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Semin Neurol 2024; 44(01): 001-015
DOI: 10.1055/s-0043-1777352
Review Article

The Natural History and Treatment of Meningiomas: An Update

Arsene Daniel Nyalundja
1   Faculty of Medicine, Center for Tropical Diseases and Global Health, Université Catholique de Bukavu, Kadutu, Bukavu, South Kivu, Democratic Republique of Congo
,
Fabrice Mugisha
2   Neurosurgery Unit, Department of Surgery, Rwanda Military Hospital, Kigali, Rwanda
,
Claire Karekezi 
2   Neurosurgery Unit, Department of Surgery, Rwanda Military Hospital, Kigali, Rwanda
› Author Affiliations Funding None.
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Abstract

Meningiomas are the most frequent nonmalignant tumors of the central nervous system (CNS). Despite their benign nature and slow-growing pattern, if not diagnosed early, these tumors may reach relatively large sizes causing significant morbidity and mortality. Some variants are located in hard-to-access locations, compressing critical neurovascular structures, and making the surgical management even more challenging. Although most meningiomas have a good long-term prognosis after treatment, there are still controversies over their management in a subset of cases. While surgery is the first-line treatment, the use of fractionated radiotherapy or stereotactic radiosurgery is indicated for residual or recurrent tumors, small lesions, and tumors in challenging locations. Advances in molecular genetics and ongoing clinical trial results have recently helped both to refine the diagnosis and provide hope for effective biomolecular target-based medications for treatment. This article reviews the natural history and current therapeutic options for CNS meningiomas.

Keywords

meningioma - central nervous system - tumor - surgery - natural history


Publication History

Article published online:
05 December 2023

© 2023. Thieme. All rights reserved.

