISMA guidelines. Searches were conducted on MEDLINE, Embase, and Cochrane. Inclusion criteria involved studies on SRS for PFPS meningiomas, reporting procedure outcomes and complications. Tumors were presumed or confirmed to be WHO grade 1. Data was systematically extracted. Meta-analysis was performed where applicable. The review included data from eight studies, 821 patients with 878 lesions. Tumor control was achieved in greater than 80% of cases. Adverse radiation effects were reported in 7.3% of them. Recurrence and further surgical approach were observed in 17.1% and 9.2% of cases, respectively. Symptom improvement was noted in 33.2% of patients. Edema occurred in approximately 25.1% of patients. A subgroup of 283 patients had upfront SRS, achieving tumor control in approximately 97% of such cases. SRS is a safe and effective treatment for PFPS meningiomas, both as an adjuvant therapy and as an upfront treatment for often smaller tumors. Post-SRS edema can typically be managed medically and usually does not require further surgical intervention. Further studies should provide more specific data on PFPS meningiomas. The use of single and hypofractionated SRS for larger volume PFPS meningiomas should be more explored to better define the risks and benefits., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: This study investigated whether Ki-67 labeling index (LI) correlated with clinical outcomes after SRS for atypical meningiomas., Methods: This retrospective study examined 39 patients with atypical meningiomas who underwent SRS over a 10-year study period. Ki-67 LI was categorized into 3 groups: low (< 5%), intermediate (5%-10%), and high (> 10%). Local tumor control rates (LCRs), progression-free rates (PFRs), disease-specific survival (DSS) rates, and adverse radiation-induced events (AREs) were evaluated., Results: The median follow-up periods were 26 months. SRS was performed at a median prescription dose of 18 Gy for tumors with a median Ki-67 LI of 9.6%. The 3-year LCRs were 100%, 74%, and 25% in the low, intermediate, and high LI groups, respectively (p = 0.011). The 3-year PFRs were 100%, 40%, and 0% in the low, intermediate, and high LI groups (p = 0.003). The 5-year DSS rates were 100%, 89%, and 50% in the low, intermediate, and high LI groups (p = 0.019). Multivariable Cox proportional hazard analysis showed a significant correlation of high LI with lower LCR (hazard ratio [HR], 3.92; 95% confidence interval [CI] 1.18-13.04, p = 0.026), lower PFR (HR 3.80; 95% CI 1.46-9.88, p = 0.006), and shorter DSS (HR 6.55; 95% CI 1.19-35.95, p = 0.031) compared with intermediate LI. The ARE rates were minimal (8%) in the entire group., Conclusion: Patients with high Ki-67 LI showed significantly more tumor progression and tumor-related death. Ki-67 LI might offer valuable predictive insights for the post-SRS management of atypical meningiomas., (© 2024. The Author(s).)

Gamma knife radiosurgery (GKRS) has emerged as a highly effective therapeutic modality for the management of intracranial meningiomas. However, the role of GKRS in treating growing meningiomas detected during active surveillance remains unclear. This study seeks to investigate the long-term outcomes of GKRS treatment for growing meningiomas. A retrospective analysis was conducted on patients who underwent GKRS as the primary treatment for growing meningiomas between 2004 and 2021. Growing meningiomas were defined as those exhibiting a > 10% increase in tumor volume (TV) compared to the previous imaging. Fifty-nine patients who received GKRS as their initial treatment were included, with a minimum follow-up period of 12 months. Comprehensive clinical, radiological, and procedural data were analyzed. Serial TV assessments were performed for all tumors before and after GKRS. Tumor progression and regression were defined as a > 10% increase or decrease in TV, respectively, compared to the pretreatment image. At a median follow-up of 41 months (range 15-197 months), TV was unchanged in 16 patients (27.1%), decreased in 41 patients (69.5%), and increased in 2 patients (3.4%). Multivariate analysis revealed that both TV (cm3) (hazard ratio [HR], 1.107; 95% confidence interval [CI], 1.002-1.222; P = .045) and volume growing rate (%/yr) (HR, 1.013; 95% CI, 1.000-1.025; P = .04) significantly correlated with tumor progression. Eleven patients (18.6%) experienced new or worsening symptoms. In multivariate analysis, factor predicting new or worsening neurological function was preexisting calcification (HR, 5.297; 95% CI, 1.328-21.124; P = .018). GKRS demonstrates a promising level of tumor control with minimal risk of neurological deterioration when applied to growing meningiomas. These findings provide compelling support for considering GKRS as a valuable therapeutic option following an initial period of active surveillance for these tumors., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: We analyzed long-term control and patterns of failure in patients with World Health Organization Grade 1 meningiomas treated with definitive or postoperative stereotactic radiosurgery at the authors' affiliated institution., Methods: 96 patients were treated between 2004 and 2019 with definitive (n = 57) or postoperative (n = 39) stereotactic radiosurgery. Of the postoperative patients, 17 were treated adjuvantly following subtotal resection and 22 were treated as salvage at time of progression. Patients were treated to the gross tumor alone without margin or coverage of the dural tail to a median dose of 15 Gy. Median follow up was 7.4 years (inter-quartile range 4.8-11.3). Local control, marginal control, regional control, and progression-free survival were analyzed., Results: Local control at 5 and 10 years was 97 % and 95 %. PFS at 5 and 10 years was 94 % and 90 % with no failures reported after 6 years. Definitive and postoperative local control were similar at 5 (95 % [82-99 %] vs. 100 %) and 10 years (92 % [82-99 %] vs. 100 %). Patients treated with postoperative SRS did not have an increased marginal failure rate (p = 0.83) and only 2/39 (5 %) experienced recurrence elsewhere in the cavity., Conclusions: Stereotactic radiosurgery targeting the gross tumor alone provides excellent local control and progression free survival in patients treated definitively and postoperatively. As in the definitive setting, patients treated postoperatively can be treated to gross tumor alone without need for additional margin or dural tail coverage., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Stereotactic radiosurgery is a well-known and influential management option for meningioma. This article aims to highlight the most cited publications on this topic., Methods: All Scopus articles published in English under Stereotactic radiosurgery and meningioma were sorted according to the number of citations. The keywords used were: "Stereotactic radiosurgery, SRS, Meningioma, Intracranial meningioma". The top 100 cited articles meeting the criteria were included. Certain features of these articles were collected and analyzed using Microsoft Excel and SPSS., Results: The included articles were published between 1991 and 2020 with a total of 9149 citations. The most cited article is "Meningiomas: Knowledge base, treatment outcomes, and uncertainties. A RANO review" by Rogers L. et al. 2015 with 349 citations. No significant association was found between the number of citations and the impact factor of the publishing journal., Conclusion: This study gives a concise and updated summary of impactful research on stereotactic radiosurgery and meningioma, highlighting the main contributors and scientific connections.

