Comprehensive assessment of atypical and anaplastic pediatric meningiomas utilizing national cancer database: a retrospective cohort study.

PURPOSE: To examine demographic and clinical characteristics and their association with survival in grade 2 and 3 pediatric meningiomas in a large cohort using the National Cancer Database (NCDB). METHODS: We conducted a comprehensive analysis using data from NCDB between 2004 to 2018. Tumor-specific data included tumor grade and size. Treatment details, including surgical resection, extent of resection, and radiotherapy, were gathered. Our analytic approach incorporated logistic and Poisson regression, Kaplan-Meier survival estimates, and Cox proportional hazards models. RESULTS: Among the included 239 patients aged 0-21 years, age category distribution was significantly different between grade 2 and grade 3 tumors (p = 0.018). For grade 2 meningiomas, 51.5% of patients were female, and 76.7% were white. 85.3% of patients with grade 2 meningiomas underwent surgical resection, of which 67% underwent gross total resection. Overall survival (OS) was significantly different between resected and non-resected patients (p = 0.048). Uninsured patients were over seven times as likely to have prolonged length of stay (LOS) versus those with private insurance (OR = 7.663, p = 0.014). For grade 3 meningiomas, 51.4% of patients were male, and 82.9% were white. 91.4% of patients with grade 3 meningiomas underwent surgical resection, of which 53.3% underwent subtotal resection. OS was not significantly different between resected and non-resected patients (p = 0.659). CONCLUSION: In summary, there were significant differences in age, maximum tumor dimension, unplanned readmission, radiotherapy, and treatment combinations between grade 2 and 3 meningiomas. These findings highlight the intricacies of managing pediatric meningiomas and emphasize the necessity for tailored therapeutic approaches to enhance outcomes in the future.

[Ga68] DOTATATE PET/MRI-guided radiosurgical treatment planning and response assessment in meningiomas.

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.

Endonasal versus supraorbital approach for anterior skull base meningiomas: Results and quality of life assessment from a single-surgeon cohort.

OBJECTIVE: In this prospective non-randomized study we reported our experience related to planum sphenoidale (PS) and tuberculum sellae (TS) meningiomas in a similar cohort of patients operated via the endonasal or the supraorbital route. A comprehensive quality of life analysis has been performed. METHODS: Being comparable in general features, between November 2017 to January 2020, a total of 20 patients with anterior skull base meningioma were included. Hence, 10 patients were treated using the supraorbital keyhole procedure (SO) while 10 patients received an endoscopic endonasal approach (EEA). Both surgical techniques were analyzed and compared. Quality of life has been analyzed with the SF-36 questionnaire. RESULTS: Twenty patients were identified who underwent either EEA (n=10) or SO (n=10). The average extent of resection achieved was not significantly different between the 2 groups. Post-operatively, the EEA group demonstrated a longer hospital stay and bed days compared with SO patients as well as a longer surgical time. There was a significant rate of more CSF leakage after EEA then after SO (20% vs 0%, p=0,0491). The follow-up period resulted shorter in the SO group, with a slight increased recurrence rate. Overall, no differences in visual outcome were detected. There were no differences in terms of quality of life between the two groups in all the explored items. CONCLUSIONS: In this single-center single-surgeon study of similarly sized and located PS and TS meningiomas, EEA showed longer hospital stays with higher degree of CSF leak compared with the SO group. Supraorbital craniotomy via eyebrow incision reported a comparable quality of life results, even if with a slightly higher percentage of recurrence and less follow-up.

Quality of Life Assessment in Patients with Surgically Treated Parasagittal Meningiomas.

