Meningioma

What is it?

Meningiomas are tumors arising from the meninges and represent the most common primary benign tumors in the CNS. Despite of their benign nature, they may entail serious morbidity and mortality according to their location, proximity to vital structures and clinical behavior.  

Histological grade (according to the WHO classification) is the most important factor in predicting the risk of recurrence and aggressive behaviour. Meningiomas are classified as grade I (the most frequent, slow-growing), grade II (atypical meningiomas, more aggressive) and grade III (anaplastic meningiomas, with high risk of local invasion and recurrence).  

Which are the symptoms?

Symptoms are caused by the compression of surrounding tissues and are linked to tumor location: headache, nausea, seizures, visual field deficit, weakness or numbness in the limbs or face and changes in mood or personality.  

How is it diagnosed?

Suggested exams

How is it treated?

Indication is given considering tumor size and symptoms.  

  • Surgery. It is aimed to diagnosis, reduction of intracranial pressure and improvement of quality of life. The ability to achieve a radical resection depend largely on the surgical experience of the neurosurgeon and it has been demonstrated to be the primary prognostic factor of long-term freedom from recurrence. Microsurgical techniques along with advanced preoperative neuroimaging, intraoperative image-guided approaches (neuronavigation) and intraoperative neurophysiological monitoring, extend neurosurgeon’s ability to remove lesions that were previously considered only partially resectable or unresectable, while minimizing morbidity.  

  • Radiation therapy may be used as primary treatment or complementary to surgery, especially when dealing with critically located meningiomas or in patients with worrisome comorbidities. Treatment goal is the interruption of tumor growth. Gamma-Knife radiosurgery is the first choice in lesion < 3 cm in diameter while conventional RT may be indicated in bigger lesions or as an adjuvant therapy in high-grade meningiomas. Stereotactic Radiosurgery allows to converge multiple beams of ionizing radiation at one defined point, providing an intense dose of radiation to a targeted area sparing surrounding tissues. The precision is given by the creation of a three-dimensional coordinate system through placement of a stereotactic frame or a thermoplastic mask (for selected cases) and the subsequent acquisition of MRI imaging on which the treatment plan is defined. Radiosurgery is generally performed in a single session with the exception of treatment near the optic nerve which requires fractionation in 3 or 5 days in order to avoid tissue damage. After the procedure, the frame can be removed and the patient can be discharged the same day or the following day. If a fractionated treatment is planned, the patient will keep the frame for the whole period he remains admitted in the hospital till the last dose fraction is delivered. At the Neurosurgery Unit in San Raffaele Hospital, Gamma Knife treatment is performed using a Leksell Gamma Knife® Icon™ model.  

The management of meningiomas is challenging and often requires a multi-disciplinary approach in which the neurosurgeon works closely with radiation oncologists while tailoring the optimal treatment for these patients to achieve the best results. For all these reasons, patients affected by meningiomas should refer to high-specialized centers: the average number of cases of meningioma that have been treated in the Neurosurgery Unit at San Raffaele Hospital are 300 cases/year considering both surgery and Gamma-Knife radiosurgery. 

In September 2020 at San Raffaele Hospital Professor Mortini together with his team successfully performed for the first time in the world a surgical removal of a brain meningioma with the use of a robotiscope, a digitally controlled robotic device with three-dimensional visualization. This up-to-date technology includes a digital, 3-dimensional (3D) high-resolution cameras on a microscope-holding arm which transmit real-time, high-resolution images to 2 micromonitors placed in front of the surgeon’s eyes on a Head Mounted Display. The display recognizes and, accordingly, translates, the surgeon’s head movements into robotic-controlled motions and adjust the camera to change the field of view. 

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