J Neurosurg 112:913–919, 2010

Risk profile associated with convexity meningioma

resection in the modern neurosurgical era

Clinical article
Nader Sanai, M.D., Michael E. Sughrue, M.D., Gopal Shangari, B.S.,
Kenny Chung, Mitchel S. Berger, M.D., and Michael W. McDermott, M.D.
Brain Tumor Research Center, Department of Neurological Surgery, University of California,
San Francisco, California

Object. Although meningiomas are commonly found along the supratentorial convexity, the risk profile associ-
ated with this subset of lesions in the modern neurosurgical era is unknown.
Methods. The authors retrospectively reviewed the clinical course of patients with supratentorial convexity
meningiomas treated during the past 10 years. All patients had undergone MR imaging within 72 hours after surgery
and at least 1 year of clinical follow-up. Patients with multiple meningiomas, hemangiopericytomas, malignant men-
ingiomas, or tumor-prone syndromes were excluded from analysis.
Results. Between 1997 and 2007, 141 consecutive patients (median age 48 years, range 18–95 years) underwent
resection of a supratentorial convexity meningioma. The most common signs or symptoms at presentation were
headache (48%), seizures (34%), and weakness (21%). The mean tumor volume was 146.3 cm3 (range 1–512 cm3).
There were no intraoperative complications or deaths. Medical or neurosurgical morbidity was noted in the post-
operative course of 14 patients, equating to a 10% overall complication rate. Postoperative surgical complications
included hematoma requiring evacuation, CSF leakage, and operative site infection. Medical complications included
pulmonary embolus and deep vein thrombosis requiring treatment. A Simpson Grade 0 or 1 resection was achieved
in 122 patients (87%). One hundred six tumors (75%) were WHO Grade I, whereas 35 (25%) were WHO Grade II.
The median clinical follow-up was 2.9 years (range 1–10 years), and the median radiographic follow-up was 3.7
years (range 1–10 years). Six patients (4%) had radiographic evidence of tumor recurrence, with 3 (2%) undergoing
repeat resection.
Conclusions. With the conservative recommendations for surgery for asymptomatic meningiomas and the ad-
vent of radiosurgery during the past 10 years, microsurgically treated convexity meningiomas are now typically large
in size. Nevertheless, the patient’s clinical course following microsurgical removal of these lesions is expected to
be uncomplicated. The authors’ findings provide a defined risk profile associated with the resection of supratentorial
convexity meningiomas in the modern neurosurgical era. (DOI: 10.3171/2009.6.JNS081490)

Key Words      •      convexity meningioma      •      risk profile      •      microsurgical removal

C
onvexity meningiomas are among the most com-
mon extraaxial tumors encountered in neurosur-
gery, yet most large studies of these lesions are at
least 2 decades old.2,7,9,12,19,22,25 In the interim, advances
in diagnostic imaging, intraoperative technology, and
nonsurgical treatment modalities have changed the face
of neurosurgical oncology. Our current understanding
of meningioma biology has similarly evolved. Histo-
pathological criteria for meningioma grading and diag-
nosis have refined atypical and malignant meningioma
categories,20,24 while new prognostic factors, including
tumor proliferative indices,13,23,29,30 chromosomal aber-
rations,4,6,8,23 and growth factor receptor profiles,10,28,31,33
now enable risk stratification for meningioma progres-
sion and recurrence.14,18 Perhaps most importantly, ste-
reotactic radiosurgery has emerged as a new standard of
care for many patients with meningioma, and thus has
altered the patient population undergoing microsurgical
removal.5,17
Some of the largest studies on convexity men-
ingiomas in the literature bear little resemblance to
modern neurosurgical experience. For example, Olive-
crona’s22 experience with 112 convexity meningiomas,
published in 1967, reveals a 25% incidence of new-onset
postoperative epilepsy. Similarly, Flyger’s11 1956 series
of 94 convexity meningiomas demonstrated a new-onset
postoperative epilepsy rate of 9.6%. In contrast, seizure
disorders attributable to microsurgical removal are rarely
encountered in the modern era, likely due to advances
in microsurgical technique as well as the routine use of
postoperative antiepileptics.
Surprisingly few studies have been published in
the radiosurgery era. Yamasaki et al.32 have described
their experience following Simpson Grade 1 resections
in 54 patients with convexity meningiomas. Six patients
(11.1%) in this series had evidence of recurrent tumor on
follow-up, with vascular endothelial growth factor ex-
This article contains some figures that are displayed in color
on­line but in black and white in the print edition.