According to the literature, cerebellopontine angle tumors cause secondary trigeminal neuralgia and other symptoms of neurovascular compression in 1-9.9% of cases. We present a 58-year-old patient with left-sided secondary trigeminal neuralgia caused by ipsilateral posterior petrous meningioma. Stereotactic irradiation was followed by effective tumor growth control. However, residual trigeminal pain paroxysms significantly reduced the quality of life and required subsequent microsurgery. Trigeminal facial pain regressed after total resection of tumor. Considering this clinical case, we would like to discuss several issues: follow-up of meningioma requiring radiosurgery, course of secondary trigeminal neuralgia in a patient with apical petrous meningioma, characteristics of pain before and after radiosurgery, the best treatment option for these patients. Stereotactic radiosurgery seems unreasonable for CPA tumors with secondary trigeminal neuralgia. Indeed, persistent pain is possible even after tumor shrinkage. Moreover, primary stereotactic irradiation significantly complicates subsequent resection of tumor.

Introduction: Meningiomas are the most common primary intracranial tumour. Gamma knife radiosurgery (GKRS) is a frequently employed non-invasive method of treatment, with good remission rates and low morbidity in literature. However, the role of GKRS in the management of "large" meningiomas is unclear, with reported outcomes that vary by centre. We aimed to assess the factors that influence long-term outcomes following GKRS in meningiomas &gt;10 cc in volume., Methods: A retrospectively analysed all patients with meningiomas exceeding 10 cc in volume who underwent GKRS between January 2006 and December 2021 at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. Demographic, clinical, radiological, and follow-up data were acquired, and factors associated with progression following GKRS were assessed., Results: The cohort comprised 76 patients 29 males (38.2%) and 47 females (61.8%) with a mean age of 46.3 ± 11.02 years. Thirty-nine patients had been previously operated (51.3%). Meningiomas were most frequently located in the parasagittal region (26 tumours, 34.2%) and sphenopetroclival region (23 tumours, 30.3%), with mean lesion volume of 12.55 ± 5.22 cc, ranging 10.3 cc-25 cc. The mean dose administered to the tumour margin was 12.5 Gy ± 1.2 Gy (range 6-15 Gy). The median duration of clinical follow-up was 48 months, over which period radiological progression occurred in 14 cases (20%), with unchanged tumour volume in 20 cases (28.6%) and reduction in size of the tumour in 36 cases (51.4%). Progression-free survival after GKRS was 72% at 5 years, was significantly poorer among meningiomas with tumour volume &gt;14 cc (log-rank test p = 0.045), tumours presenting with limb motor deficits (log-rank test p = 0.012), and tumours that underwent prior Simpson grade 3 or 4 excision (log-rank test p = 0.032)., Conclusions: Meningiomas &gt;10 cc in volume appear to display a high rate of progression and subsequent need for surgery following GKRS. Primary surgical resection, when not contraindicated, may be considered with GKRS serving an adjuvant role, especially in tumours exceeding 14 cc in volume, and presenting with limb motor deficits. Long-term clinical and radiological follow-up is essential following GKRS as the response of large meningiomas may be unpredictable., (© 2024 S. Karger AG, Basel.)

Purpose: Stereotactic radiosurgery with linear accelerators (LINACs) or Leksell Gamma Knife® (LGK, Elekta AB) is an established treatment option for intracranial tumors. When those are involving/abutting organs at risk (OAR), homogenous and normofractionated treatments outmatch single fraction deliveries. In such situations, it would be desirable to balance LINAC's homogeneity benefits with LGK's dose gradient attributes. In this study, we determined homogeneity and OAR sparing ranges using a non-clinical, homogenous prototype version of LGK Lightning., Methods: We retrospectively analyzed thirty fractionated LGK Icon in-house patients with acoustic neuromas, pituitary adenomas and meningiomas. Four treatment plans were generated (54 Gy,1.8 Gy/fx) per patient: one LINAC plan, one clinical Lightning plan ("LGK") and two prototype Lightning plans ("LGK Hom" and "LGK OAR"). We analyzed D mean and D 2% for different OAR, Gradient Index (GI), Paddick Conformity Index (PCI), Homogeneity Index (HI) and beam-on-time (BOT)., Results: While the LINAC vs. Lightning plans (LGK Hom|LGK OAR|LGK) boast better homogeneity (median: 1.08 vs. 1.18|1.24|1.35) and shorter BOT (median: 137 s vs. 432 s|510 s|510 s), Lightning plans show improved GI (median: 6.68 vs. 3.86|3.50|3.19), similar PCI (median: 0.75 vs. 0.76|0.75|0.82) and significantly reduced OAR doses. For in-tumor OAR, LGK Hom and LINAC plans achieves similar OAR sparing with improved GI for LGK Hom., Conclusions: This study is a preliminary attempt to combine the dosimetric advantages of LINAC and LGK treatment planning. We observed that LGK plan homogeneity can be improved toward LINAC standards while maintaining the LGK advantage of favorable OAR doses and GI. Additionally, in-tumor OAR hotspots can be considerably reduced., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Associazione Italiana di Fisica Medica e Sanitaria. Published by Elsevier Ltd. All rights reserved.)

