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The history of neurosurgery is ever fascinating. The journey has been tedious; nevertheless, in the landscape of success and failures we have become more efficient and polished. Skills were learned, innovations were made, and in the process we evolved. The immense contribution of meningioma surgery in this maturation process is attested by history itself. Countless stories that testify the momentous role of meningioma in the process of evolution and reformation of neurosurgical techniques exist in the literature. With every step and every attempt at conquering this tumor, we reformed to be better surgeons, more skilled and more precise. In this paper we have walked down the lane of neurosurgery and paid a due tribute to this "necessary evil.", (Copyright © 2018. Published by Elsevier Inc.)

Background: Primary focal intracranial leptomeningeal glioma (PFILG) is considered a rare solitary glial tumor arising from the leptomeninges without brain attachment or evidence of primary neoplasm elsewhere within the neuraxis. We report a case of PFILG in a left parietal location and provide a concise review on its clinicoradiologic, histopathologic, and management characteristics., Case Presentation: A 75-year-old woman presented with focal motor seizures involving the right upper limb with associated occasional headache. Magnetic resonance imaging (MRI) of the brain revealed a small focal lesion attached to the left parietal dura with underlying brain parenchymal signal changes, and contrast-enhanced images showed heterogeneous enhancement of the tumor and meninges. The repeated MRI brain images within a month of primary imaging revealed significant progression of the size of lesion along with invasion of underlying parietal lobe parenchyma. The patient underwent gross total resection of the lesion, and the histopathologic diagnosis was glioblastoma multiforme (GBM), World Health Organization grade 4, isocitrate dehydrogenase wild type. The patient recovered well from surgery without deficits; however, she refused adjuvant treatment. MRI of the brain repeated 3 months after surgery revealed significant progression of the GBM with mass effect. Although adjuvant treatment was then started, she could not tolerate it and died 4 months after surgery., Conclusion: The possibility of high-grade PFILG should be considered in any aggressive extra-axial focal lesion. The definitive diagnosis can be made after histologic examination. Although surgery followed by adjuvant treatment is considered the mainstay of treatment, the overall prognostic outcome of high-grade PFILG is dismal., (Copyright © 2018. Published by Elsevier Inc.)

Background: To analyze the differences in tumor progression patterns and histopathologic characteristics between skull base meningiomas (SBMs) and non-skull base meningiomas (NSBMs)., Methods: Retrospective data of 382 patients with SBMs and 200 patients with NSBMs who underwent primary microsurgical resection between January 1995 and December 2016 were analyzed. Data related to clinical history, neuroimaging, surgical technique, and follow-up were reviewed. A separate prospective cohort of 78 meningiomas operated on from June 2016 to July 2017 was analyzed (World Health Organization [WHO] grade and Ki-67 proliferation index) for biologic comparison., Results: Skull base location, WHO grade II tumor, and subtotal resection were independent predictors of unfavorable outcome. The overall tumor progression rate in the SBM group (33%) was higher than in the NSBM group (19.7%) (P = 0.006) (mean follow-up period, 51 months). The 3-year, 5-year, and 10-year progression-free survival (PFS) was 78%, 60%, and 45% in the SBM group, whereas it was 90%, 80%, and 53% in the NSBM group, respectively. Interestingly, there was no difference in the median PFS after 10 years of follow-up (SBMs 210 months vs. NSBM 212 months, P = 0.93). In the prospective cohort of 78 meningiomas, there was no statistically significant difference in the proportion of WHO grade I tumors and in the mean Ki-67 index of WHO grade I meningiomas between the 2 groups., Conclusion: There is a divergent tumor progression pattern for surgically treated SBMs vis-à-vis NSBMs. Differences in tumor biology and the proportion of Simpson grade I resections are likely attributable factors., (Copyright © 2017. Published by Elsevier Inc.)

