Meningioma occurring in the intracranial cavity is the most common primary extra-axial tumor of the central nervous system, accounting for 35–40% of all primary brain tumors. They are derived from the meninges, specifically from arachnoid cap cells, and are usually slow-growing and have generally benign biological behavior. Although the cells of meningiomas are non-cancerous, the tumor can still cause severe neurological dysfunction from compression of neighboring brain tissue, cranial nerves, and blood vessels. Intracranial meningioma is more common in older age groups and is more prevalent in women, indicating a possible hormonal component in the development of tumors. New developments in brain imaging are also helping to identify more non-symptomatic meningiomas, especially in older adults [1,2].

The clinical manifestations of intracranial meningioma are related mainly to the size, location, brain edema, and mass effects of the tumor. The most frequent symptoms are persistent headache, seizures, focal neurologic deficit, cognitive dysfunction, visual disturbance, cranial nerve deficit, and gait instability. Magnetic resonance imaging (MRI) remains the imaging modality of choice because it best delineates tumor margins, vascular involvement, dural attachment, and peritumoral edema. The definitive diagnosis and grading, as per the World Health Organization (WHO) classification, are made by histopathological examination following surgical removal [3,4]. Surgical resection is the most important treatment option for symptomatic, growing, or radiologically suspicious meningiomas. The goals of surgery are to remove the tumor completely, maintain neurologic function, minimize the risk of recurrence, and enhance patients' quality of life.

The extent of surgical resection is frequently evaluated using the Simpson scale, which has been shown to correlate well with long-term recurrence. Subtotal resection is usually associated with higher recurrence rates and poorer long-term outcomes. In contrast, gross total resection (Simpson Grades I and II) is associated with lower recurrence rates and better long-term outcomes. Complete removal, however, is not always possible when the tumor is near the eloquent cortex, the structures of the skull base, the venous sinuses, or the cranial nerves. These tumors are very difficult to operate on and have a higher risk of postoperative neurological deficits [5,6]. There are many patient- and tumor-related factors that influence postoperative outcomes. Poor postoperative recovery has been linked to advanced age, larger tumor size, high WHO grade, extensive peritumoral edema, skull base location, subtotal resection, and pre-existing neurological impairment. In contrast, younger patients with WHO grade I tumors who have undergone gross total resection tend to achieve excellent neurological recovery, with the majority having long periods of clinical progression-free survival.

Despite the significant improvements in microsurgical techniques, neuronavigation, neurasthenia, intraoperative neurophysiological monitoring, and perioperative critical care, postoperative complications like cerebrospinal fluid leakage, surgical site infection, seizures, intracranial hematoma, hydrocephalus, and new neurological deficits are still significant factors in patient morbidity [7,8]. The concepts of functional outcome measurement have been integrated into meningioma surgery as one of its most important components. There are objective measures of postoperative functional independence and quality of life, such as the Karnofsky Performance Status (KPS). Recurrence of the tumor is also a possibility after seemingly complete removal, especially in higher-grade lesions, and long-term surveillance with serial neuroimaging is also important. Thus, the need to identify reliable prognostic factors remains fundamental to risk stratification, patient counseling, individualized treatment planning, and optimization of follow-up protocols [9,10]. The present study aimed to assess clinical outcomes among patients with intracranial meningioma treated at a tertiary care neurosurgical center and to identify prognosis-related factors influencing neurological outcomes, complications, recurrence, and functional outcomes.

Study Objectives

To assess clinical outcomes after surgery for intracranial meningiomas and to identify prognostic factors affecting neurological recovery, complications, clinical function, recurrence, and short-term surgical results.

Study Design and Setting

This retrospective descriptive study was conducted in the Department of Neurosurgery, Ayub Teaching Hospital, MTI, Abbottabad, Pakistan, from January 2022 to December 2025.

Participants

Patients in the study were 100 consecutive adult patients in whom an intracranial meningioma was diagnosed during the study period and who underwent microsurgical resection. Contrast-enhanced magnetic resonance imaging was used to make the diagnosis, and it was confirmed by postoperative histopathology. Demographic, radiological, operative, histopathological, and follow-up data were retrieved from the electronic hospital records and patient files.