Background and Objectives: Stereotactic radiosurgery (SRS) is increasingly applied to treat meningiomas, attributable to their increased incidence in older individuals at greater surgical risk. To evaluate the effectiveness of treatment with linear accelerator (LINAC)-based stereotactic radiosurgery in skull base meningiomas as either primary treatment or postresection adjuvant therapy., Methods: This study included 241 patients diagnosed with skull base meningiomas treated by single-dose SRS, with a median age of 59 years. SRS was primary treatment in 68.1% (n = 164) and adjuvant treatment in 31.9% (n = 77), using LINAC (Varian 600, 6 MeV). The median tumor volume was 3.2 cm 3 , and the median coverage dose was 14 Gy. Bivariate and multivariate analyses were performed to determine predictive factors for tumor progression, clinical deterioration, and complications. Kaplan-Meier analysis was used for survival analysis., Results: After the median follow-up of 102 months, the tumor control rate was 91.2% (n = 220). Progression-free survival rates were 97.07%, 90.1%, and 85.7% at 5, 10, and 14 years, respectively. Clinical improvement was observed in 56 patients (23.2%). In multivariate analysis, previous surgery (hazard ratio 3.8 [95%CI 1.136-12.71], P = .030) and selectivity (hazard ratio .21 [95%CI 0.066-0.677], P = .009) were associated with tumor progression and increased maximum dose (odds ratio [OR] 4.19 [95% CI 1.287-13.653], P = .017) with clinical deterioration. The permanent adverse radiation effect rate was 6.2% (n = 15) and associated with maximum brainstem dose >12.5 Gy (OR 3.36 [95% CI .866-13.03], P = .08) and cerebellopontine angle localization (OR 3.93 [95% CI 1.29-11.98], P = .016)., Conclusion: Treatment of skull base meningiomas with single-dose SRS using LINAC is effective over the long term. Superior tumor control is obtained in patients without previous surgery. Adverse effects are related to localization in the cerebellopontine angle, and maximum brainstem radiation dose was >12.5 Gy., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Objectives: Edema is a complication of gamma knife radiosurgery (GKS) in meningioma patients that leads to a variety of consequences. The aim of this study is to construct radiomics-based machine learning models to predict post-GKS edema development., Methods: In total, 445 meningioma patients who underwent GKS in our institution were enrolled and partitioned into training and internal validation datasets (8:2). A total of 150 cases from multicenter data were included as the external validation dataset. In each case, 1132 radiomics features were extracted from each pre-treatment MRI sequence (contrast-enhanced T1WI, T2WI, and ADC maps). Nine clinical features and eight semantic features were also generated. Nineteen random survival forest (RSF) and nineteen neural network (DeepSurv) models with different combinations of radiomics, clinical, and semantic features were developed with the training dataset, and evaluated with internal and external validation. A nomogram was derived from the model achieving the highest C-index in external validation., Results: All the models were successfully validated on both validation datasets. The RSF model incorporating clinical, semantic, and ADC radiomics features achieved the best performance with a C-index of 0.861 (95% CI: 0.748-0.975) in internal validation, and 0.780 (95% CI: 0.673-0.887) in external validation. It stratifies high-risk and low-risk cases effectively. The nomogram based on the predicted risks provided personalized prediction with a C-index of 0.962 (95%CI: 0.951-0.973) and satisfactory calibration., Conclusion: This RSF model with a nomogram could represent a non-invasive and cost-effective tool to predict post-GKS edema risk, thus facilitating personalized decision-making in meningioma treatment., Clinical Relevance Statement: The RSF model with a nomogram built in this study represents a handy, non-invasive, and cost-effective tool for meningioma patients to assist in better counselling on the risks, appropriate individual treatment decisions, and customized follow-up plans., Key Points: • Machine learning models were built to predict post-GKS edema in meningioma. The random survival forest model with clinical, semantic, and ADC radiomics features achieved excellent performance. • The nomogram based on the predicted risks provides personalized prediction with a C-index of 0.962 (95%CI: 0.951-0.973) and satisfactory calibration and shows the potential to assist in better counselling, appropriate treatment decisions, and customized follow-up plans. • Given the excellent performance and convenient acquisition of the conventional sequence, we envision that this non-invasive and cost-effective tool will facilitate personalized medicine in meningioma treatment., (© 2023. The Author(s), under exclusive licence to European Society of Radiology.)

