Occipital nerve stimulation in pediatric patients with refractory occipital neuralgia.

PURPOSE: Occipital neuralgia (ON) is a disabling problem within the pediatric population. Many of these patients fail medical therapies and continue to suffer without further surgical management. Occipital nerve stimulation (ONS) is used to treat ON in the adult population leading to a 72-89% reduction in pain; however, there are limited studies regarding its use in the pediatric population. In this study, we examined the outcomes of ONS in pediatric patients with medically refractory ON. METHODS: We performed a chart review of pediatric patients at our institution who have undergone ONS for the same indications. RESULTS: We identified 3 patients at our institution who underwent ONS trial and/or permanent implantation for ON. One patient had complete pain relief after the trial and declined permanent implantation. The other patient had fewer attacks compared to his pre-trial baseline and controlled them by adjusting his permanent implant stimulation settings. The last patient had near complete relief of her symptoms and no longer required any pain medication. CONCLUSION: Our study highlights the paucity of studies evaluating the utility of ONS in the pediatric ON population. Limited data from both the literature and our institution's experience reveal that pediatric patients may benefit from trial and/or permanent implantation of ONS for medically refractory ON pain.

Obesity and meningioma: a US population-based study paired with analysis of a multi-institutional cohort.

OBJECTIVE: Whether obesity is associated with meningioma and the impact of obesity by gender has been debated. The primary objective of this study was to investigate differences in BMI between male and female patients undergoing craniotomy for meningioma and compare those with patients undergoing craniotomy for other intracranial tumors. The secondary objective was to compare meningioma location and progression-free survival (PFS) between obese and nonobese patients in a multi-institutional cohort. METHODS: National data were obtained from the National Surgical Quality Improvement Program (NSQIP) database. Male and female patients were analyzed separately. Patients undergoing craniotomies for meningioma were compared with patients of the same sex undergoing craniotomies for other intracranial tumors. Institutional data from two academic centers were collected for all male and an equivalent number of female meningioma patients undergoing meningioma resection. Multivariate regression controlling for age was used to determine differences in meningioma location. Kaplan-Meier curves and log-rank tests were computed to investigate differences in PFS. RESULTS: From NSQIP, 4163 male meningioma patients were compared with 24,266 controls, and 9372 female meningioma patients were compared with 21,538 controls. Male and female patients undergoing meningioma resection were more likely to be overweight or obese compared with patients undergoing craniotomy for other tumors, with the odds ratio increasing with increasing weight class (all p < 0.0001). In the multi-institutional cohort, meningiomas were more common along the skull base in male patients (p = 0.0123), but not in female patients (p = 0.1246). There was no difference in PFS between obese and nonobese male (p = 0.4104) or female (p = 0.5504) patients. Obesity was associated with increased risk of pulmonary embolism in both male and female patients undergoing meningioma resection (p = 0.0043). CONCLUSIONS: Male and female patients undergoing meningioma resection are more likely to be obese than patients undergoing craniotomy for other intracranial tumors. Obese males are more likely to have meningiomas in the skull base compared with other locations, but this association was not found in females. There was no significant difference in PFS among obese patients. The mechanism by which obesity increases meningioma incidence remains to be determined.

Neurosurgery trainee well-being in a pediatric neurosurgery hospital: baseline data to motivate toward implementing change.