AIM: To assess quality of life (QoL) in patients with parasagittal meningiomas (PSM), and to identify the risk factors for different levels of QoL. MATERIAL AND METHODS: Patients were contacted and interviewed via telephone. A total of 136 patients with PSM underwent surgery at our institution between 1984 and 2020. Among them, 45 had agreed to participate in the research. The scales utilized included the Functional Assessment of Cancer Therapy General (FACT-G), Brain (FACT-Br), and Meningioma (FACT-MNG). Medical records were also reviewed. RESULTS: The mean KPS was 93.3 (70-100). Overall, the mean scores for the FACT-G, FACT-Br, and FACT-MNG scales were 98.4/108 (55-108; SD: 12.9), 179.3/200 (98-200; SD: 22.4), and 219.3 (119-248; SD: 29.7). Considerable variability in scales scores was observed among those with the same KPS score. Preoperative KPS score was significantly associated with both FACT-Br [-21.64; 95% CrI (-34.04, -9.59)] and FACT-MNG [-31.88; 95% CrI (-47.24, -15.25)]. Preoperative KPS was identified as a risk factor for QoL impairment. CONCLUSION: Variability in the scale scores among those with the same KPS score highlights the importance of structured assessment. Moreover, KPS may overlook impairments in QoL. To date, this has been the first study to assess QoL in PSM patients.

The influence of facility type on intracranial meningioma treatment and outcomes: predicting overall survival using the National Cancer Database.

OBJECTIVE: There is a growing body of evidence demonstrating improved outcomes for patients with CNS neoplasms treated at academic centers (ACs) versus nonacademic centers (non-ACs), which represents a potential healthcare disparity within neurosurgery. In this paper, the authors sought to investigate the relationship between facility type and surgical outcomes in meningioma patients. METHODS: The National Cancer Database was queried for adult patients diagnosed with intracranial meningioma between 2004 and 2019. Patients were stratified by facility type, and the Mann-Whitney U-test and Fisher exact test were used for bivariate comparisons of continuous and categorical variables, respectively. Multivariate logistic regression was used to assess whether demographic variables were associated with treatment at ACs. Furthermore, multivariate Cox proportional hazards models were used to determine whether facility type was associated with overall survival (OS) outcomes. RESULTS: Data on 139,304 patients (74% male, 84% White) were retrieved. Patients were stratified by facility type, with 50,349 patients (36%) treated at ACs and 88,955 patients (64%) treated at non-ACs. Patients treated at ACs were more likely to have private insurance (41% vs 34%, p < 0.001) and less likely to have Medicare (46% vs 57%, p < 0.001). Patients treated at ACs were more likely to have larger tumors (36.91 mm vs 33.57 mm, p < 0.001) and more likely to undergo surgery (47% vs 34%, p < 0.001). Interestingly, patients treated at ACs had decreased comorbidities (Charlson Comorbidity Index rating 0: 74% vs 69%) and similar income levels (income ≥ $46,000: 44% vs 43%). With respect to survival outcomes, patients treated at ACs demonstrated a higher median OS at 10 years than patients treated at non-ACs (65.2% vs 54.1%). The association of improved OS in patients treated at ACs continued to be true when adjusting for all other clinical and demographic variables (HR 0.900, 95% CI 0.882-0.918; p < 0.001). CONCLUSIONS: The results of this study indicate that facility type is associated with disparate survival outcomes in the treatment of intracranial meningiomas. Namely, patients treated at non-ACs appear to have a survival disadvantage even when controlling for additional comorbidities.

Meningioma consistency assessment based on the fusion of deep learning features and radiomics features.