The purpose of this study was to systematically review studies in the literature to assess the superiority between microsurgery and radiosurgery regarding the efficacy in improving petroclival meningioma (PCM)-related trigeminal neuralgia (TN). PubMed, Embase, Web of Science, and Cochrane clinical trial databases were systematically searched from the inception until December 08, 2022. The overall proportion of patients with improved TN after treatment in all six included studies was 56% (95% confidence interval [CI], 35-76.9%). Higgins I 2 statistics showed significant heterogeneity (I 2  = 90%). Subgroup analysis showed that the proportion of improved TN was higher in the microsurgery group than that in the radiosurgery group (89%; 95% CI, 81-96.5% vs. 37%, 95% CI, 22-52.7%, respectively, p < 0.01). Subgroup analysis (for studies that documented the number of posttreatment Barrow Neurological Institute scores 1 and 2) revealed that the proportion of pain-free without medication after treatment was higher in the microsurgery group than that in the radiosurgery group (90.7%; 95% CI, 81-99.7% vs. 34.5%, 95% CI, 21.3-47.7.7%, respectively, p < 0.01). Based on the results of this meta-analysis, we concluded that microsurgery is superior to radiosurgery in controlling PCM-related TN., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Gross total resection, without causing neurological deficits, is challenging in skull base meningioma (SBM). Therefore, stereotactic radiosurgery (SRS) is an important approach for SBMs; however, it is difficult to predict the long-term prognosis., Objective: To identify the predictive factors for tumor progression after SRS for World Health Organization (WHO) grade I SBMs, focusing on the Ki-67 labeling index (LI)., Methods: In this single-center retrospective study, factors affecting progression-free survival rates (PFSs) and neurological outcomes in patients undergoing SRS for postoperative SBMs were evaluated. Based on the Ki-67 LI, patients were classified into 3 groups: low (<4%), intermediate (4%-6%), and high LI (>6%)., Results: In the 112 patients enrolled, the cumulative 5- and 10-year PFSs were 93% and 83%, respectively. The PFSs were significantly higher in the low LI group (95% at 10 years) compared with the other groups (intermediate LI, 60% at 10 years, P = .007; high LI, 20% at 10 years, P = .001). Multivariable Cox proportional hazard analysis demonstrated that the Ki-67 LI was significantly associated with the PFSs (low vs intermediate LI; hazard ratio, 6.00; 95% CI, 1.41-25.54; P = .015; low vs high LI; hazard ratio, 31.90; 95% CI, 5.59-181.77; P = .001)., Conclusion: Ki-67 LI may be a useful predictor of long-term prognosis in SRS for postoperative WHO grade I SBM. SRS provides excellent long- and mid-term PFSs in SBMs with Ki-67 LIs <4% or 4% to 6%, with a low risk of radiation-induced adverse events., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Objectives: To evaluate the efficacy of treatment with linear accelerator-based stereotactic radiosurgery (LINAC) in cerebellopontine angle meningiomas., Methods: We analyzed 80 patients diagnosed with cerebellopontine angle meningiomas between 2001 and 2014, treated with stereotactic radiosurgery (SRS), of whom 81.9% (n=68) were women, with an average age of 59.1 years (32-79). SRS was applied as primary treatment in 83.7% (n=67) and in 16.3% (n=13) as an adjuvant treatment to surgery. SRS treatment was provided using LINAC (Varian 600, 6MeV) with M3 micromultilamines (brainLab) and stereotactic frame. The average tumor volume was 3.12cm 3 (0.34-10.36cm 3 ) and the coverage dose was 14Gy (12-16Gy). We performed a retrospective descriptive analysis and survival analysis was performed with the Kaplan-Meier method and multivariate analysis to determine those factors predictive of tumor progression or clinical improvement., Results: After an average follow-up period of 86.9 months (12-184), the tumor control rate was 92.8% (n=77). At the end of the study, there was an overall reduction in tumor volume of 32.8%, with an average final volume of 2.11cm 3 (0-10.35cm 3 ). The progression-free survival rate at 5, 10 and 12 years was 98%, 95% and 83.3% respectively. The higher tumor volume (p=0.047) was associated with progression. There was clinical improvement in 26.5% (n=21) of cases and clinical worsening in 16.2% (n=13). Worsening is related to the radiation dose received by the brainstem (p=0.02). Complications were 8.7% (7 cases) of hearing loss, 5% (4 cases) of brain radionecrosis, and 3.7% (3 cases) of cranial nerve V neuropathy. Hearing loss was related to initial tumor size (p=0.033) and maximum dose (p=0.037). The occurrence of radionecrosis with the maximum dose (p=0.037)., Conclusions: Treatment of cerebellopontine angle meningiomas with single-dose SRS using LINAC is effective in the long term. Better tumor control rates were obtained in patients with small lesions., (Copyright © 2022 Sociedad Española de Neurocirugía. Published by Elsevier España, S.L.U. All rights reserved.)

Background and Objectives: Meningiomas in children are uncommon, with distinct characteristics that set them apart from their adult counterparts. The existing evidence for stereotactic radiosurgery (SRS) in this patient population is limited to only case series. The objective of this study was to evaluate the safety and efficacy of SRS in managing pediatric meningiomas., Methods: Children and adolescents who had been treated for meningioma with single-fraction SRS were included in this retrospective, multicenter study. The assessment included local tumor control, any complications related to the tumor or SRS, and the emergence of new neurological deficits after SRS., Results: The cohort included 57 patients (male-to-female ratio 1.6:1) with a mean age of 14.4 years who were managed with single-fraction SRS for 78 meningiomas. The median radiological and clinical follow-up periods were 69 months (range, 6-268) and 71 months (range, 6-268), respectively. At the last follow-up, tumor control (tumor stability and regression) was achieved in 69 (85.9%) tumors. Post-SRS, new neurological deficits occurred in 2 (3.5%) patients. Adverse radiation effects occurred in 5 (8.8%) patients. A de novo aneurysm was observed in a patient 69 months after SRS., Conclusion: SRS seems to be a safe and effective up-front or adjuvant treatment option for surgically inaccessible, recurrent, or residual pediatric meningiomas., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Perioptic meningiomas, defined as those that are less than 3 mm from the optic apparatus, are challenging to treat with stereotactic radiosurgery (SRS). Tumor control must be weighed against the risk of radiation-induced optic neuropathy (RION), as both tumor progression and RION can lead to visual decline. We performed a systematic review and meta-analysis of single fraction SRS and hypofractionated radiosurgery (hfRS) for perioptic meningiomas, evaluating tumor control and visual preservation rates. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we reviewed articles published between 1968 and December 8, 2022. We retained 5 studies reporting 865 patients, 438 cases treated in single fraction, while 427 with hfRS. For single fraction SRS, the overall rate of tumor control was 95.1%, with actuarial rates at 5 and 10 years of 96% and 89%, respectively; tumor progression was 7.7%. The rate of visual stability was 90.4%, including visual improvement in 29.3%. The rate of visual decline was 9.6%, including blindness in 1.2%. For hfRS, the overall rate of tumor control was 95.6% (range 92.1-99.1, p < 0.001); tumor progression was 4.4% (range 0.9-7.9, p = 0.01). Overall rate of visual stability was 94.9% (range 90.9-98.9, p < 0.001), including visual improvement in 22.7% (range 5.0-40.3, p = 0.01); visual decline was 5.1% (range 1.1-9.1, p = 0.013). SRS is an effective and safe treatment option for perioptic meningiomas. Both hypofractionated regimens and single fraction SRS can be considered., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To report clinical features and outcomes of cats undergoing either stereotactic radiotherapy (SRT) or surgical excision for the treatment of intracranial meningioma., Animals: 61 client-owned cats., Methods: Medical records were retrospectively reviewed of cats with intracranial meningiomas that were treated with surgical removal and/or SRT between 2005 and 2017. Signalment, clinical signs, duration of clinical signs, diagnostic imaging reports, histopathology reports, treatment protocol, complications, recurrence or progression, and survival time were obtained from the medical record and through follow-up phone calls., Results: Of the 61 patients, 46 had surgery, 14 had SRT, and 1 had surgery followed by SRT for initial treatment. Significantly more cats that underwent surgery had peritreatment complications compared to the SRT group (P < .0001). Cats that received surgery initially had a significantly longer median survival time (MST) of 1,345 days compared to the MST of 339 days for the SRT cats (P = .002). Fourteen (30%) cats in the surgery group and 4 cats in the SRT group (28%) had MRI- or CT-confirmed tumor regrowth or new tumor growth (P = 1.00). Five cases that had SRT for subsequent recurrence had an MST of 700 days (range, 335 to 1,460 days) after the last treatment., Clinical Relevance: SRT proved to be a safe, alternative treatment option for feline patients with intracranial meningiomas; however, the survival times with surgery alone were significantly longer. SRT for the treatment of recurrence following initial surgery may show promising results.