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  • References

  • 1 Albayrak SB, Black PM. The origin of meningiomas. In: Pamir MN, Black PM, Fahlbusch R. eds. Meningiomas. W.B. Saunders; 2010: 53-60
    CrossrefGoogle Scholar
  • 2 Kshettry VR, Ostrom QT, Kruchko C, Al-Mefty O, Barnett GH, Barnholtz-Sloan JS. Descriptive epidemiology of World Health Organization grades II and III intracranial meningiomas in the United States. Neuro-oncol 2015; 17 (08) 1166-1173
    CrossrefPubMedGoogle Scholar
  • 3 Ostrom QT, Cioffi G, Gittleman H. et al. CBTRUS Statistical Report: primary brain and other central nervous system tumors diagnosed in the United States in 2012-2016. Neuro-oncol 2019; 21 (Suppl. 05) v1-v100
    CrossrefPubMedGoogle Scholar
  • 4 Lim YS, Kim MK, Park BJ, Kim TS, Lim YJ. Long term clinical outcomes of malignant meningiomas. Brain Tumor Res Treat 2013; 1 (02) 85-90
    CrossrefPubMedGoogle Scholar
  • 5 Wiemels J, Wrensch M, Claus EB. Epidemiology and etiology of meningioma. J Neurooncol 2010; 99 (03) 307-314
    CrossrefPubMedGoogle Scholar
  • 6 Baldi I, Engelhardt J, Bonnet C. et al. Epidemiology of meningiomas. Neurochirurgie 2018; 64 (01) 5-14
    CrossrefPubMedGoogle Scholar
  • 7 Louis DN, Perry A, Reifenberger G. et al. The 2016 World Health Organization Classification of tumors of the central nervous system: a summary. Acta Neuropathol 2016; 131 (06) 803-820
    CrossrefPubMedGoogle Scholar
  • 8 Louis DN, Perry A, Wesseling P. et al. The 2021 WHO Classification of tumors of the central nervous system: a summary. Neuro-oncol 2021; 23 (08) 1231-1251
    CrossrefPubMedGoogle Scholar
  • 9 Harter PN, Braun Y, Plate KH. Classification of meningiomas-advances and controversies. Chin Clin Oncol 2017; 6 (Suppl. 01) S2-S2
    CrossrefPubMedGoogle Scholar
  • 10 Sun C, Dou Z, Wu J. et al. The preferred locations of meningioma according to different biological characteristics based on voxel-wise analysis. Front Oncol 2020; 10: 1412
    CrossrefPubMedGoogle Scholar
  • 11 Ostrom QT, Gittleman H, Fulop J. et al. CBTRUS Statistical Report: primary brain and central nervous system tumors diagnosed in the United States in 2008-2012. Neuro-oncol 2015; 17 (Suppl. 04) iv1-iv62
    CrossrefPubMedGoogle Scholar
  • 12 Dziuk TW, Woo S, Butler EB. et al. Malignant meningioma: an indication for initial aggressive surgery and adjuvant radiotherapy. J Neurooncol 1998; 37 (02) 177-188
    CrossrefPubMedGoogle Scholar
  • 13 Hammouche S, Clark S, Wong AHL, Eldridge P, Farah JO. Long-term survival analysis of atypical meningiomas: survival rates, prognostic factors, operative and radiotherapy treatment. Acta Neurochir (Wien) 2014; 156 (08) 1475-1481
    CrossrefPubMedGoogle Scholar
  • 14 Kanmounye US, Karekezi C, Nyalundja AD, Awad AK, Laeke T, Balogun JA. Adult brain tumors in Sub-Saharan Africa: a scoping review. Neuro-oncol 2022; 24 (10) 1799-1806
    CrossrefPubMedGoogle Scholar
  • 15 Meningiomas. Their classification, regional behaviour, life history, and surgical end results. Bull Med Libr Assoc 1938; 27 (02) 185
    PubMedGoogle Scholar
  • 16 Kurland LT, Schoenberg BS, Annegers JF, Okazaki H, Molgaard CA. The incidence of primary intracranial neoplasms in Rochester, Minnesota, 1935-1977. Ann N Y Acad Sci 1982; 381: 6-16
    CrossrefPubMedGoogle Scholar
  • 17 Achey RL, Gittleman H, Schroer J, Khanna V, Kruchko C, Barnholtz-Sloan JS. Nonmalignant and malignant meningioma incidence and survival in the elderly, 2005-2015, using the Central Brain Tumor Registry of the United States. Neuro-oncol 2019; 21 (03) 380-391
    CrossrefPubMedGoogle Scholar
  • 18 Ostrom QT, Gittleman H, Farah P. et al. CBTRUS statistical report: primary brain and central nervous system tumors diagnosed in the United States in 2006-2010. Neuro-oncol 2013; 15 (Suppl. 02) ii1-ii56
    CrossrefPubMedGoogle Scholar