Sample Size Calculation

The WHO sample size calculator was used to determine a sample size of 100 patients at a 95% confidence level, 8% margin of error, with an expected proportion of favorable postoperative outcomes of 80%. All patients who had surgery during the study period were recruited by consecutive sampling.

Inclusion Criteria

• Adults, 18 years or older.
• Intracranial meningioma with confirmation on the X-ray.
• Histopathological diagnosis after surgery for meningioma.
• Patients with primary microsurgical tumor resection.
• Fill out demographic, operative, and follow-up charts.
• At least six months of follow-up period.

Exclusion Criteria

• Recurrent intracranial meningiomas.
• Patients only treated with stereotactic radiosurgery.
• Incomplete medical records.
• Multiple intracranial tumors.
• Spinal meningiomas.
• Follow-up time is less than 6 months.

Diagnostic & Management Strategy

Neurological examination, contrast-enhanced MRI, routine laboratory tests, and anesthetic assessment were performed for all patients. Microsurgical tumor resection was undertaken with neuronavigation, if available. Histopathological grading was performed according to WHO criteria. Patients were given standardized postoperative intensive care and rehabilitation, and a radiological follow-up was planned.

Statistical Analysis

The data obtained were analyzed using the SPSS program version 27. Data were presented using mean ± SD for continuous variables and frequencies and percentages for categorical variables. Categorical comparisons were performed using chi-square or Fisher's exact tests, and continuous variables were analyzed using Student's t-test. Statistically significant results were defined as p-values <0.05.

A total of 100 patients underwent surgical resection for intracranial meningioma. The mean age was 52.8 ± 11.6 years (range: 24–78 years), with females accounting for 68% and males for 32%. Headache (76%) was the most common presenting complaint, followed by seizures (34%), focal neurological deficits (29%), visual disturbances (18%), and cognitive impairment (11%). Convexity meningiomas constituted 35% of tumors, followed by parasagittal (24%), sphenoid wing (18%), fascine (12%), and posterior fossa (11%).

WHO Grade I tumors represented 82% of cases, Grade II 14%, and Grade III 4%. Gross total resection (Simpson Grade I–II) was achieved in 78 patients, and subtotal resection in 22 patients. Favorable postoperative functional outcomes (KPS ≥80) were observed in 84% of patients at six months. Postoperative complications occurred in 19% of patients, including seizures (6%), surgical site infection (5%), cerebrospinal fluid leakage (4%), and postoperative hematoma (4%).

Tumor recurrence developed in 8% during follow-up. Gross total resection was significantly associated with better functional recovery than subtotal resection (91.0% vs. 59.1%; p=0.002). Higher WHO tumor grade independently predicted recurrence (p=0.001), while age >60 years was significantly associated with postoperative complications (p=0.021). Overall mortality was 2%.

Table 1. Baseline Demographic and Clinical Characteristics of the Study Population (n = 100)

Values are presented as frequency (percentage) unless otherwise specified. Patients may have presented with more than one clinical symptom.

Table 2. Tumor Characteristics and Surgical Findings (n = 100)

Tumor grading was based on the World HeWorld Health Organization (WHO) classification. Extent of surgical resection was categorized according to the Simpson grading system.

Table 3. Postoperative Clinical Outcomes and Complications

Functional outcome was evaluated using the Karnofsky Performance Status (KPS) at six-month follow-up. Some patients experienced more than one postoperative complication.

Table 4. Prognostic Factors Associated with Favorable Functional Outcome

Associations were evaluated using the Chi-square test. A p-value <0.05 was considered statistically significant. Gross total resection, lower WHO tumor grade, and younger age were significantly associated with favorable postoperative functional outcomes.