Endolymphatic sac tumors (ELST), though benign are locally invasive lesions. Owing to its vascularity, complete surgical resection is often not possible and adjuvant gamma knife radiosurgery (GKRS) is advocated to control tumor growth. These lesions do not uniformly respond to radiation therapy in the initial phase and their early radiobiological course after GKRS is less understood. We discuss a case of residual ELST where a mild increase was noted at 36 months following GKRS and then regressed completely after a decade. This report possibly has the longest follow-up revealing the true efficacy of GKRS in these tumors. ELST shows a variable response in the early years after GKRS. They may remain static, regress or increase in size. One should be aware of these patterns of early radiological responses and a long term follow up is warranted as some lesions may show radiosurgical effectiveness after a long latent period.

Meningeal melanocytomas are rare, benign tumours of the central nervous system arising from the melanocytes of the leptomeninges. First-line treatment consists of either gross or subtotal resection with or without radiotherapy. However, given the sensitive locations of these tumours, alternative treatment options such as definitive radiotherapy may be warranted in patients deemed high-risk or without accessible tumours. A 67-year-old male presenting with spastic gait, frequent falls, and vertical gaze palsy was diagnosed with a 2.4 cm primary meningeal melanocytoma arising from the interpeduncular fossa. Given the critical tumour position within the brainstem, definitive radiotherapy was recommended. He received fractionated stereotactic radiotherapy (FSRT) to a total dose of 54 Gy in 27 fractions, resulting in a gradual improvement in gait and ocular range of motion. Follow-up imaging over the next three years revealed largely stable disease and an increase in edema with mild upper extremity weakness that improved with steroids. He was followed for three years and expired four years after treatment due to pneumonia. For patients unable to receive surgical resection, definitive RT may provide local control with minimal morbidity.

Background: Sterotactic radiosurgery is becoming an integral modality in the management of intracranial meningiomas, both as the primary treatment or as adjuvant therapy. This study analyzes the scholarly impact of the top 100 cited articles on the stereotactic radiosurgical management of intracranial meningiomas., Methods: A ranked list of the 100 most-cited articles was generated using the Scopus database by searching the keywords 'intracranial meningioma' and 'stereotactic radiosurgery'. All articles were then evaluated on multiple criteria regarding both the publication of the articles (year of publication, journal, country of origin, and authors) as well as their methods and foci (type of study, location of studied meningiomas, and type of radiosurgical modality). Quantitaitve and qualitative analyses were then performed from the collected data., Results: The most frequently cited articles on stereotactic radiosurgical management of intracranial meningiomas were published between 1990 and 2016. The average citation-per-year across all papers in the list was 6.1. The most studied anatomic area of intracranial meningiomas was the skull base, with the cavernous sinus being the most well-studied specific site. The most utilized stereotactic radiosurgical modality was Gamma Knife radiosurgery. The country with the highest number of publications was the United States. Twenty-six percent of the articles were published in the journal Neurosurgery; Lunsford, Kondziolka, Flickinger, Sheehan, and Pollock were respectively the most frequent listed authors among this list. The most active academic institute publishing on this topic was the University of Pittsburgh Medical Center., Conclusion: Stereotactic radiosurgery is an integral modality in the management of intracranial meningiomas. This bibliometric analysis sheds the light on the ways in which intracranial meningiomas have been studied in the past two decades in order to identify trends among neurosurgeons and radiation oncologists and to reveal areas of rising and declining focus.

Objective: Petroclival meningiomas (PCMs) are challenging lesions to treat because of their deep location and proximity to critical neurovascular structures. Patients with these lesions commonly present because of local mass effect. A symptom that proves challenging to definitively manage is trigeminal neuralgia (TN), which occurs in approximately 5% of PCM cases. To date, there is no consensus on whether microsurgical resection or stereotactic radiosurgery (SRS) leads to better outcomes in the treatment of TN secondary to PCM. In this systematic review and meta-analysis, the authors aimed to evaluate the available literature on the efficacy of microsurgical resection versus SRS for controlling TN secondary to PCM., Methods: The Embase, MEDLINE, Scopus, and Cochrane databases were queried from database inception to May 17, 2022, using the search terms "(petroclival AND meningioma) AND (trigeminal AND neuralgia)." Study inclusion criteria were as follows: 1) reports on patients aged ≥ 18 years and diagnosed with TN secondary to PCM, 2) cases treated with microsurgical resection or SRS, 3) cases with at least one posttreatment follow-up report of TN pain, 4) cases with at least one outcome of tumor control, and 5) publications describing randomized controlled trials, comparative or single-arm observational studies, case reports, or case series. Exclusion criteria were 1) literature reviews, technical notes, conference abstracts, or autopsy reports; 2) publications that did not clearly differentiate data on patients with PCMs from data on patients with different tumors or with meningiomas in different locations (other intracranial or spinal meningiomas); 3) publications that contained insufficient data on treatments and outcomes; and 4) publications not written in the English language. References of eligible studies were screened to retrieve additional relevant studies. Data on pain and tumor outcomes were compared between the microsurgical resection and SRS treatment groups. The DerSimonian-Laird random-effects model with Hartung-Knapp-Sidik-Jonkman variance correction was used to pool estimates from the included studies., Results: Two comparative observational studies and 6 single-arm observational studies describing outcomes after primary intervention were included in the analyses (138 patients). Fifty-seven patients underwent microsurgical resection and 81 underwent SRS for the management of TN secondary to PCM. By the last follow-up (mean 71 months, range 24-149 months), the resection group had significantly higher rates of pain resolution than the SRS group (82%, 95% CI 50%-100% vs 31%, 95% CI 18%-45%, respectively; p = 0.004). There was also a significantly longer median time to tumor recurrence following resection (43.75 vs 16.7 months, p < 0.01). The resection group showed lower rates of pain persistence (0%, 95% CI 0%-6% vs 25%, 95% CI 13%-39%, p = 0.001) and pain exacerbation (0% vs 12%, 95% CI 3%-23%, p = 0.001). The most common postintervention Barrow Neurological Institute pain score in the surgical group was I (66.7%) compared with III (27.2%) in the SRS group. Surgical reintervention was less frequently required following primary resection (1.8%, 95% CI 0%-37% vs 19%, 95% CI 1%-48%, p < 0.01)., Conclusions: Microsurgical resection is associated with higher rates of TN pain resolution and lower rates of pain persistence and exacerbation than SRS in the treatment of PCM. SRS with further TN management is a viable alternative in patients who are not good candidates for microsurgical resection.