PURPOSE: This study aims to combine deep learning features with radiomics features for the computer-assisted preoperative assessment of meningioma consistency. METHODS: 202 patients with surgery and pathological diagnosis of meningiomas at our institution between December 2016 and December 2018 were retrospectively included in the study. The T2-fluid attenuated inversion recovery (T2-Flair) images were evaluated to classify meningioma as soft or hard by professional neurosurgeons based on Zada's consistency grading system. All the patients were split randomly into a training cohort (n = 162) and a testing cohort (n = 40). A convolutional neural network (CNN) model was proposed to extract deep learning features. These deep learning features were combined with radiomics features. After multiple feature selections, selected features were used to construct classification models using four classifiers. AUC was used to evaluate the performance of each classifier. A signature was further constructed by using the least absolute shrinkage and selection operator (LASSO). A nomogram based on the signature was created for predicting meningioma consistency. RESULTS: The logistic regression classifier constructed using 17 radiomics features and 9 deep learning features provided the best performance with a precision of 0.855, a recall of 0.854, an F1-score of 0.852 and an AUC of 0.943 (95 % CI, 0.873-1.000) in the testing cohort. The C-index of the nomogram was 0.822 (95 % CI, 0.758-0.885) in the training cohort and 0.943 (95 % CI, 0.873-1.000) in the testing cohort with good calibration. Decision curve analysis further confirmed the clinical usefulness of the nomogram for predicting meningioma consistency. CONCLUSIONS: The proposed method for assessing meningioma consistency based on the fusion of deep learning features and radiomics features is potentially clinically valuable. It can be used to assist physicians in the preoperative determination of tumor consistency.

Utility of texture analysis for objective quantitative ex vivo assessment of meningioma consistency: method proposal and validation.

BACKGROUND: Tumor consistency is considered to be a critical factor for the surgical removal of meningiomas and its preoperative assessment is intensively studied. A significant drawback in the research of predictive methods is the lack of a clear shared definition of tumor consistency, with most authors resorting to subjective binary classification labeling the samples as "soft" and "hard." This classification is highly observer-dependent and its discrete nature fails to capture the fine nuances in tumor consistency. To compensate for these shortcomings, we examined the utility of texture analysis to provide an objective observer-independent continuous measure of meningioma consistency. METHODS: A total of 169 texturometric measurements were conducted using the Brookfield CT3 Texture Analyzer on meningioma samples from five patients immediately after the removal and on the first, second, and seventh postoperative day. The relationship between measured stiffness and time from sample extraction, subjectively assessed consistency grade and histopathological features (amount of collagen and reticulin fibers, presence of psammoma bodies, predominant microscopic morphology) was analyzed. RESULTS: The stiffness measurements exhibited significantly lower variance within a sample than among samples (p = 0.0225) and significant increase with a higher objectively assessed consistency grade (p = 0.0161, p = 0.0055). A significant negative correlation was found between the measured stiffness and the time from sample extraction (p < 0.01). A significant monotonic relationship was revealed between stiffness values and amount of collagen I and reticulin fibers; there were no statistically significant differences between histological phenotypes in regard to presence of psammoma bodies and predominant microscopic morphology. CONCLUSIONS: We conclude that the values yielded by texture analysis are highly representative of an intrinsic consistency-related quality of the sample despite the influence of intra-sample heterogeneity and that our proposed method can be used to conduct quantitative studies on the role of meningioma consistency.

Endoscopic Extended Transsphenoidal Surgery Aiming for Radical Resection of Skull Base Tumors Involving Cavernous Sinus: Assessment of Resectability and Risks of Complications.

BACKGROUND AND OBJECTIVES: Surgical resection of tumors invading the cavernous sinus (CS) still shows therapeutic challenges. For "nonadenomatous" skull base tumors invading in CS, there were only a few reports showing the outcomes of radical resection. Therefore, the outcomes of endoscopic transsphenoidal surgery (ETS) aiming for radical resection thus remain largely unknown regarding resectability and functional results of the cranial nerves. METHODS: We performed ETS aiming for radical resection in 35 skull base tumors involving CS (17 chondrosarcomas, 12 chordomas, 3 meningiomas, and 3 trigeminal schwannomas; median follow-up 36.5 months ranging from 12 to 91 months). Gross total resection (GTR) is attempted in all the cases for real-time findings from electrophysiological monitoring of the cranial nerves. When the tumor was strongly adherent to the cranial nerves or internal carotid artery, maximum volume reduction of the tumor was attempted. RESULTS: GTR was achieved in 28 patients (80.0%), subtotal resection in 3 (8.6%), and partial resection in 4 (11.4%). One patient experienced internal carotid artery injury during surgery. After ETS, 15 patients showed symptom improvement (51.7% in all 29 patients with preoperative cranial nerve symptoms, CNS). Four (11.4%) transiently developed abducens nerve palsy, and one required repair surgery for cerebrospinal leakage. In univariate analyses, extension to the lateral compartment of CS ( P = .04) was significantly associated with reduced achievement of GTR. Previous transcranial surgery was associated with reduced possibility of improvement and worsening in CNS. Eleven patients underwent stereotactic radiosurgery, at a median of 12 months after ETS. 32 patients (91.4%) did not show recurrence at the final follow-up. CONCLUSION: ETS can achieve sufficient surgical resection in most of the patients, with acceptable neurological complications. For patients with CNS, ETS may offer the opportunity for improving CNS. We should also always prioritize avoidance of critical situations by preventing internal carotid artery injury.