J Neurosurg / Volume 112 / May 2010 913


pression and a high MIB-1 labeling index—both found to
be predictors of recurrence. In another study by Morokoff
et al.,21 163 convexity meningiomas were treated over a
19-year period with a remarkably low morbidity profile.
We retrospectively reviewed our experience with
supratentorial convexity meningiomas resected during
the past 10 years in an effort to characterize this patient
population in the modern neurosurgical era, examine the
risk profile associated with microsurgical removal, and
highlight the technical nuances that optimize patient out-
come.
Methods
Patient Population and Outcome Assessment
One hundred forty-one consecutive patients with su-
pratentorial convexity meningiomas treated during the
past 10 years were included in this study. These patients
were adults (age ≥ 18 years) who had undergone surgery
at the University of California, San Francisco, between
1997 and 2007, preoperative and postoperative (< 72 hours
after surgery) MR imaging, and at least 1 year of clinical
follow-up. Patients with multiple meningiomas, heman-
giopericytomas, malignant meningiomas, or tumor-prone
syndromes were excluded from our analysis. Magnetic
resonance images were reviewed for each patient to con-
firm the diagnosis of a convexity meningioma, which was
defined as a lesion with an attachment located primarily
at the convexity dura. Tumors originating from the cranial
base, falx, tentorium, and sphenoid wing were excluded,
as were all infratentorial tumors. Lesions associated with
both the convexity dura as well as a dural sinus were in-
cluded if > 50% of the attachment was associated with
the convexity and the epicenter of the tumor was convex-
ity dura. Central pathology review was performed on the
basis of the WHO guidelines.16 Clinical data were col-
lected from patient records and telephone interviews. All
clinical assessments were performed by a neurosurgeon.
In each case, the extent of resection and Simpson resec-
tion grade15,25 were determined using a combination of the
surgeon’s assessment and MR imaging. The Committee
on Human Research at the University of California, San
Francisco, approved this study.
Microsurgical Technique and Perioperative Management
Standard craniotomies overlying the lesion were used
in all cases, as was a microsurgical technique using loupe
magnification or the operating microscope or a combi-
nation of the 2. Intraoperative neuronavigation was used
as a matter of routine to minimize the skin incision and
craniotomy while attempting a Simpson Grade 0 or 1 re-
section. In cases in which the dural attachment involved
the sinus, a Simpson Grade 2 resection was the opera-
tive goal. Preoperative embolization was considered for
all large tumors, although often the vascular supply for
these larger lesions included pial supply. In general, en
bloc resection was not attempted because of tumor size,
and instead the meningioma was debulked from within
using a Cavitron ultrasonic aspirator (Valleylab) or, more
recently, a Sonopet ultrasonic aspirator (Miwatec). Care-
914
N. Sanai et al.
TABLE 1: Summary of characteristics in 141 patients who
underwent resection of a supratentorial convexity meningioma
Characteristic No.
total no. of patients 141
median age in yrs (range) 48 (18–95)
sex (M/F) 49:92
signs or symptoms at presentation (%)
    headache 68 (48)
    seizure 48 (34)
    hemiparesis 30 (21)
    none 20 (14)
previous treatment (%)
    microsurgical removal 13 (9)
    radiation therapy 18 (13)
ful attention was paid to identifying and respecting the
arachnoid plane at the tumor-brain interface, which fa-
cilitates complete resection and minimizes pial vessel in-
jury. Whenever possible, involved dura was resected with
a 2-cm circumferential margin, and the dura was closed
with either a pericranial graft or the artificial dura sub-
stitute. For lesions with bony invasion, the craniectomy
site was repaired using a combination of titanium mesh
and methylmethacrylate. This composite cranioplasty
technique was applied given that the craniectomy defects
tended to be large and the resultant construct provided
strength in compression and tension.
Intraoperatively, all patients received Decadron (10
mg), mannitol (1 g/kg), and ceftriaxone (1 or 2 g) at the
time of incision. After surgery, all patients were cared for
in a neurointensive care unit for 1 day before returning to
the ward. On postoperative Day 2, a prophylactic dose of
enoxaparin (40 mg subcutaneously each day) was initi-
ated in all patients and was continued for 1 week. The
routine use of venous thrombosis prophylaxis was not
started until after 2001.1 The incidence of postoperative
intracranial hemorrhage was no different in the patient
groups before or after prophylaxis was begun (data not
shown). Regardless of the preoperative seizure history, all
patients were also loaded with an antiepileptic agent at
the time of surgery (Dilantin initially, Keppra more re-
cently), which was continued for 1 week postoperatively
and then discontinued.
Results
Patient and Tumor Characteristics
Of the 141 patients selected for this study, the me-
dian age at presentation was 48 years (range 18–95 years;
Table 1). Ninety-two patients (65%) were female and 49
(35%) were male. Most patients presented with signs and
symptoms attributable to mass effect and the tumor site,
including headache (48%), seizure (34%), and hemipare-
J Neurosurg / Volume 112 / May 2010
Microsurgical removal of convexity meningiomas
TABLE 2: Lesion characteristics TABLE 3: Extent of resection according to Simpson grade