Background: Cavernous sinus tumours comprise 0.1-0.2% of all intracranial tumours, and are most commonly meningiomas or schwannomas. Central nervous system and cranial nerve granular cell tumours (GCTs) are extremely rare. We report the tenth case of a GCT arising from a cranial nerve, and the second case reported in a cavernous sinus location, and review the literature., Clinical Presentation: A 67-year-old man presented with right sided trigeminal neuralgia. Imaging findings suggested a trigeminal schwannoma and he was treated with CyberKnife radiosurgery. Over a period of 41 months follow up, there was a progression in both symptoms and imaging findings, requiring debulking surgery. Histopathology identified a GCT., Conclusions: This is the first case of a cranial nerve GCT treated with stereotactic radiosurgery. Trigeminal nerve GCTs are a rare differential in cases of presumed schwannomas.

Background: Studies of novel microsurgical adjuncts, such as 5-aminolevulinic acid (5-ALA) fluorescence have shown various fluorescence patterns within meningiomas, opening new avenues for complete microsurgical resection. Here, we present a recurrent, radiation-induced meningioma, previously operated on two occasions (initial gross total resection and subtotal 12 years later) and also irradiated by Gamma Knife radiosurgery (GKR, 6 years after the first surgery). We thought to assess the usefulness of 68- Ga Dotatoc in surgical target planning and of 5-ALA as an adjunct for maximal microsurgical excision., Case Report: We report on a 43 years-old Caucasian male diagnosed with atypical, radiation induced WHO II meningioma, with left basal temporal bone implantation. Hodgkin lymphoma treated with cranial and mediastinal radiation during infancy marked his personal history. He underwent a first gross total microsurgical resection, followed 6 and 12 years later by Gamma Knife radiosurgery (GKR) and second subtotal microsurgical resection, respectively. Magnetic resonance imaging (MRI) displayed new recurrence 13 years after initial diagnosis. He was clinically asymptomatic but routine Magnetic resonance imaging showed constant progression. There was strong 68- Ga Dotatoc uptake. We used 5-ALA guided microsurgical resection. Intraoperative views confirmed strong fluorescence, in concordance with both preoperative Magnetic resonance imaging enhancement and 68- Ga Dotatoc. The tumor was completely removed, with meningeal and bone resection., Conclusion: The authors conclude that fluorescence-guided resection using 5-ALA is useful for recurrent atypical, radiation-induced meningioma even despite previous irradiation and multiple recurrences., (© 2023. The Author(s).)

Meningiomas represent the most common type of benign tumor of the extra-axial compartment. Although most meningiomas are benign World Health Organization (WHO) grade 1 lesions, the increasingly prevalent of WHO grade 2 lesion and occasional grade 3 lesions show worsened recurrence rates and morbidity. Multiple medical treatments have been evaluated but show limited efficacy. We review the status of medical management in meningiomas, highlighting successes and failures of various treatment options. We also explore newer studies evaluating the use of immunotherapy in management., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The rise in availability of neuroimaging has led to an increase in incidentally discovered meningiomas. These tumors are typically asymptomatic and tend to display slow growth. Treatment options include observation with serial monitoring, radiation, and surgery. Although optimal management is unclear, clinicians recommend a conservative approach, which preserves quality of life and limits unnecessary intervention. Several risk factors have been investigated for their potential utility in the development of prognostic models for risk assessment. Herein, the authors review the current literature on incidental meningiomas, focusing their discussion on potential predictive factors for tumor growth and appropriate management practices., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: For patients with either an incompletely resected meningioma or recurrence after surgery, stereotactic radiosurgery is frequently used. MRI is typically used for stereotactic radiosurgery targeting, but differentiating tumor growth from postoperative change can be challenging. 68 Ga-DOTATATE, a positron emission tomography (PET) radiotracer targeting the somatostatin receptor type 2, has been shown to be a reliable meningioma biomarker., Objective: To evaluate the impact of 68 Ga-DOTATATE on treatment planning in patients who had previously undergone meningioma resection., Methods: We present a consecutive case series of 12 patients with pathology-proven meningioma who received a 68 Ga-DOTATATE PET between April 2019 and April 2021. Treatment planning was performed first using MRI. DOTATATE-PET images were then used to assess accurate tumor identification., Results: Ten patients had WHO Grade 2 meningioma, and 2 patients had Grade 1 tumor. Eight patients had recurrent meningiomas, and 4 patients had newly diagnosed disease. Overall, 68 Ga-DOTATATE PET scans altered previously formulated treatment plans in 5 of 12 patients. In addition, 9 of 12 patients had disease foci not appreciated on MRI., Conclusion: In this series, incorporating 68 Ga-DOTATATE PET imaging had clinical utility for most patients in whom it was used. It proved particularly adept in demonstrating intraosseous meningiomas, differentiating recurrence from postoperative changes, and identifying subcentimeter disease foci. It is an imaging modality that our center will continue to use as a means of improving postoperative treatment plans after the surgical resection of meningiomas., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