OBJECTIVE: The aim of this study was to obtain aggregated baseline pediatric neurosurgery well-being data at a tertiary care institution. METHODS: An institutional grant funded the completion of the Maslach Burnout Inventory (MBI) by 100% (n = 13) of the trainees during a 1-year period, including 1 pediatric neurosurgery fellow and 12 residents from 4 regional neurosurgery training programs. Aggregated and anonymized group results included frequency scores ranging from 0 (never) to 6 (every day). The mean ± SD group scores were compared to the general population of > 11,000 people in the human services professions. Burnout profiles were calculated on the basis of MBI scale scores by using established comparisons to standardized normal values. Burnout profile types include engaged, ineffective, overextended, disengaged, and burnout. RESULTS: The mean ± SD score for emotional exhaustion was 2.6 ± 1.1 for trainees compared with 2.3 ± 1.2 in the comparison population. The mean ± SD score for depersonalization was 1.6 ± 1 compared with 1.7 ± 1.2 in the comparison population. The mean ± SD score for personal accomplishment was 4.9 ± 0.7 compared with 4.3 ± 0.9 in the comparison population. Profiles were classified as engaged (n = 6), ineffective (n = 3), overextended (n = 3), and burnout (n = 1). CONCLUSIONS: Problematic profiles were present for more than half (7 [53.8%]) of pediatric neurosurgery trainees who cited higher emotional exhaustion than the general population of healthcare providers. Trainees scored lower in depersonalization and higher in personal accomplishment compared with the general population, which are both protective against burnout. Targeting factors that contribute to emotional exhaustion may have an impact on improving the overall well-being of pediatric neurosurgery trainees.

On-Call Workload Differences in Neurosurgery: Resident Call "Weather" and a Departure from Colored Cloud Labels.

BACKGROUND AND OBJECTIVES: Labeling residents as "black" or "white" clouds based on perceived or presumed workloads is a timeworn custom across medical training and practice. Previous studies examining whether such perceptions align with objective workload patterns have offered conflicting results. We assessed whether such peer-assigned labels were associated with between-resident differences in objective, on-call workload metrics in three classes of neurosurgery junior residents. In doing so, we introduce more inclusive terminology for perceived differences in workload metrics. METHODS: Residents were instructed to complete surveys to identify "sunny", "neutral", and "stormy" residents, reflecting least to greatest perceived workloads, of their respective classes. We retrospectively reviewed department and electronic medical records to record volume of on-call work over the first 4 months of each resident's 2nd postgraduate academic year. Inter-rater agreement of survey responses was measured using Fleiss' kappa. All statistical analyses were performed with a significance threshold of P < .05. RESULTS: Across all classes, there was strong inter-rater agreement in the identification of stormy and sunny residents (Kappa = 1.000, P = .003). While differences in on-call workload measures existed within each class, "weather" designations did not consistently reflect these differences. There were significant intraclass differences in per shift consult volume in two classes ( P = .035 and P = .009); however, consult volume corresponded to a resident's weather designations in only one class. Stormy residents generally saw more emergencies and, in 2 classes, performed more bedside procedures than their peers. CONCLUSION: Significant differences in objective on-call experience exist between junior neurosurgery residents. Self- and peer-assigned weather labels did not consistently align with a pattern of these differences, suggesting that other factors contribute to such labels.

Low body mass index patients have worse outcomes after mechanical thrombectomy.

BACKGROUND: There is evidence that frailty is an independent predictor of worse outcomes after stroke. Similarly, although obesity is associated with a higher risk for stroke, there are multiple reports describing improved mortality and functional outcomes in higher body mass index (BMI) patients in a phenomenon known as the obesity paradox. We investigated the effect of low BMI on outcomes after mechanical thrombectomy (MT). METHODS: We conducted a retrospective analysis of 231 stroke patients who underwent MT at an academic medical center between 2020-2022. The patients' BMI data were collected from admission records and coded based on the Centers for Disease Control and Prevention (CDC) obesity guidelines. Recursive partitioning analysis (RPA) in R software was employed to automatically detect a BMI threshold associated with a significant survival benefit. Frailty was quantified using the Modified Frailty Index 5 and 11. RESULTS: In our dataset, by CDC classification, 2.6% of patients were underweight, 27.3% were normal BMI, 30.7% were overweight, 19.9% were class I obese, 9.5% were class II obese, and 10% were class III obese. There were no significant differences between these groups. RPA identified a clinically significant BMI threshold of 23.62 kg/m2. Independent of frailty, patients with a BMI ≤23.62 kg/m2 had significantly worse overall survival (P<0.001) and 90-day modified Rankin Scale (P=0.027) than patients above the threshold. CONCLUSIONS: Underweight patients had worse survival and functional outcomes after MT. Further research should focus on the pathophysiology underlying poor prognosis in underweight MT patients, and whether optimizing nutritional status confers any neuroprotective benefit.