In-Hospital Cost Comparison for Open Versus Endoscopic Endonasal Approach for Meningioma Resection.

OBJECTIVE: To determine the in-hospital cost implications of an endoscopic expanded endonasal approach (EEEA) for meningioma resection relative to the open transcranial approach. METHODS: All anterior skull base meningioma surgeries performed over a period from January 1st, 2015 to October 31th, 2017 were evaluated. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables associated with each hospital stay and univariate analysis was performed using R software. All cost data were converted into August 2021-equivalent dollar amounts using the United States Bureau of Labor Statistics consumer price index. RESULTS: Thirty-five patients met study criteria, including 27 patients undergoing an open transcranial approach and 8 undergoing an EEEA. Average length of stay for patients undergoing an open approach was 9.3 days compared to 5.6 within the EEEA group (P = .126). The average total in-hospital cost of patient undergoing an EEEA was $35417.1 compared to $46406.9 among patients undergoing an open transcranial approach (P = .168). On univariate analysis, the cost of an open transcranial approach relative to the EEEA was $10989.8 (P = .411). CONCLUSIONS: The open transcranial approach remained the dominant surgical approach to anterior skull base meningiomas over our study time period. However, despite limited patient numbers the EEEA was associated with decreased total in-hospital costs.

Preoperative surgical risk assessment of meningiomas: a narrative review based on MRI radiomics.

Meningiomas are one of the most common intracranial primary central nervous system tumors. Regardless of the pathological grading and histological subtypes, maximum safe resection is the recommended treatment option for meningiomas. However, considering tumor heterogeneity, surgical treatment options and prognosis often vary greatly among meningiomas. Therefore, an accurate preoperative surgical risk assessment of meningiomas is of great clinical importance as it helps develop surgical treatment strategies and improve patient prognosis. In recent years, an increasing number of studies have proved that magnetic resonance imaging (MRI) radiomics has wide application values in the diagnostic, identification, and prognostic evaluations of brain tumors. The vital importance of MRI radiomics in the surgical risk assessment of meningiomas must be apprehended and emphasized in clinical practice. This narrative review summarizes the current research status of MRI radiomics in the preoperative surgical risk assessment of meningiomas, focusing on the applications of MRI radiomics in preoperative pathological grading, assessment of surrounding tissue invasion, and evaluation of tumor consistency. We further analyze the prospects of MRI radiomics in the preoperative assessment of meningiomas angiogenesis and adhesion with surrounding tissues, while pointing out the current challenges of MRI radiomics research.

Meningioma systematic reviews and meta-analyses: an assessment of reporting and methodological quality.