Background: Tentorial meningiomas are notorious for their critical location. Selection of a suitable approach that exposes the multicompartmental growth of tumor is important for a complete and safe resection. This paper discusses about various operative approaches and their overall surgical outcome., Methods: We retrospectively reviewed our 41 patients with tentorial meningiomas. They were classified according to the modified Yasargil classification. The symptomatic improvement and progression-free survival (PFS) were analyzed at follow-up., Results: Tumors were almost equally distributed in all location groups. Tumors along the lateral tentorial hiatus were operated on via a subtemporal or transsylvian approach. Tumors along the posterior tentorial hiatus, tentorial membrane, or torcula were operated on by an occipital interhemispheric transtentorial, infratentorial supracerebellar, or a combined approach. Tumors along the petrous attachment were operated on by a retromastoid suboccipital or a combined presigmoid-retrosigmoid approach. Seventy-six percent had total excision (Simpson grade 1 and 2). Group II tumors had the highest total resection rate (100%). Headache and diplopia were the symptoms that significantly improved postoperatively. Over a median follow-up of 65 months, 13 patients (31.7%) had recurrence. There was no significant difference in recurrence rates and PFS in tumors at different locations. Extent of excision and tumor grade were the significant factors affecting PFS in both univariate and multivariate analysis (P = 0.01 and 0.03, respectively)., Conclusions: Similar to intracranial meningiomas at other locations, extent of resection and tumor grade significantly affect the PFS for tentorial meningiomas. Careful preoperative planning based on the location and extension of the tumor guides the optimal surgical approach that translates into maximal safe resection., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The giant intracranial meningioma (GIM) constitutes a different spectrum of brain tumors that invade the vital neurovascular structures, which makes the primary mode of treatment, surgery, a technically challenging one. The surgery for GIM is unique because of the large size of the tumor, prominent vascularity, entangling and limited visualization of various neurovascular structures, and severe cerebral edema. This study reports the authors surgical experience of 80 GIM cases, the operative challenges and surgical outcome., Methods: A retrospective analysis of 80 patients with histologically proven meningioma (≥5 cm) who underwent surgical treatment at Louisiana State University Health Sciences Center (Shreveport, Louisiana, USA) over a 20-year period (1995-2015) is presented. The clinical and radiologic data were collected from the hospital database. The tumors were categorized into histologic groups according to World Health Organization (WHO) classification. The relevant statistical analysis of the study was conducted using SPSS software, version 22.0., Results: The study included 27 male patients (33.8%) and 53 female patients (66.3%). The mean age of the cohort was 56 years (56.3±16.1). The mean size of the tumor was 56.4 ±4 mm with a range from 50 mm to 84 mm. Skull base was the most common location of GIM (57 patients, 71.3%). Simpson grade 1 excision was achieved in 9 patients (11.3%), whereas grade 2 excision was achieved in 57 patients (71.3%); 80% of the tumors belonged to WHO grade 1. The operative mortality was seen in 4 patients (5%). Regression analysis showed that age, sex, location of the tumor, neuronavigation, Simpson grade of excision, and histology of tumor were the factors that significantly affected the recurrence-free survival (RFS)., Conclusions: The surgery for GIM is unique in different ways. As surgery for GIM is formidable, radiologic characteristics can be useful adjuncts for planning an effective and safe surgical strategy. The factors such as young age, male sex, use of neuronavigation, and skull base location positively influenced RFS, whereas Simpson grade 3 or 4 and poor histologic grade adversely influenced RFS. A careful preoperative evaluation, understanding of the risk factors, effective surgical approach, and judicious use of intraoperative adjuncts are the key factors with pivotal roles in GIM resection., (Copyright © 2017. Published by Elsevier Inc.)

Meningiomas arising from the posterior clinoid process pose a great surgical challenge because of their location and propensity to cause critical neurovascular compression. The authors' patient was a 66-year-old female who had a large posterior clinoid meningioma with significant brainstem compression that was operated on through the retrosigmoid approach. This 3D surgical video emphasizes the various technical concepts that are important to preserving compressed neural and vascular structures during the surgery. It would also be interesting to note the extent of visualization around the posterior clinoid region gained through a retrosigmoid corridor. The video can be found here: https://youtu.be/CBmT_0ov0YA .