Stereotactic electroencephalography in epilepsy patients for mapping of neural circuits related to emotional and psychiatric behaviors: a systematic review.

OBJECTIVE: Stereotactic electroencephalography (sEEG) is an increasingly utilized method for identifying electrophysiological processes underlying sensorimotor, cognitive, and emotional behaviors. In this review, the authors outline current research using sEEG to investigate the neural activity underlying emotional and psychiatric behaviors. Understanding the current structure of intracranial research using sEEG will inform future studies of psychiatric disease and therapeutics for effective neuromodulation. METHODS: The authors conducted a comprehensive systematic review of studies according to PRISMA guidelines to investigate behaviors related to psychiatric conditions in patients with epilepsy undergoing monitoring with sEEG. Articles indexed on PubMed between 2010 and 2022 were included if they studied emotions or affective behaviors or met the National Institute of Mental Health Research Domain Criteria positive and negative valence domains. Data extracted from articles included study sample size, paradigms and behavioral tasks employed, cortical and subcortical targets, EEG analysis methods, and identified electrophysiological activity underlying the studied behavior. The Newcastle-Ottawa Scale was used to assess bias risk. RESULTS: Thirty-two primary articles met inclusion criteria. Study populations ranged from 3 to 39 patients. The most common structures investigated were the amygdala, insula, orbitofrontal cortex (OFC), hippocampus, and anterior cingulate cortex (ACC). Paradigms, stimuli, and behavioral tasks widely varied. Time-frequency analyses were the most common, followed by connectivity analyses. Multiple oscillations encoded a variety of behaviors related to emotional and psychiatric conditions. High gamma activity was observed in the amygdala and anterior insula in response to aversive audiovisual stimuli and in the OFC in response to reward processing. ACC beta band power increases and hippocampal-amygdala beta coherence variations were predictive of worsening mood states. Insular and amygdalar theta oscillations encoded social pain and fear learning, respectively. Most studies performed passing recordings, allowing for the decoding of affective states and depression symptoms, while other studies utilized direct stimulation, such as in the OFC to improve mood symptoms. CONCLUSIONS: Stereotactic EEG in epilepsy has identified multiple corticolimbic structures with specific oscillatory and synchronization activity underlying a diverse range of behaviors related to emotions and affective conditions. Given the heterogeneity of psychiatric conditions, sEEG provides an opportunity to study these neural correlates to develop personalized effective neuromodulatory treatments. Future studies should focus on optimizing paradigms and tasks to investigate a broad range of behavioral phenotypes that overlap across psychiatric conditions.

Minimally Invasive Preganglionic C2 Root Section for Occipital Neuralgia: 2 Case Reports and Operative Video.

BACKGROUND: Occipital neuralgia is a painful condition that is believed to occur from processes that affect the greater, lesser, or third occipital nerves. Diagnosis is often made with a combination of classical symptoms, tenderness over the occipital region, and response to occipital nerve blocks. Cervical computed tomography or MRI may be obtained in multiple positions to detect any impingement. Diagnosis can be made with MRI tractography. Nonsurgical treatments include local anesthetic and steroid injections, anticonvulsant medications, botulinum toxin injections, physical therapy, acupuncture, transcutaneous electrical stimulation, cryoneurolysis, and radiofrequency ablation. Surgical treatments include greater occipital nerve decompression, C2 root section, intradural dorsal root rhizotomy, C1-2 fusion, and occipital nerve stimulation. Although stimulation has been favored in the past decade, complications and maintenance of the devices have led us to return to C2 ganglionectomy. OBJECTIVE: To report on the use of a minimally invasive technique for C2 ganglionectomy to treat occipital neuralgia. METHODS: Review demographic, surgery, and outcome data of a minimally invasive C2 root ganglionectomy used to treat to 2 patients with occipital neuralgia. RESULTS: We report on 2 patients with clinically stereotypical unilateral occipital neuralgia confirmed by greater occipital nerve block, but with no imaging correlate. Both were successfully managed by C2 ganglionectomy through an 18-mm tubular retractor and outpatient surgery. Accompanying text, still photographs, and video describe the technique in detail. CONCLUSION: Minimally invasive C2 ganglionectomy can be used to successfully treat occipital neuralgia.