INTRODUCTION: Systematic reviews (SR) and systematic reviews with meta-analysis (SRMA) can constitute the highest level of research evidence. Such evidence syntheses are relied upon heavily to inform the clinical knowledge base and to guide clinical practice for meningioma. This review evaluates the reporting and methodological quality of published meningioma evidence syntheses to date. METHODS: Eight electronic databases/registries were searched to identify eligible meningioma SRs with and without meta-analysis published between January 1990 and December 2020. Articles concerning spinal meningioma were excluded. Reporting and methodological quality were assessed against the following tools: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), A MeaSurement Tool to Assess systematic Reviews (AMSTAR 2), and Risk Of Bias in Systematic reviews (ROBIS). RESULTS: 116 SRs were identified, of which 57 were SRMAs (49.1%). The mean PRISMA score for SRMA was 20.9 out of 27 (SD 3.9, 77.0% PRISMA adherence) and for SR without meta-analysis was 13.8 out of 22 (SD 3.4, 63% PRISMA adherence). Thirty-eight studies (32.8%) achieved greater than 80% adherence to PRISMA. Methodological quality assessment against AMSTAR 2 revealed that 110 (94.8%) studies were of critically low quality. Only 21 studies (18.1%) were judged to have a low risk of bias against ROBIS. CONCLUSION: The reporting and methodological quality of meningioma evidence syntheses was poor. Established guidelines and critical appraisal tools may be used as an adjunct to aid methodological conduct and reporting of such reviews, in order to improve the validity and transparency of research which may influence clinical practice.

Clinical and pathological impact of an optimal assessment of brain invasion for grade 2 meningioma diagnosis: lessons from a series of 291 cases.

Brain invasion has not been recognized as a standalone criterion for atypical meningioma by the WHO classification until 2016. Since the 2007 edition suggested that meningiomas harboring brain invasion could be classified as grade 2, brain invasion study was progressively strengthened in our center, based on a strong collaboration between neurosurgeons and neuropathologists regarding sample orientation and examination. Practice changes were considered homogeneous enough in 2011. The aim of the present study was to evaluate the impact of gross practice change on the clinical and pathological characteristics of intracranial meningiomas classified as grade 2.The characteristics of consecutive patients with a grade 2 meningioma surgically managed before (1998-2005, n = 125, group A) and after (2011-2014, n = 166, group B) practices changed were retrospectively reviewed.Sociodemographical and clinical parameters were comparable in groups A and B, and the median age was 62 years in both groups (p = 0.18). The 5-year recurrence rates (23.2% vs 29.5%, p = 0.23) were similar. In group A, brain invasion was present in 48/125 (38.4%) cases and was more frequent than in group B (14/166, 8.4%, p < 0.001). In group A, 33 (26.4%) meningiomas were classified as grade 2 solely based on brain invasion (group ASBI), and 92 harbored other grade 2 criteria (group AOCA). Group ASBI meningiomas had a similar median progression-free survival compared to groups AOCA (68 vs 80 months, p = 0.24) and to AOCA and B pooled together (n = 258, 68 vs 90 months, p = 0.42).An accurate assessment of brain invasion is mandatory as brain invasion is a strong predictor of meningioma progression.

Cone-Beam Computed Tomography Fusion Technique for Vascular Assessment of Skull Base Meningiomas.

OBJECTIVE: Cone-beam computed tomography (CBCT) images for skull base tumors provide detailed vascular information and localization in regard to surrounding bony structures. We report use of the CBCT fusion technique for skull base meningiomas. METHODS: Six patients with petroclival or petrotentorial meningiomas supplied by multiple arterial systems were preoperatively evaluated using CBCT fusion imaging. Fusion images were reconstructed from three-dimensional rotational angiography with contrast agent injections from the internal carotid artery (ICA) and external carotid artery in 4 cases, vertebral artery and external carotid artery in 1 case, and ICA and vertebral artery in 1 case. RESULTS: The feeding pedicles and tumor stains from 2 arterial systems were differentiated by separate colors. The courses and territories of the ICA dural feeders or ICA/vertebral artery pial feeders were easily distinguished from the external carotid artery dural feeders. Anastomoses between thin feeders from different arterial systems could be detected. Mixed stain (stain with both colors) was observed in some tumor compartments, suggesting dual supply from 2 arterial systems and the presence of peritumoral anastomoses. All patients underwent preoperative embolization without complications. CONCLUSIONS: CBCT fusion images clearly visualized the feeders from each arterial system, the vascular compartments within the tumor, and possible peritumoral anastomoses. This technique provides a substantial contribution to both preoperative embolization and surgical resection of skull base meningiomas.

