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M eningioMas are the most frequently reported primary intracranial neoplasms in the US. Most of these lesions are benign (i.e., WHO Grade I) with a low tendency for invasion and recurrence and a natural history of slow growth. Within the intracranial space, there is a narrow capacity for mass expansion. The primary approach for large meningiomas has been resection. Despite a dramatic decline in surgical morbidity for abbreviatioNs CN = cranial nerve; CPA = cerebellopontine angle; GKRS = Gamma Knife radiosurgery; HR = hazard ratio; SRS = stereotactic radiosurgery. submitted January 26, 2014. accepted October 14, 2014. iNclude wheN citiNg Published online December 5, 2014; DOI: 10.3171/2014.10.JNS14198. disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. obJect Stereotactic radiosurgery (SRS) has become a common treatment modality for intracranial meningiomas. Skull base meningiomas greater than 8 cm 3 in volume have been found to have worse outcomes following SRS. When symptomatic, patients with these tumors are often initially treated with resection. For tumors located in close proximity to eloquent structures or in patients unwilling or unable to undergo a resection, SRS may be an acceptable therapeutic approach. In this study, the authors review the SRS outcomes of skull base meningiomas greater than 8 cm 3 in volume, which corresponds to a lesion with an approximate diameter of 2.5 cm. methods The authors reviewed the data in a prospectively compiled database documenting the outcomes of 469 patients with skull base meningiomas treated with single-session Gamma Knife radiosurgery (GKRS). Seventy-five patients had tumors greater than 8 cm 3 in volume, which was defined as a large tumor. All patients had a minimum follow-up of 6 months, but patients were included if they had a complication at any time point. Thirty patients were treated with upfront GKRS, and 45 were treated following microsurgery. Patient and tumor characteristics were assessed to determine predictors of new or worsening neurological function and tumor progression following GKRS. results After a mean follow-up of 6.5 years (range 0.5-21 years), the tumor volume was unchanged in 37 patients (49%), decreased in 26 patients (35%), and increased in 12 patients (16%). Actuarial rates of progression-free survival at 3, 5, and 10 years were 90.3%, 88.6%, and 77.2%, respectively. Four patients had new or worsened edema following GKRS, but preexisting edema decreased in 3 patients. In Cox multivariable analysis, covariates associated with tumor progression were 1) presentation with any cranial nerve (CN) deficit from III to VI (hazard ratio [HR] 3.78, 95% CI 1.91-7.45; p < 0.001), history of radiotherapy (HR 12.06, 95% CI 2.04-71.27; p = 0.006), and tumor volume greater than 14 cm 3 (HR 6.86, p = 0.066). In those patients with detailed clinical follow-up (n = 64), neurological function was unchanged in 37 patients (58%), improved in 16 patients (25%), and d...
Compared with drip-and-ship, the trip-and-treat model demonstrated shorter treatment times for endovascular therapy in our series. The trip-and-treat model offers a valid alternative to current interhospital stroke transfers in urban environments.
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