Management of High Convexity, Parasagittal and Falcine Meningiomas

Background: Neurosurgery has witnessed steady change in both technological capacity and in conceptualization of certain diseases. High convexity and falco/parasagittal Meningiomas are good examples of this change. Objectives: We aimed to analyze 25 consecutive cases of high convexity, parasagittal and falcine meningiomas with respect to surgical technique, image-guidance, complication rate, and pathological factors leading to recurrence in this particular midline location. Patients and Methods: We retrospectively reviewed 25 cases of closely related meningiomas by location operated by the first author over 6 years in two centers in KSA between 2007 and 2013. The median follow-up time was 29.7 months (range, 12–42 Ms). Results: High convexity and falco/parasagittal meningiomas represented 30 % of all meningiomas operated by the first author. Median age was 58.8 years (range, 48–72 yr), there was a female: male ratio of 1.8:1(16 female and 9 male). Image guided surgery was used on 10 cases (40%) operated at the second center (2010-2013). 8 cases (32%) presented with preoperative neurological deficit showed improvement during the postoperative follow up period. The incidence of new neurological deficits was 8% (2 cases), No permanent deficit and the overall complication rate was 16% (4 cases). The 30-day mortality rate was one case (4%).The pathology of the tumors was benign in 21 (84%), atypical in 4 (16%), and no cases diagnosed as anaplastic/malignant. In 3/21 cases designated “benign, there were borderline atypical features with Ki-67 LI more than 5%. No cases of recurrence within the follow –up period for purely benign meningioma (72%).We reported two cases of recurrence (8%), one case of falcine benign meningioma (Grade I) with features of atypia and another case of atypical parasagittal meningioma (Grade II) recurred in 39 months and 21 months respectively. Both were sent to radiosurgery. Conclusion: High convexity, parasagittal and falcine meningiomas can be safely removed using modern image guided surgical techniques with acceptable operative morbidity and mortality. The conservative surgical approach with saving the sinus and the major veins with adjuvant radiation therapy for the misbehaving residual has a very satisfactory longterm effect. The real behavior of the borderline tumors (Grade I with atypia) needs more cases, deep research and long term follow up.