A Method of Intraoperative Registration Verification to Prevent Accuracy Errors in Robot-Assisted Stereotactic Electroencephalography Electrode Placement.

BACKGROUND: Robotic-assisted stereotactic electroencephalography (sEEG) electrode placement is increasingly common at specialized epilepsy centers. High accuracy and low complication rates are essential to realizing the benefits of sEEG surgery. The aim of this study was to describe for the first time in the literature a method for a stereotactic registration checkpoint to verify intraoperative accuracy during robotic-assisted sEEG and to report our institutional experience with this technique. METHODS: All cases performed with this technique since the adoption of robotic-assisted sEEG at our institution were retrospectively reviewed. RESULTS: In 4 of 111 consecutive sEEG operations, use of the checkpoint detected an intraoperative registration error, which was addressed before completion of sEEG electrode placement. CONCLUSIONS: The use of a registration checkpoint in robotic-assisted sEEG surgery is a simple technique that can prevent electrode misplacement and improve the safety profile of this procedure.

Stealth Autoguide for robotic-assisted laser ablation for lesional epilepsy: illustrative case.

BACKGROUND: Laser interstitial thermal therapy has been used in tumor and epilepsy surgery to maximize clinical treatment impact while minimizing morbidity. This intervention places a premium on accuracy. With the advent of robotics, neurosurgery is entering a new age of improved accuracy. Here, the authors described the use of robotic-assisted laser placement for the treatment of epileptiform lesions. OBSERVATIONS: The authors presented a case of a 21-year-old woman with medically intractable epilepsy, localized to left mesial temporal sclerosis and left temporal encephalocele by way of stereotactic electroencephalography, who presented for consideration of surgical intervention. When presented with resection versus laser ablation, the patient opted for laser ablation. The patient received robotic-assisted stereotactic laser ablation (RASLA) using a Stealth Autoguide. The patient was seizure free (10 weeks) after surgical ablation. LESSONS: RASLA is an effective way to treat epilepsy. Here, the authors reported the first RASLA procedure with a Stealth Autoguide to treat epilepsy. The procedure can be performed effectively and efficiently for multiple epileptic foci without the need for bulkier robotic options or head frames that may interfere with the use of magnetic resonance imaging for heat mapping.

Effects of 24-hour versus night-float call schedules on the clinical and operative experiences of postgraduate year 2 and 3 neurosurgical residents.

OBJECTIVE: To comply with the removal of the 88-hour week exemption and to support additional operative experience during junior residency, Oregon Health & Science University (OHSU) switched from a night-float call schedule to a modified 24-hour call schedule on July 1, 2019. This study compared the volumes of clinical, procedural, and operative cases experienced by postgraduate year 2 (PGY-2) and PGY-3 residents under these systems. METHODS: The authors retrospectively studied billing and related clinical records, call schedules, and Accreditation Council for Graduate Medical Education case logs for PGY-2 and PGY-3 residents at OHSU, a tertiary academic health center, for the first 4 months of the academic years from 2017 to 2020. The authors analyzed the volumes of new patient consultations, bedside procedures, and operative procedures performed by each PGY-2 and PGY-3 resident during these years, comparing the volumes experienced under each call system. RESULTS: Changing from a PGY-2 resident-focused night-float call system to a 24-hour call system that was more evenly distributed between PGY-2 and PGY-3 residents resulted in decreased volume of new patient consultations, increased volume of operative procedures, and no change in volume of bedside procedures for PGY-2 residents. PGY-3 residents experienced a decrease in operative procedure volume under the 24-hour call system. CONCLUSIONS: Transition from a night-float system to a 24-hour call system altered the distribution of clinical and procedural experiences between PGY-2 and PGY-3 residents. Further research is necessary to understand the impact of these changes on educational outcomes, quality and safety of patient care, and resident satisfaction.