Cost-effectiveness of endoscopic endonasal vs transcranial approaches for olfactory groove meningioma.

BACKGROUND: Endoscopic endonasal approaches (EEAs) have been adopted as an alternative to standard transcranial approaches for olfactory groove meningiomas (OGMs). However, the relative cost-effectiveness remains controversial. METHODS: Cost-utility analysis from a societal perspective comparing EEA vs transcranial approaches for OGM was used in this study. Surgical treatment was modeled using decision analysis, and a Markov model was adopted over a 20-year horizon. Parameters were obtained from literature review. Costs were expressed in 2017 Canadian dollars. RESULTS: In the base case, EEA was cost-effective compared with transcranial surgery with an incremental cost-effectiveness ratio of $33 523 ($30 475 USD)/QALY. There was a 55% likelihood that EEA was cost-effective at a willingness-to-pay of $50 000/QALY. EEA remained cost-effective at a cerebrospinal fluid leak rate below 60%, gross total resection rate above 25%, and base cost less than $66 174 ($60 158 USD). CONCLUSION: EEA may be a cost-effective alternative to transcranial approaches for selected OGM.

Predictive Model and Online Calculator for Discharge Disposition in Brain Tumor Patients.

BACKGROUND: In the era of value-based payment models, it is imperative for neurosurgeons to eliminate inefficiencies and provide high-quality care. Discharge disposition is a relevant consideration with clinical and economic ramifications in brain tumor patients. We developed a predictive model and online calculator for postoperative non-home discharge disposition in brain tumor patients that can be incorporated into preoperative workflows. METHODS: We reviewed all brain tumor patients at our institution from 2017 to 2019. A predictive model of discharge disposition containing preoperatively available variables was developed using stepwise multivariable logistic regression. Model performance was assessed using receiver operating characteristic curves and calibration curves. Internal validation was performed using bootstrapping with 2000 samples. RESULTS: Our cohort included 2335 patients who underwent 2586 surgeries with a 16% non-home discharge rate. Significant predictors of non-home discharge were age >60 years (odds ratio [OR], 2.02), African American (OR, 1.73) or Asian (OR, 2.05) race, unmarried status (OR, 1.48), Medicaid insurance (OR, 1.90), admission from another health care facility (OR, 2.30), higher 5-factor modified frailty index (OR, 1.61 for 5-factor modified frailty index ≥2), and lower Karnofsky Performance Status (increasing OR with each 10-point decrease in Karnofsky Performance Status). The model was well calibrated and had excellent discrimination (optimism-corrected C-statistic, 0.82). An open-access calculator was deployed (https://neurooncsurgery.shinyapps.io/discharge_calc/). CONCLUSIONS: A strongly performing predictive model and online calculator for non-home discharge disposition in brain tumor patients was developed. With further validation, this tool may facilitate more efficient discharge planning, with consequent improvements in quality and value of care for brain tumor patients.

Predictors of readmission after craniotomy for meningioma resection: a nationwide readmission database analysis.

BACKGROUND: Meningiomas are the most common benign primary brain tumors. The mainstay of treatment, surgical resection, is often curative. Given the excellent prognosis of these lesions, minimizing perioperative complications is of the utmost importance. With the establishment of the National Readmissions Database (NRD), researchers are now able to identify variables associated with postoperative complications beyond the index admission. OBJECTIVE: In this study, we sought to identify the leading causes for non-elective readmission and variables associated with increased likelihood of readmission at 30 and 90 days after discharge following a craniotomy for meningioma resection. METHODS: Adult inpatients who underwent craniotomy for meningioma resection between 2010 and 2014 were queried from the NRD. All-cause readmissions following craniotomy at 30 and 90 days were identified, and a multivariable logistic regression model was used to characterize independent risk factors. RESULTS: Among 26,034 patients who received craniotomy for meningioma resection, 2825 (10.9%) were readmitted at 30 days and 3436 (16.1%) were readmitted at 90 days. Postoperative wound infection was the most common readmission diagnosis, occurring in 9.32% and 10.2% of 30- and 90-day readmissions respectively. Patient factors associated with increased likelihood of readmission included male gender, greater illness severity, non-routine discharge, index length of hospitalization, and having Medicare or Medicaid insurance. CONCLUSIONS: Readmission following craniotomy for meningioma resection occurs at a clinically significant rate. Several patient factors were identified in association with all-cause 30- and 90-day readmissions. Further studies are required to identify means for preventing complications following discharge in these vulnerable patient populations.