Characteristic No. Simpson Grade No. of Patients (%)

lt-sided/rt-sided 72:69 0 21 (15)

mean vol in cm3 (range) 146.3 (1–512) 1 101 (72)

median max tumor dimension in cm 5.2 2 19 (13)

tumor location on convexity dura (%) 3 0

   anterior 74 (52) 4 0

   posterior 15 (11)
   temporal 28 (20)
   median 24 (17)
WHO tumor grade (%)
   I 106 (75)
   II 35 (25)
sis (21%). Twenty patients (14%) were asymptomatic, but
serial MR imaging demonstrated growth > 2 mm in a
single calendar year. Thirty-one patients (22%) had un-
dergone previous treatment of their meningiomas, includ-
ing resection (13 patients [9%]) and stereotactic or whole-
brain irradiation (18 patients [13%]).
Sixty-nine tumors (49%) were right-sided and 72
(51%) were left-sided (Table 2). Tumor location corre-
sponded to the relative surface area of the supratentorial
dura, with the most common location being along the an-
terior convexity (74 lesions [52%]), followed by the tem-
poral convexity (28 lesions [20%]), median convexity (24
lesions [17%]), and posterior convexity (15 lesions [11%]).
The mean tumor volume was 146.3 cm3 (range 1–512
cm3), and 95% of all tumors had a maximal diameter of
at least 3 cm (Fig. 1).
Microsurgical Outcome and Tumor Recurrence
One hundred forty-four operations were performed in
these 141 patients. Forty-eight patients (34%) underwent
Fig. 1.  Bar graph depicting the distribution of tumor volumes (cc =
cm3) by the number of patients.
preoperative embolization, with the most common embo-
lized vessels being the middle meningeal and superficial
temporal arteries. A Simpson Grade 0 or 1 resection was
achieved in 122 patients (87%), with a Simpson Grade 2
in the remaining 19 patients (13%; Table 3). All 19 pa-
tients with Simpson Grade 2 resections had a portion of
their tumor’s dural attachment involved with a dural si-
nus wall. In these cases, an intrasinus resection26,27 was
not pursued in favor of dural leaflet coagulation along the
course of important segments of venous sinuses.
The pathology of these tumors was benign in 106
cases (75%) and atypical in 35 cases (25%). As mentioned
above, anaplastic or malignant meningiomas were ex-
cluded from this study. The median age of patients with a
benign histology was 45 years, whereas the median age of
those with an atypical histology was 62 years.
The median clinical follow-up time was 2.9 years
(range 1–10 years), and the median radiographic follow-
up time was 3.7 years (range 1–10 years). Overall, 135
patients (96%) have demonstrated no clinical or radio-
graphic evidence of recurrence to date. Of the 6 patients
(4%) with radiographic recurrence, none were symptom-
atic and 3 (2%) proceeded to a repeat microsurgical re-
moval after showing evidence of steady lesion growth.
All patients with recurrent tumors underwent postop-
erative stereotactic radiotherapy, and in cases in which
the tumor was re-resected, irradiation was delayed until
after the second resection. The mean time to recurrence
was 11 months (range 7–27 months). All 3 re-resected tu-
mors demonstrated WHO Grade II histology, as they did
at the time of the first craniotomy. Overall, no Grade I
tumors recurred, whereas 6 (17%) of 35 Grade II tumors
recurred according to radiography studies. Five of 6 re-
current meningiomas initially showed a Simpson Grade
2 resection, and 1 a Simpson Grade 3 resection. In each
case, this less extensive resection was attributed to direct
dural sinus infiltration, precluding a Simpson Grade 0 or
1 resection.
Morbidity Profile
No deaths occurred within 30 days of resection, al-
though 5 patients died of unrelated causes in the ensuing
years since their operation. There was no incidence of
intraoperative complications; however, medical or neuro-
surgical morbidity was noted in the postoperative course
of 14 patients (Table 4)—which was equal to a 10% overall
complication rate, with a nearly even distribution of med-
ical and neurosurgical complications. Medical complica-