  • 19 Holleczek B, Zampella D, Urbschat S. et al. Incidence, mortality and outcome of meningiomas: a population-based study from Germany. Cancer Epidemiol 2019; 62: 101562
    CrossrefPubMedGoogle Scholar
  • 20 Kang H, Song SW, Ha J. et al. A nationwide, population-based epidemiology study of primary central nervous system tumors in Korea, 2007-2016: a comparison with United States data. Cancer Res Treat 2021; 53 (02) 355-366
    CrossrefPubMedGoogle Scholar
  • 21 Mbi Feh MKN, Lyon KA, Brahmaroutu AV, Tadipatri R, Fonkem E. The need for a central brain tumor registry in Africa: a review of central nervous system tumors in Africa from 1960 to 2017. Neurooncol Pract 2021; 8 (03) 337-344
    PubMedGoogle Scholar
  • 22 Ostrom QT, Gittleman H, Truitt G, Boscia A, Kruchko C, Barnholtz-Sloan JS. CBTRUS Statistical Report: primary brain and other central nervous system tumors diagnosed in the United States in 2011-2015. Neuro-oncol 2018; 20 (Suppl. 04) iv1-iv86
    CrossrefPubMedGoogle Scholar
  • 23 Bachir S, Shah S, Shapiro S. et al. Neurofibromatosis Type 2 (NF2) and the implications for vestibular schwannoma and meningioma pathogenesis. Int J Mol Sci 2021; 22 (02) 690
    CrossrefPubMedGoogle Scholar
  • 24 Goutagny S, Kalamarides M. Meningiomas and neurofibromatosis. J Neurooncol 2010; 99 (03) 341-347
    CrossrefPubMedGoogle Scholar
  • 25 Aboukais R, Bonne NX, Baroncini M. et al. Management of multiple tumors in neurofibromatosis type 2 patients. Neurochirurgie 2018; 64 (05) 364-369
    CrossrefPubMedGoogle Scholar
  • 26 Phillips D, Auguste KI, Gupta N. Meningiomas in children. In: McDermott MW. ed. Handbook of Clinical Neurology. Vol 169. Meningiomas, Part I. Elsevier; 2020: 253-259 DOI: 10.1016/B978-0-12-804280-9.00016-0
    CrossrefGoogle Scholar
  • 27 Fan M-C, Fang W, Liu K. et al. Paediatric intracranial meningiomas: eight-year experience with 32 cases. Chin Neurosurg J 2017; 3 (01) 21
    CrossrefPubMedGoogle Scholar
  • 28 Thevandiran D, Nga V, Chang KTE. et al. Paediatric meningiomas in Singapore - case series of a rare entity. J Clin Neurosci 2020; 73: 62-66
    CrossrefPubMedGoogle Scholar
  • 29 Sadetzki S, Flint-Richter P, Starinsky S. et al. Genotyping of patients with sporadic and radiation-associated meningiomas. Cancer Epidemiol Biomarkers Prev 2005; 14 (04) 969-976
    CrossrefPubMedGoogle Scholar
  • 30 Ron E, Modan B, Boice Jr JD. et al. Tumors of the brain and nervous system after radiotherapy in childhood. N Engl J Med 1988; 319 (16) 1033-1039
    CrossrefPubMedGoogle Scholar
  • 31 Thompson DE, Mabuchi K, Ron E. et al. Cancer incidence in atomic bomb survivors. Part II: Solid tumors, 1958-1987. Radiat Res 1994; 137 (2, suppl): S17-S67
    CrossrefPubMedGoogle Scholar
  • 32 Bowers DC, Nathan PC, Constine L. et al. Subsequent neoplasms of the CNS among survivors of childhood cancer: a systematic review. Lancet Oncol 2013; 14 (08) e321-e328
    CrossrefPubMedGoogle Scholar
  • 33 Harrison MJ, Wolfe DE, Lau TS, Mitnick RJ, Sachdev VP. Radiation-induced meningiomas: experience at the Mount Sinai Hospital and review of the literature. J Neurosurg 1991; 75 (04) 564-574
    CrossrefPubMedGoogle Scholar
  • 34 Rubinstein AB, Shalit MN, Cohen ML, Zandbank U, Reichenthal E. Radiation-induced cerebral meningioma: a recognizable entity. J Neurosurg 1984; 61 (05) 966-971
    CrossrefPubMedGoogle Scholar
  • 35 Soffer D, Gomori JM, Siegal T, Shalit MN. Intracranial meningiomas after high-dose irradiation. Cancer 1989; 63 (08) 1514-1519
    CrossrefPubMedGoogle Scholar
  • 36 Tabernero MD, Maillo A, Gil-Bellosta CJ. et al. Gene expression profiles of meningiomas are associated with tumor cytogenetics and patient outcome. Brain Pathol 2009; 19 (03) 409-420
    CrossrefPubMedGoogle Scholar
  • 37 Ragel BT, Jensen RL. Molecular genetics of meningiomas. Neurosurg Focus 2005; 19 (05) E9