Impact of insurance on hospital course and readmission after resection of benign meningioma.

INTRODUCTION: Surgical outcomes and healthcare utilization have been shown to vary based on patient insurance status. We analyzed whether patients' insurance affects case urgency for and readmission after craniotomy for meningioma resection, using benign meningioma as a model system to minimize confounding from the disease-related characteristics of other neurosurgical pathologies. METHODS: We analyzed 90-day readmission for patients who underwent resection of a benign meningioma in the Nationwide Readmission Database from 2014-2015. RESULTS: A total of 9783 meningioma patients with private insurance (46%), Medicare (39%), Medicaid (10%), self-pay (2%), or another scheme (3%) were analyzed. 72% of all cases were elective; with 78% of cases in privately insured patients being elective compared to 71% of Medicare (p > 0.05), 59% of Medicaid patients (OR 2.3, p < 0.001), and 49% of self-pay patients (OR 3.4, p < 0.001). Medicare (OR 1.5, p = 0.002) and Medicaid (OR 1.4, p = 0.035) were both associated with higher likelihood of 90-day readmission compared to private insurance. In comparison, 30-day analyses did not unveil this discrepancy between Medicaid and privately insured, highlighting the merit for longer-term outcomes analyses in value-based care. Patients readmitted within 30 days versus those with later readmissions possessed different characteristics. CONCLUSIONS: Compared to patients with private insurance coverage, Medicaid and self-pay patients were significantly more likely to undergo non-elective resection of benign meningioma. Medicaid and Medicare insurance were associated with a higher likelihood of 90-day readmission; only Medicare was significant at 30 days. Both 30 and 90-day outcomes merit consideration given differences in readmitted populations.

Multi-parametric qualitative and quantitative MRI assessment as predictor of histological grading in previously treated meningiomas.

PURPOSE: Meningiomas are mainly benign tumors, though a considerable proportion shows aggressive behaviors histologically consistent with atypia/anaplasia. Histopathological grading is usually assessed through invasive procedures, which is not always feasible due to the inaccessibility of the lesion or to treatment contraindications. Therefore, we propose a multi-parametric MRI assessment as a predictor of meningioma histopathological grading. METHODS: Seventy-three patients with 74 histologically proven and previously treated meningiomas were retrospectively enrolled (42 WHO I, 24 WHO II, 8 WHO III) and studied with MRI including T2 TSE, FLAIR, Gradient Echo, DWI, and pre- and post-contrast T1 sequences. Lesion masks were segmented on post-contrast T1 sequences and rigidly registered to ADC maps to extract quantitative parameters from conventional DWI and intravoxel incoherent motion model assessing tumor perfusion. Two expert neuroradiologists assessed morphological features of meningiomas with semi-quantitative scores. RESULTS: Univariate analysis showed different distributions (p < 0.05) of quantitative diffusion parameters (Wilcoxon rank-sum test) and morphological features (Pearson's chi-square; Fisher's exact test) among meningiomas grouped in low-grade (WHO I) and higher grade forms (WHO II/III); the only exception consisted of the tumor-brain interface. A multivariate logistic regression, combining all parameters showing statistical significance in the univariate analysis, allowed discrimination between the groups of meningiomas with high sensitivity (0.968) and specificity (0.925). Heterogeneous contrast enhancement and low ADC were the best independent predictors of atypia and anaplasia. CONCLUSION: Our multi-parametric MRI assessment showed high sensitivity and specificity in predicting histological grading of meningiomas. Such an assessment may be clinically useful in characterizing lesions without histological diagnosis. Key points • When surgery and biopsy are not feasible, parameters obtained from both conventional and diffusion-weighted MRI can predict atypia and anaplasia in meningiomas with high sensitivity and specificity. • Low ADC values and heterogeneous contrast enhancement are the best predictors of higher grade meningioma.