Meningiomas are thought to originate from the meningothelial cells of the arachnoid mater and are the most common primary brain tumor in adults. Histologically confirmed meningiomas occur with an incidence of 9.12/100,000 population and account for 39% of all primary brain tumors and 54.5% of all non-malignant brain tumors. Risk factors for meningioma include age 65 years and older, female gender, African-American race, history of exposure to head and neck ionizing radiation, and certain genetic disorders such as neurofibromatosis II. Intracranial meningiomas are the most commonly benign, WHO Grade I neoplasms. Atypical and anaplastic are considered malignant lesions., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Stereotactic radiosurgery (SRS) is an effective adjuvant therapy for residual tumor after subtotal resection of parasellar meningiomas. Fat graft placement between the optic nerve/chiasm and residual tumor (optic neuropexy [OPN]) allows for safe SRS therapy., Objective: To evaluate the radiological temporal profile of the fat graft after OPN, immediately after surgery and at 3, 6, and 12 months intervals, to elucidate the optimal time point of adjuvant SRS., Methods: A single-center, retrospective, cohort study of 23 patients after surgery for parasellar meningioma was conducted. Fat graft volume and MRI signal ratios were calculated. SRS dosimetric parameters (tumor/optic nerve) were measured at the time of SRS and compared with a hypothetical dosimetric plan based on an early postoperative MRI., Results: Of 23 patients, 6 (26%) had gross total resection and 17 (74%) had subtotal resection. Fat grafts showed a progressive loss of volume and signal ratio over time. Radiosurgery was performed in 14 (82.3%; 8 hypofractionated radiosurgery and 6 single fraction). At 3 months, there is a loss of 46% of the fat volume and degradation of its tissue intensity, decreasing differentiation from tumor and nerve. The hypothetical treatment plan (performed on an early postoperative MRI) showed that single-fraction SRS would have been possible in 6 of the 8 hypofractionated cases., Conclusion: OPN is a technique that can be safely performed after resection of parasellar meningiomas. Because of the reduction of the fat volume and tissue differentiation between fat and tumor/nerves, adjuvant radiosurgery is better performed within the first 3 months after surgery., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Congress of Neurological Surgeons.)

Background: The most effective treatment method for meningiomas is surgical treatment. However, complete resection of cavernous sinus meningiomas is quite difficult. The biggest reasons for this are; narrow surgical corridor, the optic chiasm is the close relationship between the cranial nerves and anterior cerebral and internal carotid arteries. Gamma knife radiosurgery (GKRS) may be a good option in these lesions with high mortality and morbidity., Aim: This study aimed to evaluate and compare the early effects at a mean of 6 months and 3 years and outcomes between surgery followed by gamma knife radiosurgery (GKRS) and GKRS alone for cavernous sinus meningiomas., Methods: We included 20 patients with cavernous sinus meningioma treated via single fraction Leksell Gamma Knife Perfexion (Elekta Instruments; Stockholm, Sweden) between 2015 and 2018. The mean age of the patients was 54.95 (range: 32-77) years. Nine patients underwent primary surgery (for the resection of extracavernous components of the tumor) followed by GKRS (for the resection of intracavernous components of the tumor) (group A). Meanwhile, 11 patients were managed with GKRS alone (group B). The tumor volume ranged from 2.8 to 32.8 (mean: 14.76) cm3 and the isodose to the tumor margin from 10 to 13.5 (mean: 11.65) Gy., Results: In total, 20 patients were followed up at a mean time of 18.95 (range: 6-36) months. The mean Karnofsky Performance Score of the patients was 95.2%. The mean follow up times of groups A and B were 23.6 and 15 months, respectively. Meanwhile, only patients with a follow up time of at least 6 months were included in the study. The mean follow up time after GKRS in group A was 17.6 months. There was no change in the tumor volume in 15% of patients. In the remaining cases, the tumor volume decreased. The mean tumor regression rates were 82.2% in Group A and 17.7% in Group B. The tumor volume did not decrease in three patients (n = 1, group A and n = 2, group B). Cranial nerve deficits improved, worsened, and remained stable in 46.6%, 26.6%, and 26.6% of cases, respectively. The temporary morbidity rate was 10%. In group A, transient postoperative diabetes insipidus was observed in one patient and atelectasis in another. None of these complications affected the final status of patients. The mortality rate after treatment was 0%., Conclusion: Volume staged GKRS is safe and effective for cavernous sinus meningioma. GKRS is effective for long term tumor growth control and has a low complication rate. Hence, it is the preferred management strategy for tumors with a suitable volume (average tumor diameter: 3 cm or volume: 10 cm3 ). In tumors with a volume of more than 10 mL and/or without a 3 mm safety margin with the optical system, it is recommended to prepare for radiosurgery by cytoreducing the tumor volume surgically. Based on our opinion, the best results were obtained by GKRS to the intracavernous., Competing Interests: None

Background: Secondary trigeminal neuralgia is a facial pain in trigeminal nerve dermatome caused by an underlying disease, such as cerebellopontine angle tumours. Treatment options to relieve the pains were surgical tumour resection and stereotactic radiosurgery of the tumour or trigeminal nerve. This study aims to review the efficacy of open surgery and stereotactic radiosurgery and recommend the treatment of choice for secondary trigeminal neuralgia due to cerebellopontine angle tumours., Method: The inclusion criteria were studies covering patients with trigeminal neuralgia associated with cerebellopontine angle tumours that were treated with either open surgery or stereotactic radiosurgery and reported pain outcomes after treatment. Non-English articles or studies with a population of less than five were excluded. We systematically searched studies from PubMed, Ebscohost, and Cochrane Library from inception until December 20, 2021. Several works of literature from manual search were also added. Selected articles were appraised using a critical appraisal tool for prognostic studies., Result: Included articles were 26 retrospective studies and one prospective study comprising 517 patients. Of 127 schwannomas, 226 epidermoids, 154 meningiomas, and ten other tumours, 320 cases received surgical tumour excision with or without MVD, 196 had tumour-targeted radiosurgery, and 22 underwent nerve-targeted radiosurgery. In surgical series, 92.2 % gained pain improvement, 2.8 % were unchanged, and 4.5 % had recurrence; none of the patients had worsened outcomes. In cases treated with tumour-targeted radiosurgery, the improvement rate was 79.1 %, unchanged at 14.3 %, recurrence at 26.5 %, and worse symptoms rate after the intervention was 6.6 %. Six patients with recurrent pain after tumour-targeted radiosurgery received secondary nerve-targeted radiosurgery with improved outcomes. Only one patient in our review underwent primary nerve-targeted radiosurgery, and the result was satisfactory. One study treated 15 patients with a single session of tumour-targeted and nerve-targeted radiosurgery, with an improvement rate of 93.3 % and a recurrence rate of 21.4 %., Conclusion: Open surgery releasing the nerve root from compressive lesions is advocated to be the first-line treatment to gain satisfactory outcomes. Total removal surgery is recommended if possible. Nerve-targeted radiosurgery should be reserved as a secondary treatment for recurrent cases., Competing Interests: Declaration of interest None., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: To (1) measure surgical outcomes associated with stereotactic radiosurgery treatment of cerebellopontine angle meningiomas, and (2) determine if differences in radiation dosages or preoperative tumor volumes affect surgical outcomes., Methods: A systematic search was performed on the PubMed, Medline, Embase and Cochrane Library databases searching for patients under stereotactic radiosurgery for meningiomas of the cerebellopontine angle. After data extraction and Newcastle-Ottawa scale quality assessment, meta-analysis of the data was performed with Review Manager 3.4.5., Results: In total, 6 studies including 406 patients were included. Postprocedure, patients had minimal cranial nerve complications while having an overall tumor control rate of 95.6%. Complications were minimal with facial nerve deficits occurring in 2.4%, sensation deficits of the trigeminal nerve in 4.0%, hearing loss in 5.9%, hydrocephalus in 2.0% and diplopia in 2.6% of all patients. Individuals with tumors extending into the internal auditory canal extension did not have significantly increases in hearing loss. There was a higher likelihood of tumor regression on postprocedure imaging in studies with a median prescription dose of >13 Gy (RR 1.27 [95% CI 1.04-1.56, p  = 0.0225). There was no evidence of publication bias detected., Conclusions: Radiosurgery is an effective modality for offering excellent tumor control of CPA meningiomas while allowing for only minimal complications postprocedure. A higher prescription dose may achieve higher tumor regression at follow up. Future studies should aim at establishing and optimizing accurate dosimetric guidelines for this patient population.