J Neurosurg / Volume 112 / May 2010 915


TABLE 4: Medical and neurosurgical morbidity
No. of
Complication Patients (%)
medical
   deep venous thrombosis 6 (4.2)
   pulmonary embolus 2 (1.4)
neurosurgical
   CSF leak 2 (1.4)
   postop hematoma 2 (1.4)
   wound infection 5 (3.5)
tions occurred in 6 patients (4.2%) who had a pulmonary
embolism requiring anticoagulation (2 patients [1.4%]) or
a deep venous thrombosis requiring anticoagulation (6 pa-
tients [4.2%]) or both. Surgical complications (8 patients
[5.6%]) included CSF leakage (2 patients [1.4%]), epidural
hematoma requiring evacuation (2 patients [1.4%]), and
wound infection requiring antibiotics (5 patients [3.5%]).
Among patients with wound infections, only 2 required
reoperation for wound washout; however, in both cases
the bone flap was left in place and the patient was suc-
cessfully treated with an indwelling antibiotic irrigation
system.3 Among all patients, there was no incidence of
postoperative myocardial infarction, meningitis, hydro-
cephalus, new-onset seizures, or new or worsened neuro-
logical deficits. There were no significant differences in
medical or neurosurgical morbidity rates among anterior,
median, posterior, and temporal convexity sites.9
Discussion
In the modern neurosurgical literature, few reports
describe the expected outcome for patients with convexity
meningiomas treated using resection. Publications from
decades ago, while critical to our understanding of the
natural history of convexity meningiomas, do not reflect
the surgical and nonsurgical management strategies cur-
rently in practice for this patient population. The present
study captures a contemporary experience with convexity
meningiomas and defines the morbidity profile associated
with modern-day practice. Our patient population, most
with large or giant meningiomas, reflects a combination
of conventional patient selection criteria and the impact
of radiosurgery as a treatment option for most patients.
Our findings are directly or indirectly the result of
several developments over the past 2 decades in the field
of meningioma surgery. Perhaps most notably, the ubiq-
uitous nature of CT and MR imaging has increasingly
allowed early detection of convexity meningiomas and
easy surveillance of tumor growth and proliferative po-
tential. As a consequence, many convexity meningiomas
are diagnosed while they are small and an easy target
for radiation therapy.17,21 This circumstance, in turn, has
altered the composition of patients undergoing resection
and thus many tumors subjected to resection are larger
than in previous years.
916
N. Sanai et al.
Fig. 2.  Images demonstrating microdissection of the tumor-brain
interface. The morbidity profile for convexity meningiomas, such as
the lateral convexity mass seen in this preoperative axial contrast-en-
hanced T1-weighted MR image (A), is primarily driven by the extent to
which there is meticulous microdissection of the tumor-brain interface.
For larger tumors, the arachnoid plane at this interface is often ill-de-
fined, making dissection difficult. Despite achieving a Simpson Grade
0 resection, shown on this postoperative axial contrast-enhanced T1-
weighted MR image (B), small pial vessel injury can occur, as demon-
strated on this postoperative axial diffusion weighted MR image (C),
leading to potential deficits.
Furthermore, the detailed anatomical information
provided by routine preoperative MR imaging—and in
some cases, angiography—has improved operative out-
comes by defining critical vasculature in and around
the tumor. This technological edge combined with the
routine use of an operative microscope and neuronavi-
gational guidance has changed the face of convexity men-
ingioma surgical outcomes. For example, new-onset post-
operative epilepsy, a relatively common phenomenon in
prior decades, is now exceedingly rare and was not seen
in our study. While this result may, in part, be attributed
to the use of perioperative antiepileptic agents, it is also
likely a consequence of meticulous microdissection at the
tumor–brain arachnoid interface. Failure to respect this
plane can lead to small pial vessel injury and neurological
deficit (Fig. 2).
Our experience suggests that, when selecting pa-
tients on the basis of symptomatology and/or documented
growth, the typical convexity meningioma undergoing
neurosurgical removal is large and, as a consequence, not
infrequently adherent to the pial surface of the brain or a
sinus wall in its lateral extensions. Achieving a Simpson
Grade 0 or 1 resection in these patients is therefore less
likely and may account for the our relatively low rate of
J Neurosurg / Volume 112 / May 2010
Microsurgical removal of convexity meningiomas

Fig. 3.  Images revealing intracapsular decompression of tumor mass effect. In cases of significant tumor mass effect, as seen
on this preoperative axial contrast-enhanced T1-weighted MR image (A), decompression of the tumor internally prior to complete
dural opening can prevent adjacent tissue injury. Using image guidance to make sure that the adjacent brain is not exposed,
a cruciate dural opening is centered over the tumor (B). Once the tumor has been internally debulked (C), the dural opening is
completed (D) and the brain-tumor interface is easily dissected without the risk of normal tissue damage from mass effect (E).