Background: Patients with small (<3 cm) intracranial meningiomas can be either observed or treated. Treatment can be either radiosurgery or microsurgery if and when tumor progression occurs. We compared local tumor growth control and recurrence-free survival (RFS) of microsurgical resection and radiosurgery in small intracranial meningiomas and identified predictors of unfavorable outcome., Methods: A retrospective review (2005-2016) was performed of 90 consecutive patients with intracranial meningiomas who underwent either microsurgery (n = 31) or Gamma Knife radiosurgery (GKRS) (n = 59). The study population was evaluated clinically and radiographically after treatment., Results: GKRS in meningiomas showed a significantly higher percentage of local control of tumor growth compared with microsurgery (P = 0.02) 5 and 10 years (P = 0.003) after treatment. The median RFS was also significantly higher in the GKRS group compared with the microsurgery group (P = 0.04). There was no difference in RFS between Simpson grade I resection and GKRS (P = 0.69). In univariate analysis, RFS after procedures was significantly affected by tumor involvement of cranial nerves, presence of comorbidities, and preoperative Karnofsky performance scale score ≤70. In multivariate analysis, only preoperative Karnofsky performance scale score ≤70 was a predictor of unfavorable outcome., Conclusions: GKRS offers a high rate of tumor control and longer RFS that is comparable to Simpson grade I resection. Subtotal resection is not a good choice for small meningiomas. The treatment procedure should be tailored according to the presence of comorbidities and the maximum benefit for the patient., (Copyright © 2017 Elsevier Inc. All rights reserved.)

OBJECTIVE Spinal meningiomas are benign tumors with a wide spectrum of clinical and radiological features at presentation. The authors analyzed multiple clinicoradiological factors to predict recurrence and functional outcome in a cohort with a mean follow-up of more than 4 years. The authors also discuss the results of clinical studies regarding spinal meningiomas in the last 15 years. METHODS The authors retrospectively reviewed the clinical and radiological details of patients who underwent surgery for spinal tumors between 2001 and 2015 that were histopathologically confirmed as meningiomas. Demographic parameters, such as age, sex, race, and association with neurofibromatosis Type 2, were considered. Radiological parameters, such as tumor size, signal changes of spinal cord, spinal level, number of levels, location of tumor attachment, shape of tumor, and presence of dural tail/calcification, were noted. These factors were analyzed to predict recurrence and functional outcome. Furthermore, a pooled analysis was performed from 13 reports of spinal meningiomas in the last 15 years. RESULTS A total of 38 patients were included in this study. Male sex and tumors with radiological evidence of a dural tail were associated with an increased risk of recurrence at a mean follow-up of 51.2 months. Ventral or ventrolateral location, large tumors, T2 cord signal changes, and poor preoperative functional status were associated with poor functional outcome at 1-year follow-up. CONCLUSIONS Spine surgeons must be aware of the natural history and risk factors of spinal meningiomas to establish a prognosis for their patients.

Background: Tuberculosis has long been a major health concern in developing countries and now has troubled developed world as well, owing to increase in patients with human immunodeficiency virus and immigration. Central nervous system tuberculosis accounts for approximately 1% of cases of tuberculosis. The pathologic presentation is varied, with intraparenchymal tuberculomas and pachymeningitis being the most common. Being a great mimicker, it simulates numerous diseases radiologically, and this is best realized when atypical forms are encountered. Here an atypical case of dural en-plaque tuberculoma is presented with comprehensive review of dural en-plaque lesions with their differentiating features., Case Report: A 20-year-old man presented with features of increased intracranial pressure. On imaging, there was an enhancing dural-based lesion in the left frontoparietal region. In view of herniation syndrome, urgent surgical decompression of the lesion was performed. Histopathology showed features of tuberculosis. The patient is now asymptomatic with antitubercular therapy without any residual lesion at 6 months of follow-up., Conclusions: Tuberculoma en-plaque is an unusual entity characterized by a plaque-like meningitic process without exudation. It is easily confused with meningiomas as can other dural-based lesions comprising benign to malignant neoplastic, infectious, and granulomatous lesions. A preoperative diagnosis is imperative to differentiate it at least from neoplastic lesions, which are usually curable with surgical intervention in contrast to tuberculosis, which needs only optimal chemotherapy in most of the cases. Knowledge of differentiating imaging features, in corroboration with clinical history and high index of suspicion, helps in a proper preoperative diagnosis and optimal patient treatment., (Copyright © 2016 Elsevier Inc. All rights reserved.)