Background: A 70-year male had previous gamma knife (GK) for left cavernous sinus and Meckel's cave meningioma for facial numbness. He presented 11 years later with facial pain (both typical and atypical) and worsening numbness., Observations: MRI showed tumor growth and an infratentorial extension. FIESTA MRI showed left superior cerebellar artery (SCA) contact with the V nerve root entry zone (REZ) accounting for Type 1/ lancinating pain. After discussing available options, he opted for surgery. Lumbar drain, and a middle fossa anterior petrosectomy (Kawase) combined with posterior petrosectomy (retrolabyrinthine) approach was employed to perform tumor debulking along with microvascular decompression (mobilization of SCA). SSEP, BAERS, MEP, V nerve monitoring were performed. Fat graft was used for multilayered closure. He experienced resolution of both type 1 & type 2 facial pain, improvement in sensation in V3. Symptomatic improvement was recorded at 11 months follow up., Lessons: The combined skull base approach provided visualization of the entire length of V nerve (Cisternal, Meckel's cave, V2 and V3) allowing for decompression at various points to achieve relief of both types of facial pain. The patient provided consent for use of his images and operative video for publication., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

The role of radiotherapy (RT) and stereotactic radiosurgery (SRS) as adjuvant or salvage treatment in high-grade meningiomas (HGM) is still debated. Despite advances in modern neuro-oncology, HGM (WHO grade II and III) remains refractory to multimodal therapies. Published reports present aggregated data and are extremely varied in population size, exclusion criteria, selection bias, and inclusion of mixed histologic grades, making it extremely difficult to draw conclusions when taken individually. This current work aims to gather the existing evidence on RT and SRS as adjuvants following surgery or salvage treatment at recurrence after multimodality therapy failure and to conduct a systematic comparison between these two modalities. An extensive systematic literature review and meta-analysis were performed. A total of 42 papers were eligible for final analysis (RT n = 27; SRS n = 15) after searching MEDLINE via PubMed, Web-of-science, Cochrane Wiley, and Embase databases. Adjuvant regimens were addressed in 37 papers (RT n = 26; SRS n = 11); salvage regimens were described in 5 articles (RT n = 1; SRS n = 4). The primary outcomes of the study were the overall recurrence rate and mortality. Other actuarial rates (local and distant control, OS, PFS, and complications) were retrieved and analyzed as secondary outcomes. A total of 2853 patients harboring 3077 HGM were included. The majority were grade II (87%) with a mean pre-radiation volume of 8.7 cc. Adjuvant regimen: 2742 patients (76.4% RT; 23.6% SRS) with an overall grade II/III rate of 6.6/1. Lesions treated adjSRS were more frequently grade III (17 vs 12%, p < 0.001), and received subtotal resection (57 vs 27%, p = 0.001) compared to the RT cohort. AdjSRS cohort had a significantly shorter mean follow-up than adjRT (36.7 vs 50.3 months, p = 0.01). The overall recurrence rate was 38% in adjRT vs 25% in adjSRS (p = 0.01), while mortality did not differ between the groups (20% vs 23%, respectively; p = 0.80). The median time to recurrence was 1.5 times longer in the RT group (p = 0.30). Five-year local control was 55% in adjRT and 26% in adjSRS (p = 0.01), while 5-year OS was 73% and 78% (p = 0.62), and 5-year PFS was 62% and 40% in adjRT and adjSRS (p = 0.008). No difference in the incidence of complications (24% vs 14%, p = 0.53). Salvage regimen: 110 patients (37.3% RT; 62.7% SRS) with a grade II/III rate of 8.6/1. The recurrence rate was 46% in salRT vs 24% in salSRS (p = 0.39), time to recurrence was 1.8 times longer in the salRT group (35 vs 18.5 months, p = 0.74). Mortality was slightly yet not significantly higher in salRT (34% vs 12%, p = 0.54). Data on local and distant control were only available for salSRS. The 5-year OS was 49% and 83% (p = 0.90), and the 5-year PFS was 39% and 50% in salRT and salSRS (p = 0.66), respectively. High-grade meningiomas (WHO grade II and III) receiving adjuvant RT showed a higher overall recurrence rate than meningiomas receiving adjuvant SRS. The adjRT cohort, however, achieved higher 5-year LC and PFS rates, thus suggesting a potentially longer time to recurrence compared to adjSRS patients, who, meanwhile, experienced a significantly shorter follow-up. This result must also consider the higher number of grade III lesions and the smaller extent of resection achieved in the adjSRS group. Overall mortality did not differ between the two groups. No differences in outcome measures were observed in salvage regimens., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)