Simpson Grade 0 or 1 resection (87%) as compared with
that in a recently published study of 163 convexity men-
ingiomas, one-fifth of which were incidentally diagnosed.
In that study, the “vast majority” of patients had under-
gone a Simpson Grade 1 resection, which we assume im-
plies > 90% resection.21 Although operating on inciden-
tal meningiomas in the absence of documented growth
remains controversial, our understanding of meningioma
natural history suggests that 63% will not progress in size
and 94% will remain asymptomatic in the first several
years of clinical and radiographic follow-up.34 Therefore,
therapeutic intervention of any type, whether radiosurgery
or microsurgery, can safely be withheld pending docu-
mented growth or development of symptoms specific to
the tumor site. This recommendation is especially true
for small meningiomas, but when a patient presents with
a large meningioma, issues related to his or her current
age, life expectancy, anesthetic risks, and the probability
of tumor growth for noncalcified tumors, all of these fac-
tors enter into the equation when deciding on a course of
management.
Convexity meningioma recurrence happens almost
exclusively among atypical and malignant histologies.
Morokoff et al.21 have described a 1.8% 5-year recurrence
rate for WHO Grade I histology, 27.2% for Grade II, and
50% for Grade III, assuming an equal extent of resec-
tion for each subgroup. Comparatively, our 0% rate of
recurrence for Grade I tumors and 17% recurrence rate
for Grade II lesions are within range of reported results,
considering our relatively shorter clinical and radiograph-
ic follow-up intervals. Moreover, given our high rate of
Simpson Grade 0 resections of WHO Grade I tumors, it
remains possible that patients with these lesions will have
a recurrence rate lower than the reported 1.8%.
For larger convexity meningiomas, one technical nu-
ance that can facilitate resection in cases of significant
mass effect is decompressing the tumor internally prior
to a complete dural opening (Fig. 3). In these cases, we
begin with a cruciate dural opening centered over the tu-
mor, using image guidance to avoid exposing the adjacent
cortex. The convexity dura is detached from the underly-
ing tumor by using bipolar electrocautery and scissors. A
combination of sharp dissection and ultrasonic aspiration
is then used to internally debulk the tumor. Once adequate
decompression is achieved, dural opening is completed
and the brain-tumor interface is easily dissected without
risking damage to normal tissue and vasculature due to
tumor mass effect and/or herniation of normal brain tis-
sue around the tumor when the dura is widely opened at
the outset of the operation.
When the tumor densely adheres to the dura and cra-
nium, another option is to perform a central craniectomy
prior to the craniotomy (Fig. 4). With this approach, neu-
ronavigation is used to drill a trough circumferentially
around the dural attachment. A craniotomy is then un-
dertaken, leaving the central bony island attached to the
tumor during the course of the dissection. Following the
resection, the bone flap is reconstructed using a combi-
nation of titanium mesh and methylmethacrylate. In our
experience, this combined bone flap reconstruction pro-
vides the highest level of reinforcement, as it resists both
tensile (mesh) and compressive (methylmethacrylate)
forces.

J Neurosurg / Volume 112 / May 2010 917

 N. Sanai et al.

Fig. 4.  Images demonstrating central craniectomy for adherent tumors. For tumors densely adherent to dura, such as the le-
sion seen on this preoperative axial contrast-enhanced T1-weighted MR image (A), a central craniectomy prior to the craniotomy
can facilitate resection. A central craniectomy is performed by drilling a trough around the dural attachment (B). A craniotomy
is then performed, leaving the central bony island attached to the tumor (C). Following the resection and duraplasty (D and E),
the bone flap is reconstructed (F and G) by using a combination of titanium mesh and methylmethacrylate. Successful cosmetic
reconstruction is demonstrated in a postoperative axial CT (H).

