Staged Resection of Difficult-to-treat Intracranial Meningiomas: A Systematic Review of the Indications, Surgical Approaches, and Postoperative Outcomes

Introduction: Meningiomas are extra-axial intracranial tumors that are characterized as benign and slow-growing intracranial tumors of the dura. Large meningiomas encroach on critical vascular and neural structures, sometimes making gross total resection challenging. Multi-staged surgeries are becoming increasingly utilized as they can help improve resectability while minimizing adverse sequela.We performed a systematic review of all articles reporting on resections of meningiomas of intracranial origin as a multi-staged approach. For the purposes of this study, preoperative embolization of feeder vessels alone was not regarded as an independent “stage”; rather, “stage” was defined as surgery for tumor resection.

Methods: PubMed, Scopus and Web of Science databases were queried and articles were screened for possible inclusion in a systematic process performed by two authors.

Results: 536 studies were included with a total of 169 patients undergoing multi-staged resection of meningioma. Common indications for using a multi-staged approach include resecting tumors of large size, resecting tumors encroaching on critical neurovascular structures, minimizing time of brain retraction, devascularizing tumors, staging the approach and resection in different operations and resecting residual tumor found on postoperative imaging. Most second stage surgeries were performed < 3 months after the initial surgery. Multi-staged surgical resections consisted of a wide variety of surgical approaches depending on location of the tumor. There were little complications resulting from increased surgical time or the requirement for multiple inductions of anesthesia, and multi-staged resections appeared to be well tolerated overall.

Conclusion : Multi-staged approaches to resection of challenging meningiomas appear to be well tolerated. However, there is not enough evidence or statistical power present within currently available studies regarding this technique. We encourage neurosurgeons who perform staged resections to publish the results of these techniques in order to further assess their safety and viability when compared to single stage resections.