Lumbar Pneumorrhachis Associated With Basilar Skull Fractures.

Lumbar pneumorrhachis following head injury is rare and commonly asymptomatic but can be indicative of skull fracture and cerebrospinal fluid (CSF) leak, which may warrant intervention. A PubMed review of the literature was performed using a keyword search to identify cases examining lumbar pneumorrhachis following head injury. Our case series included two patients who had lumbar pneumorrhachis between September 2019 and May 2020 at our center. The literature review summarizes 16 patients from 14 prior reports of pneumorrhachis. In our two-patient case series, neither patient required direct intervention for either pneumorrhachis or CSF leak. Pneumorrhachis is rare following an isolated head injury and is associated with basilar skull fractures and CSF leak. Pneumorrhachis should alert clinicians to the possibility of a CSF leak, which may require intervention.

Regression of Multiple Meningiomas after Discontinuation of Chronic Hormone Therapy: A Case Report.

Introduction Meningiomas are more common in females and frequently express progesterone and estrogen receptors. Recent studies have revealed a high incidence of meningiomas in situations in which estrogen/progesterone levels are increased such as pregnancy, gender reassignment therapy, and fertility treatment. While the relationship remains unclear and controversial, these findings suggest exposure to high levels of endogenous or exogenous hormones may increase the risk of developing a meningioma. Patients and Methods A 40-year-old female with a history of endometriosis treated with chronic progesterone therapy presented with a visual deficit and was found to have multiple meningiomas, which regressed after cessation of exogenous progesterone. Conclusion A history of chronic hormone therapy should be included when evaluating patients diagnosed with meningiomas, particularly at a younger age and with multiple meningiomas. Cessation of exogenous progesterone resulting in regression of meningiomas suggests a direct action of progesterone on growth. Future studies are warranted to better elucidate this relationship.

A Novel Protocol for Reducing Intensive Care Utilization After Craniotomy.

BACKGROUND: There is a growing body of evidence suggesting not all craniotomy patients require postoperative intensive care. OBJECTIVE: To devise and implement a standardized protocol for craniotomy patients eligible to transition directly from the operating room to the ward-the Non-Intensive CarE (NICE) protocol. METHODS: We preoperatively identified patients undergoing elective craniotomy for simple neurosurgical procedures with age <65 yr and American Society of Anesthesiologists (ASA) class of 1, 2 or 3. Postoperative eligibility was confirmed by the surgical and anesthesia teams. Upon arrival to the ward, patients were staffed with a neuroscience nurse for hourly neurological examinations for the first 8 h. Patient demographics, clinical characteristics, and outcomes were prospectively collected to evaluate the NICE protocol. RESULTS: From February 2018 to 2019, 63 patients were included in the NICE protocol with a median age of 46 yr and 65% female predominance. Of the operations performed, 38.1% were microvascular decompressions, 31.7% were craniotomy for tumor, 15.9% were cavernous malformation resections, and 14.3% were Chiari decompressions. No patients required transfer to the intensive care unit (ICU). Median length of stay was 2 d. There was an 11.1% overall readmission rate within the median follow-up period of 48 d. Three patients (4.8%) required reoperation at time of readmission within the follow-up period (1 postoperative subdural hematoma, 2 cerebrospinal fluid leak repair). None of these complications could have been identified with a postoperative ICU stay. CONCLUSION: In our pilot trial of the NICE protocol, no patients required postoperative transfer to the ICU.

Cerebrospinal Fluid Hypovolemia: A Case Report of a Red Herring.