    CrossrefPubMedGoogle Scholar
  • 38 Kalamarides M, Niwa-Kawakita M, Leblois H. et al. Nf2 gene inactivation in arachnoidal cells is rate-limiting for meningioma development in the mouse. Genes Dev 2002; 16 (09) 1060-1065
    CrossrefPubMedGoogle Scholar
  • 39 Müller P, Henn W, Niedermayer I. et al. Deletion of chromosome 1p and loss of expression of alkaline phosphatase indicate progression of meningiomas. Clin Cancer Res 1999; 5 (11) 3569-3577
    PubMedGoogle Scholar
  • 40 Ketter R, Henn W, Niedermayer I. et al. Predictive value of progression-associated chromosomal aberrations for the prognosis of meningiomas: a retrospective study of 198 cases. J Neurosurg 2001; 95 (04) 601-607
    CrossrefPubMedGoogle Scholar
  • 41 Karsy M, Azab MA, Abou-Al-Shaar H. et al. Clinical potential of meningioma genomic insights: a practical review for neurosurgeons. Neurosurg Focus 2018; 44 (06) E10
    CrossrefPubMedGoogle Scholar
  • 42 Ogasawara C, Philbrick BD, Adamson DC. Meningioma: a review of epidemiology, pathology, diagnosis, treatment, and future directions. Biomedicines 2021; 9 (03) 319
    CrossrefPubMedGoogle Scholar
  • 43 Lee YS, Lee YS. Molecular characteristics of meningiomas. J Pathol Transl Med 2020; 54 (01) 45-63
    CrossrefPubMedGoogle Scholar
  • 44 Yakubov E, Ghoochani A, Buslei R, Buchfelder M, Eyüpoglu IY, Savaskan N. Hidden association of Cowden syndrome, PTEN mutation and meningioma frequency. Oncoscience 2016; 3 (5-6): 149-155
    CrossrefPubMedGoogle Scholar
  • 45 Youngblood MW, Duran D, Montejo JD. et al. Correlations between genomic subgroup and clinical features in a cohort of more than 3000 meningiomas. J Neurosurg 2019; DOI: 10.3171/2019.8.JNS191266.
    CrossrefPubMedGoogle Scholar
  • 46 Sahm F, Schrimpf D, Stichel D. et al. DNA methylation-based classification and grading system for meningioma: a multicentre, retrospective analysis. Lancet Oncol 2017; 18 (05) 682-694
    CrossrefPubMedGoogle Scholar
  • 47 Driver J, Hoffman SE, Tavakol S. et al. A molecularly integrated grade for meningioma. Neuro-oncol 2022; 24 (05) 796-808
    CrossrefPubMedGoogle Scholar
  • 48 Perry A, Stafford SL, Scheithauer BW, Suman VJ, Lohse CM. Meningioma grading: an analysis of histologic parameters. Am J Surg Pathol 1997; 21 (12) 1455-1465
    CrossrefPubMedGoogle Scholar
  • 49 Nassiri F, Liu J, Patil V. et al. A clinically applicable integrative molecular classification of meningiomas. Nature 2021; 597 (7874): 119-125
    CrossrefPubMedGoogle Scholar
  • 50 Goldbrunner R, Stavrinou P, Jenkinson MD. et al. EANO guideline on the diagnosis and management of meningiomas. Neuro-oncol 2021; 23 (11) 1821-1834
    CrossrefPubMedGoogle Scholar
  • 51 Yamashita J, Handa H, Iwaki K, Abe M. Recurrence of intracranial meningiomas, with special reference to radiotherapy. Surg Neurol 1980; 14 (01) 33-40
    PubMedGoogle Scholar
  • 52 Goffaux P, Fortin D. Brain tumor headaches: from bedside to bench. Neurosurgery 2010; 67 (02) 459-466
    CrossrefPubMedGoogle Scholar
  • 53 Zouaoui S, Darlix A, Rigau V. et al; French Brain Tumor DataBase (FBTDB) Participants and Investigators, with the participation of the Société française de neurochirurgie (SFNC), Club de neuro-oncologie de la SFNC, Société française de neuropathologie (SFNP), Association des neuro-oncologues d'expression française (ANOCEF). Descriptive epidemiology of 13,038 newly diagnosed and histologically confirmed meningiomas in France: 2006-2010. Neurochirurgie 2018; 64 (01) 15-21
    CrossrefPubMedGoogle Scholar
  • 54 Elbadry Ahmed R, Tang H, Asemota A, Huang L, Boling W, Bannout F. Meningioma related epilepsy - pathophysiology, pre/postoperative seizures predicators and treatment. Front Oncol 2022; 12: 905976
    CrossrefPubMedGoogle Scholar
