Clinical Features, Surgical Considerations, Techniques, and Approaches to Resection of Falcotentorial Meningiomas: Systematic Review and Meta-analysis

Introduction: Clinical management of FT meningiomas (~1%) of all meningiomas. can be challenging due to intimate involvement with the dural venous sinus system. We sought to gather and consolidate information from the neurosurgical literature to identify the key surgical strategies for FT meningiomas.

Methods: The authors queried three databases per PRISMA guidelines, identifying 30 studies reporting indications for surgical resection of FT meningioma. Two authors screened studies and extracted pertinent variables from each study using standardized pro-forma. Where applicable, descriptive statistics were performed; all quantitative meta-analysis was performed using Review Manager v5.4.

Results: Thirty studies reporting 223 FT meningioma cases featuring patients (70.8% female) aged 31–83 years were identified. Headache was the mostly commonly reported symptom, present more often than visual disturbance (p < 0.001), ataxia (p < 0.001), or cognitive disturbance (p = 0.004). The primary arterial feeders supplying the predominantly benign, Grade I (80.2%) FT lesions originated most commonly from the branches of the vertebrobasilar circulation (n = 35). Visual deficits (n = 32, 14.3%) were the most common postoperative complication. Bassiouni classification of the tumors was reported in 10 studies; the majority were classified as type III [37 (43.5%)] and type I [27 (31.8%)]. Performing multi-stage resection did not influence extent of resection (RR 1.42 [0.72, 2.80], I2=0%, p = 0.31). Furthermore, there was no significant association between WHO Grade I (versus higher grade. classification and risk for STR (RR 1.37 [0.64, 2.97], I2 = 5%, p = 0.42). On comparison of the OCT and SCIT approaches, both offered comparable likelihood for GTR.

Conclusion : When treating FT meningiomas, GTR should be pursued while minimizing cerebellar retraction and protecting vital vascular structures, such as the Galenic venous system. This is often performed via the OCT approach. SCIT approaches can play a very important role for resection of infratentorial lesions, especially when performed in the gravity dependent sitting position.