Conclusions   2.  Al-Mefty O: Meningiomas. New York: Raven Press, 1991

In the modern neurosurgical era—when menin-
giomas are often managed conservatively and radiosurgi-
cal treatment is an established alternative—we are seeing
a predominance of large or giant convexity meningiomas
treated with resection. It remains our practice that inciden-
tally discovered meningiomas are monitored with serial
imaging and resected only when they are symptomatic
or growing, regardless of their size. Our data suggest that
the current morbidity profile for these convexity menin-
giomas includes a 10% overall complication rate and at
least a 4% recurrence rate over nearly 4 years. Many of
the previously reported neurological morbidities, such
as new-onset postoperative epilepsy, have all but disap-
peared in current practice.
Disclaimer
The authors report no conflict of interest concerning the mate-
rials or methods used in this study or the findings specified in this
paper.
Acknowledgments
The authors thank their departmental illustrator, Kenneth X.
Probst, for all manuscript artwork.
References
  1.  Agnelli G, Piovella F, Buoncristiani P, Severi P, Pini M,
D’Angelo A, et al: Enoxaparin plus compression stockings
compared with compression stockings alone in the prevention
of venous thromboembolism after elective neurosurgery. N
Engl J Med 339:80–85, 1998
  3.  Auguste KI, McDermott MW: Salvage of infected craniotomy
bone flaps with the wash-in, wash-out indwelling antibiotic ir-
rigation system. Technical note and case series of 12 patients.
J Neurosurg 105:640–644, 2006
  4.  Baia GS, Stifani S, Kimura ET, McDermott MW, Pieper RO,
Lal A: Notch activation is associated with tetraploidy and en-
hanced chromosomal instability in meningiomas. Neoplasia
10:604–612, 2008
  5.  Black PM, Morokoff AP, Zauberman J: Surgery for extra-axial
tumors of the cerebral convexity and midline. Neurosurgery
62:1115–1123, 2008
  6.  Carvalho LH, Smirnov I, Baia GS, Modrusan Z, Smith JS,
Jun P, et al: Molecular signatures define two main classes of
meningiomas. Mol Cancer 6:64, 2007
  7.  Chan RC, Thompson GB: Morbidity, mortality, and quality of
life following surgery for intracranial meningiomas. A retro-
spective study in 257 cases. J Neurosurg 60:52–60, 1984
  8.  Cuevas IC, Slocum AL, Jun P, Costello JF, Bollen AW, Rig-
gins GJ, et al: Meningioma transcript profiles reveal deregu-
lated Notch signaling pathway. Cancer Res 65:5070–5075,
2005
  9.  Cushing H, Eisenhardt L: Meningiomas: Their Classifica-
tion, Regional Behaviour, Life History, and Surgical End
Results. Springfield: Charles C. Thomas, 1938
10.  Figarella-Branger D, Vagner-Capodano AM, Bouillot P, Gra-
ziani N, Gambarelli D, Devictor B, et al: Platelet-derived
growth factor (PDGF) and receptor (PDGFR) expression in
human meningiomas: correlations with clinicopathological
features and cytogenetic analysis. Neuropathol Appl Neuro-
biol 20:439–447, 1994
11.  Flyger G: Epilepsy following radical removal of parasagittal
and convexity meningiomas. Acta Psychiatr Neurol Scand
31:245–251, 1956
12.  Giombini S, Solero CL, Morello G: Late outcome of opera-
tions for supratentorial convexity meningiomas. Report on
207 cases. Surg Neurol 22:588–594, 1984

