Preoperative tumor and edema volumes as predictors of ischemia and morbidity after intracranial meningioma surgery

Abstract Background Ischemic complications remain a significant risk indicator of morbidity after meningioma surgery. While tumor size and extent of resection (EOR) are recognized risk factors, the prognostic impact of peritumoral brain edema volume (PTBEV) is not fully established. This study investigated whether preoperative tumor volume (TV) and PTBEV independently predict postoperative ischemia and neurological morbidity. Methods We retrospectively investigated 152 patients who underwent resection of intracranial meningiomas from 2008 to 2023. Preoperative post-contrast T1W and Fluid-Attenuated Inversion Recovery (FLAIR) MRI were used to quantify TV and PTBEV, and postoperative DWI within 72 hours post-surgery was used to identify ischemic lesions. Volumetric segmentation was performed in 3D Slicer™ and validated by five independent reviewers. Statistical analysis included Spearman’s correlation, univariate and multivariate linear regression for predictors of postoperative ischemic volume (PIV), and binary logistic regression for new neurological deficits. The P value < .05 was considered significant. Results Median preoperative TV was 23.1 cm³ (IQR 9.3-48.4 cm³), and PTBEV was 3.5 cm³ (IQR 0.0-28.4 cm³). Median PIV was 1.5 cm³ (IQR 0.0-5.3). PIV correlated with preoperative TV (r = 0.393, P < .001) and PTBEV (r = 0.446, P < .001). Multivariate regression identified preoperative PTBEV (P < .001), preoperative TV (P = .015), and subtotal resection (STR) vs. GTR (P = .033) as independent predictors of postoperative ischemia. Overall, 11.8% of the patients developed new neurological deficits (1.3% permanent). Ischemic volumes >2 cm³ significantly increased risk of new neurological non-cranial nerve deficits (OR = 6.667, 95% CI 1.408-31.556, P = .017). Conclusion Preoperative tumor and edema volumes are independent predictors of postoperative ischemia. Even modest ischemic lesions (>2 cm³) can cause clinically relevant morbidity. Volumetric biomarkers should be integrated into surgical planning, with prospective multicenter validation warranted.