This retrospective cohort study aimed to assess clinical outcomes and prognostic factors among 100 patients with intracranial meningioma who underwent surgical resection. The results showed good overall functional outcomes following surgery in most patients, with an 84% Karnofsky Performance Status (KPS) score≥80 at six months. Gross total resection (Simpson Grades I–II) was significantly correlated with better postoperative outcomes, and worse functional outcomes were associated with advanced WHO tumor grade, older age, and subtotal resection. Overall, 78% of patients achieved gross total resection and experienced better outcomes. The study agrees with the current literature on the importance of complete tumor removal and tumor biology for long-term prognosis [11,12].

The demographic features of this current study revealed that females constituted 68% of the sample, and the mean age was 52.8 ± 11.6 years. The current multi-center studies from 2020 to 2025 have shown that intracranial meningiomas are more common in middle-aged and older women, due to the hormonal influence and the age-related rise in the incidence of the tumor [13,14]. The prevalence of convexity and parasagittal meningiomas in our cohort is also similar to recent epidemiological studies, which found that these were the most frequently surgically treated intracranial meningiomas [15]. The primary goal of surgery for meningioma is gross total resection (GTR), as it results in better local tumor control and reduces recurrence. Gross total resection was achieved in 78% of patients and was associated with significantly better functional results than subtotal resection (91.0% vs. 59.1%, p=0.002). These results are corroborated by recent neurosurgical series, which show that complete resection is associated with improved progression-free survival and neurological function, and reduced risk of recurrence [16].

However, subtotal resection is still required in those tumors involving the skull base, venous sinuses, and eloquent brain areas where further surgical procedures might lead to permanent neurological deficits [17]. Another significant prognostic factor was histopathological grade. The majority of cases were WHO Grade I (82%), with the remainder WHO Grades II and III (18%). Patients with higher-grade tumors had significantly higher recurrence rates (p=0.001), as several recent studies have shown that atypical and anaplastic meningiomas have a more aggressive biological behavior, higher proliferation rate, and shorter progression-free survival despite a good surgical resection [18]. The observations confirm the current indications for close postoperative surveillance and the use of adjuvant radiotherapy in a selected group of high-grade tumors [19]. Postoperative complications were observed in 19% of the patients, the most common of which were seizures, surgical site infection, cerebrospinal fluid leakage, and postoperative hematoma.

The overall complication rate is similar to recent reports of complications ranging from 15% to 25% in patients with intracranial meningioma surgery. Most importantly, the overall mortality rate in the present study, which is low at only 2%, is due to progress in microsurgical skills, neuronavigational, neuroasthenia, neurocritical care during the perioperative period, and standardized management during the postoperative period, the latter of which has been achieved in the past decade [20,21]. Increased age was the only factor that was significant for postoperative complications (p=0.021), consistent with more recent studies showing that elderly patients are at higher perioperative risk due to impaired physiological reserve, multiple comorbidities, and impaired capacity for neurological recovery [22]. Despite these difficulties, several recent studies have demonstrated that good functional outcomes can still be achieved in well-selected elderly patients when they are optimally treated in the perioperative period and when the operation is carefully planned [23].

Complete recovery is the main objective of meningioma surgery. The results of the present study indicate that 84% of patients had good postoperative functional status, a rate similar to recent international studies reporting good recovery (75%–90%) after complete resection of WHO Grade I meningiomas. Taken together, these results indicate that thorough patient selection, maximal safe resection, early diagnosis, and planned after-treatment are critical factors for the successful long-term results. Longer follow-up periods and molecular characterization in prospective multicenter studies could further elucidate prognosis and inform personalized treatment approaches for patients with intracranial meningioma [24,25].

Limitations

There are several limitations of this study. It is a single-center retrospective study, which may limit the generalizability of the results. The six-month follow-up period and small number of patients may have led to an underestimation of long-term outcomes, including recurrence and survival. Also, molecular markers and health-related quality of life were not assessed, which could further stratify prognosis.

Surgical resection is the mainstay of management for intracranial meningiomas and is associated with favorable functional outcomes in most patients. A better prognosis was correlated with gross total resection, lower WHO tumor grade, and younger age. To achieve optimal outcomes and minimize recurrence of the tumor, careful surgical planning, individualized treatment, and long-term postoperative follow-up are crucial.

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