918 J Neurosurg / Volume 112 / May 2010

Microsurgical removal of convexity meningiomas
13.  Ho DM, Hsu CY, Ting LT, Chiang H: Histopathology and
MIB-1 labeling index predicted recurrence of meningiomas: a
proposal of diagnostic criteria for patients with atypical men-
ingioma. Cancer 94:1538–1547, 2002
14.  Kim YJ, Ketter R, Henn W, Zang KD, Steudel WI, Feiden W:
Histopathologic indicators of recurrence in meningiomas:
correlation with clinical and genetic parameters. Virchows
Arch 449:529–538, 2006
15.  Kinjo T, al-Mefty O, Kanaan I: Grade zero removal of su-
pratentorial convexity meningiomas. Neurosurgery 33:394–
399, 1993
16.  Kleihues P, Sobin LH: World Health Organization classifica-
tion of tumors. Cancer 88:2887, 2000
17.  Kondziolka D, Mathieu D, Lunsford LD, Martin JJ, Madhok
R, Niranjan A, et al: Radiosurgery as definitive management
of intracranial meningiomas. Neurosurgery 62:53–60, 2008
18.  Maiuri F, De Caro Mdel B, Esposito F, Cappabianca P, Straz-
zullo V, Pettinato G, et al: Recurrences of meningiomas:
predictive value of pathological features and hormonal and
growth factors. J Neurooncol 82:63–68, 2007
19.  Mirimanoff RO, Dosoretz DE, Linggood RM, Ojemann RG,
Martuza RL: Meningioma: analysis of recurrence and pro-
gression following neurosurgical resection. J Neurosurg
62:18–24, 1985
20.  Modha A, Gutin PH: Diagnosis and treatment of atypical and
anaplastic meningiomas: a review. Neurosurgery 57:538–
550, 2005
21.  Morokoff AP, Zauberman J, Black PM: Surgery for convexity
meningiomas. Neurosurgery 63:427–434, 2008
22.  Olivecrona H: The meningiomas, in Olivecrona H, Tönnis
W (eds): Handbuch der Neurochirurgie. Berlin: Springer-
Verlag, 1967, pp 125–191
23.  Ozen O, Demirhan B, Altinors N: Correlation between histo-
logical grade and MIB-1 and p53 immunoreactivity in menin-
giomas. Clin Neuropathol 24:219–224, 2005
24.  Pimentel J, Fernandes A, Pinto AE, Fonseca I, Moura Nunes
JF, Lobo Antunes J: Clear cell meningioma variant and clini-
cal aggressiveness. Clin Neuropathol 17:141–146, 1998
25.  Simpson D: The recurrence of intracranial meningiomas after
surgical treatment. J Neurol Neurosurg Psychiatry 20:22–