Feasibility of Bundled Payments in Anterior, Middle, and Posterior Cranial Fossa Skull Base Meningioma Surgery: MarketScan Analysis of Health Care Utilization and Outcomes.

BACKGROUND: The aim of our study was to compare the health care utilization and outcomes after surgery for anterior cranial fossa skull base meningioma (AFM), middle cranial fossa skull base meningioma (MFM), and posterior cranial fossa skull base meningioma (PFM) across the United States. METHODS: We queried the MarketScan database using International Classification of Diseases, Ninth Revision and Current Procedural Terminology 4, from 2000 to 2016. We included adult patients who had at least 24 months of enrollment after the surgical procedure. The outcome of interest was length of hospital stay, disposition, complications, and reoperation after the procedure. RESULTS: A cohort of 1191 patients was identified from the database. Less than half of patients (43.66%) were in the AFM cohort, 32.24% were in the MFM cohort, and only 24.1% were in the PFM cohort. Patients who underwent surgery for PFM had longer hospital stay (P = 0.0009), high complication rate (P = 0.0011), and less likely to be discharged home (P = 0.0013) during index hospitalization. There were no differences in overall payments at 12 months and 24 months among the cohorts. There was no significant difference in 90-day median payments among the groups ($66,212 [AFM] vs. $65,602 [MFM] and $71,837 [PFM]; P = 0.198). Male gender, commercial insurance (compared with Medicare), and higher comorbidity scores (score 3 compared with score 0) were associated with higher 90-day payments in the PFM cohort. CONCLUSIONS: Overall payments (at 12 months and 24 months) and 90-day payments were not different among the cohorts. Patients with PFM had longer hospital stay and higher complication rate and were less likely to be discharged home with higher utilization of outpatient services at 12 months and 24 months.

Efficacy and toxicity of particle radiotherapy in WHO grade II and grade III meningiomas: a systematic review.

OBJECTIVEAdjuvant radiotherapy has become a common addition to the management of high-grade meningiomas, as immediate treatment with radiation following resection has been associated with significantly improved outcomes. Recent investigations into particle therapy have expanded into the management of high-risk meningiomas. Here, the authors systematically review studies on the efficacy and utility of particle-based radiotherapy in the management of high-grade meningioma.METHODSA literature search was developed by first defining the population, intervention, comparison, outcomes, and study design (PICOS). A search strategy was designed for each of three electronic databases: PubMed, Embase, and Scopus. Data extraction was conducted in accordance with the PRISMA guidelines. Outcomes of interest included local disease control, overall survival, and toxicity, which were compared with historical data on photon-based therapies.RESULTSEleven retrospective studies including 240 patients with atypical (WHO grade II) and anaplastic (WHO grade III) meningioma undergoing particle radiation therapy were identified. Five of the 11 studies included in this systematic review focused specifically on WHO grade II and III meningiomas; the others also included WHO grade I meningioma. Across all of the studies, the median follow-up ranged from 6 to 145 months. Local control rates for high-grade meningiomas ranged from 46.7% to 86% by the last follow-up or at 5 years. Overall survival rates ranged from 0% to 100% with better prognoses for atypical than for malignant meningiomas. Radiation necrosis was the most common adverse effect of treatment, occurring in 3.9% of specified cases.CONCLUSIONSDespite the lack of randomized prospective trials, this review of existing retrospective studies suggests that particle therapy, whether an adjuvant or a stand-alone treatment, confers survival benefit with a relatively low risk for severe treatment-derived toxicity compared to standard photon-based therapy. However, additional controlled studies are needed.