Mild intracranial hypotension can lead to classically recognizable symptoms such as positional headaches, nausea, vomiting, and occasionally blurred vision. Less commonly, severe cerebrospinal fluid (CSF) hypovolemia can lead to a life-threatening condition that mimics intracranial hypertension, including transtentorial herniation and subsequent rapid neurologic decline. In this report we present a unique case of severe intracranial hypotension from a thoracic tumor resection that led to symptoms initially mistaken for intracranial hypertension, however ultimately correctly diagnosed as severe CSF hypovolemia that improved with dural repair. Additionally, we describe a rare angiography finding associated with CSF hypovolemia, kinking of the basilar artery. Here we report a 47-year-old female with neurofibromatosis Type 2 found to have a T3 intradural extramedullary tumor. She initially presented with urinary incontinence and gait/balance difficulty. She underwent thoracic laminectomies at T3 and T4 for the excision of the lesion. She was discharged on postoperative day 4. On postoperative day 9, she was noted to have nausea, vomiting, and decreased consciousness. Head computed tomography (CT) demonstrated acute downward herniation. She was transferred to our institution from a community facility obtunded and was intubated for airway protection. She was placed in the Trendelenburg position with immediate improvement, and declined every time her head was raised. Angiogram showed significant kinking of her basilar artery. A CT myelogram revealed a CSF leak from her recent thoracic surgery. She underwent exploration of her thoracic wound, and a ventral durotomy was repaired. Following this, she began to tolerate the head of bed elevations and recovered back to her neurologic baseline. A postoperative head CT angiography obtained before discharge showed improvement of her basilar kink. Mild intracranial hypotension is a common finding in patients who undergo procedures that enter the CSF space. Severe intracranial hypotension can easily be missed diagnosed as the signs on the exam are similar to patients with signs of intracranial hypertension. It is of paramount importance that the clinician recognizes brain sag, as the treatment algorithms are vastly different from that of intracranial hypertension leading to transtentorial herniation.

Hyperostosing sphenoid wing meningiomas: surgical outcomes and strategy for bone resection and multidisciplinary orbital reconstruction.

OBJECTIVE: Hyperostosing sphenoid wing meningiomas cause bony hyperostosis that may extend into the orbit, resulting in proptosis, restriction of extraocular movements, and/or compressive optic neuropathy. The extent of bony removal necessary and the optimal reconstruction strategy to prevent enophthalmos is debated. Herein, the authors present their surgical outcomes and reconstruction results. METHODS: This is a retrospective review of 54 consecutive patients undergoing resection of sphenoid wing meningiomas associated with bony hyperostosis. The majority of cases were operated on by the senior author. Extent of tumor resection, volumetric bone resection, radiographic exophthalmos index, complications, and recurrence were analyzed. RESULTS: The median age of the cohort was 52.1 years, with women comprising 83% of patients. Proptosis was a presenting symptom in 74%, and 52% had decreased visual acuity. The WHO grade was I (85%) or II (15%). The median follow-up was 2.6 years. On volumetric analysis, a median 86% of hyperostotic bone was resected. Gross-total resection of the intracranial tumor was achieved in 43% and the orbital tumor in 27%, and of all intracranial and orbital components in 20%. Orbital reconstruction was performed in 96% of patients. Postoperative vision was stable or improved in 98% of patients and diplopia improved in 89%. Postoperative complications occurred in 44% of patients, and 26% of patients underwent additional surgery for complication management. The most frequent complications were medical complications and extraocular movement deficits. The median preoperative exophthalmos index was 1.26, which improved to 1.12 immediately postoperatively and to 1.09 at the 6-month follow-up (p < 0.001). Postoperatively, 18 patients (33%) underwent adjuvant radiotherapy after subtotal resection. Tumors recurred/progressed in 12 patients (22%). CONCLUSIONS: Resection of hyperostosing sphenoid wing meningiomas, particularly achieving gross-total resection of hyperostotic bone with a good aesthetic result, is challenging and associated with notable medical and ocular morbidity. Recurrence rates in this series are higher than previously reported. Nevertheless, the authors were able to attain improvement in proptosis and visual symptoms in the majority of patients by using a multidisciplinary approach.

Meningioma metastases: incidence and proposed screening paradigm.