39, 1957
26.  Sindou M, Hallacq P: Venous reconstruction in surgery of
J Neurosurg / Volume 112 / May 2010
meningiomas invading the sagittal and transverse sinuses.
Skull Base Surg 8:57–64, 1998
27.  Sindou MP, Alvernia JE: Results of attempted radical tumor
removal and venous repair in 100 consecutive meningiomas
involving the major dural sinuses. J Neurosurg 105:514–525,
2006
28.  Smith JS, Lal A, Harmon-Smith M, Bollen AW, McDermott
MW: Association between absence of epidermal growth fac-
tor receptor immunoreactivity and poor prognosis in patients
with atypical meningioma. J Neurosurg 106:1034–1040,
2007
29.  Takahashi JA, Ueba T, Hashimoto N, Nakashima Y, Katsuki
N: The combination of mitotic and Ki-67 indices as a useful
method for predicting short-term recurrence of meningiomas.
Surg Neurol 61:149–156, 2004
30.  Torp SH, Lindboe CF, Gronberg BH, Lydersen S, Sundstrom
S: Prognostic significance of Ki-67/MIB-1 proliferation index
in meningiomas. Clin Neuropathol 24:170–174, 2005
31.  Tsai JC, Goldman CK, Gillespie GY: Vascular endothelial
growth factor in human glioma cell lines: induced secretion
by EGF, PDGF-BB, and bFGF. J Neurosurg 82:864–873,
1995
32.  Yamasaki F, Yoshioka H, Hama S, Sugiyama K, Arita K,
Kurisu K: Recurrence of meningiomas. Cancer 89:1102–
1110, 2000
33.  Yang SY, Xu GM: Expression of PDGF and its receptor as
well as their relationship to proliferating activity and apopto-
sis of meningiomas in human meningiomas. J Clin Neurosci
8 (Suppl 1):49–53, 2001
34.  Yano S, Kuratsu J: Indications for surgery in patients with as-
ymptomatic meningiomas based on an extensive experience.
J Neurosurg 105:538–543, 2006
Manuscript submitted November 11, 2008.
Accepted June 26, 2009.
Please include this information when citing this paper: pub-
lished online July 31, 2009; DOI: 10.3171/2009.6.JNS081490.
Address correspondence to: Michael W. McDermott, M.D., De­­­-
part­­ment of Neurological Surgery, University of California, San
Francisco, 505 Parnassus Avenue, Box 0112, San Francisco,
California 94143. email: mcdermottm@neurosurg.ucsf.edu.
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