OBJECTIVE: Extracranial meningioma metastases are uncommon, occurring in less than 1% of patients diagnosed with meningioma. Due to the rarity of meningioma metastases, patients are not routinely screened for distant disease. In this series, we report their experience with meningioma metastases and results of screening for metastases in select patients with recurrent meningiomas. METHODS: All patients undergoing resection or stereotactic radiosurgery for primary or recurrent meningioma from 2009 to 2017 at a single center were retrospectively reviewed to identify patients who were diagnosed with or underwent imaging to evaluate for systemic metastases. Imaging to evaluate for metastases was performed with CT scanning of the chest, abdomen, and pelvis or whole-body PET/CT using either FDG or 68Ga-DOTA-octreotate (DOTATATE) tracers in 28 patients. Indications for imaging were symptomatic lesions concerning for metastasis or asymptomatic screening in patients with greater than 2 recurrences being evaluated for additional treatment. RESULTS: Of 1193 patients treated for meningioma, 922 (77.3%) patients had confirmed or presumed WHO grade I tumors, 236 (19.8%) had grade II tumors, and 35 (2.9%) had grade III tumors. Mean follow-up was 4.3 years. A total of 207 patients experienced recurrences (17.4%), with a mean of 1.8 recurrences. Imaging for metastases was performed in 28 patients; 1 metastasis was grade I (3.6%), 16 were grade II (57.1%), and 11 were grade III (39.3%). Five patients (17.9%) underwent imaging because of symptomatic lesions. Of the 28 patients screened, 27 patients had prior recurrent meningioma (96.4%), with a median of 3 recurrences. On imaging, 10 patients had extracranial lesions suspicious for metastasis (35.7%). At biopsy, 8 were meningioma metastases, 1 was a nonmeningioma malignancy, and 1 patient was lost to follow-up prior to biopsy. Biopsy-confirmed metastases occurred in the liver (5), lung (3), mediastinum (1), and bone (1). The observed incidence of metastases was 0.67% (n = 8). Incidence increased to 2% of WHO grade II and 8.6% of grade III meningiomas. Using the proposed indications for screening, the number needed to screen to identify one patient with biopsy-confirmed malignancy was 3.83. CONCLUSIONS: Systemic imaging of patients with multiply recurrent meningioma or symptoms concerning for metastasis may identify extracranial metastases in a significant proportion of patients and can inform decision making for additional treatments.

Fertility treatment is associated with multiple meningiomas and younger age at diagnosis.

PURPOSE: Meningiomas are more common in females and 70-80% express the progesterone receptor, raising the possibility that high-dose exogenous estrogen/progesterone exposure, such as occurs during fertility treatments, may increase the risk of developing a meningioma. The goal of this study was to report the incidence of prior fertility treatment in a consecutive series of female meningioma patients. METHODS: A retrospective review (2015-2018) was performed of female patients with meningioma, and those with prior fertility treatment were compared to those without fertility treatment using standard statistical methods. RESULTS: Of 206 female patients with meningioma, 26 (12.6%) had a history of fertility treatments. Patients underwent various forms of assisted reproductive technology including: in vitro fertilization (50.0%), clomiphene with or without intrauterine insemination (34.6%), and unspecified (19.2%). Median follow up was 1.8 years. Tumors were WHO grade I (78.6%) or grade II (21.4%). Patients who underwent fertility treatments presented at significantly younger mean age compared to those who had not (51.8 vs. 57.3 years, p = 0.0135, 2-tailed T-test), and on multivariate analysis were more likely to have multiple meningiomas (OR 4.97, 95% CI 1.4-18.1, p = 0.0154) and convexity/falx meningiomas (OR 4.45, 95% CI 1.7-11.5, p = 0.0021). CONCLUSIONS: Patients in this cohort with a history of fertility treatment were more likely to present at a younger age and have multiple and convexity/falx meningiomas, emphasizing the importance of taking estrogen/progesterone exposure history when evaluating patients with meningioma. Future clinical studies at other centers in larger populations and laboratory investigations are needed to determine the role of fertility treatment in meningioma development.