  • 55 Hess K, Spille DC, Adeli A. et al. Brain invasion and the risk of seizures in patients with meningioma. J Neurosurg 2018; 130 (03) 789-796
    CrossrefPubMedGoogle Scholar
  • 56 Alruwaili AA, De Jesus O. Meningioma. In: StatPearls. StatPearls Publishing; 2022. Accessed February 19, 2023 at: http://www.ncbi.nlm.nih.gov/books/NBK560538/
    Google Scholar
  • 57 Musa MJ, Zeppieri M. Foster Kennedy Syndrome. In: StatPearls.: StatPearls Publishing; 2022. Accessed February 25, 2023 at: http://www.ncbi.nlm.nih.gov/books/NBK582149/
    Google Scholar
  • 58 Samartzis D, Gillis CC, Shih P, O'Toole JE, Fessler RG. Intramedullary spinal cord tumors: Part I - Epidemiology, pathophysiology, and diagnosis. Global Spine J 2015; 5 (05) 425-435
    CrossrefPubMedGoogle Scholar
  • 59 Huang RY, Bi WL, Griffith B. et al; International Consortium on Meningiomas. Imaging and diagnostic advances for intracranial meningiomas. Neuro-oncol 2019; 21 (Suppl. 01) i44-i61
    CrossrefPubMedGoogle Scholar
  • 60 Lyndon D, Lansley JA, Evanson J, Krishnan AS. Dural masses: meningiomas and their mimics. Insights Imaging 2019; 10 (01) 11
    CrossrefPubMedGoogle Scholar
  • 61 Hou J, Kshettry VR, Selman WR, Bambakidis NC. Peritumoral brain edema in intracranial meningiomas: the emergence of vascular endothelial growth factor-directed therapy. Neurosurg Focus 2013; 35 (06) E2
    CrossrefPubMedGoogle Scholar
  • 62 Kim BW, Kim MS, Kim SW, Chang CH, Kim OL. Peritumoral brain edema in meningiomas: correlation of radiologic and pathologic features. J Korean Neurosurg Soc 2011; 49 (01) 26-30
    CrossrefPubMedGoogle Scholar
  • 63 Aoki S, Sasaki Y, Machida T, Tanioka H. Contrast-enhanced MR images in patients with meningioma: importance of enhancement of the dura adjacent to the tumor. AJNR Am J Neuroradiol 1990; 11 (05) 935-938
    PubMedGoogle Scholar
  • 64 Watts J, Box G, Galvin A, Brotchie P, Trost N, Sutherland T. Magnetic resonance imaging of meningiomas: a pictorial review. Insights Imaging 2014; 5 (01) 113-122
    CrossrefPubMedGoogle Scholar
  • 65 Kessler RA, Garzon-Muvdi T, Yang W. et al. Metastatic atypical and anaplastic meningioma: a case series and review of the literature. World Neurosurg 2017; 101: 47-56
    CrossrefPubMedGoogle Scholar
  • 66 Goldsher D, Litt AW, Pinto RS, Bannon KR, Kricheff II. Dural “tail” associated with meningiomas on Gd-DTPA-enhanced MR images: characteristics, differential diagnostic value, and possible implications for treatment. Radiology 1990; 176 (02) 447-450
    CrossrefPubMedGoogle Scholar
  • 67 Sotoudeh H, Yazdi HR. A review on dural tail sign. World J Radiol 2010; 2 (05) 188-192
    CrossrefPubMedGoogle Scholar
  • 68 Tsuchiya K, Katase S, Yoshino A, Hachiya J. MR digital subtraction angiography in the diagnosis of meningiomas. Eur J Radiol 2003; 46 (02) 130-138
    CrossrefPubMedGoogle Scholar
  • 69 Yin Y, Li Y, Jiang Z. et al. Clinical outcomes and complications of preoperative embolization for intracranial giant meningioma tumorectomy: a retrospective, observational, matched cohort study. Front Oncol 2022; 12: 852327
    CrossrefPubMedGoogle Scholar
  • 70 Papacci F, Pedicelli A, Montano N. The role of preoperative angiography in the management of giant meningiomas associated to vascular malformation. Surg Neurol Int 2015; 6: 114
    CrossrefPubMedGoogle Scholar
  • 71 Meling TR, Da Broi M, Scheie D, Helseth E, Smoll NR. Meningioma surgery - Are we making progress?. World Neurosurg 2019; 125: e205-e213
    CrossrefPubMedGoogle Scholar
  • 72 NCCN Clinical Practice Guidelines in Oncology - Central Nervous System Cancers. National Comprehensive Cancer Network. Accessed February 27, 2023 at: https://www.nccn.org/professionals/physician_gls/pdf/cns.pdf
    PubMed
  • 73 Chotai S, Schwartz TH. The Simpson grading: Is it still valid?. Cancers (Basel) 2022; 14 (08) 2007
    CrossrefPubMedGoogle Scholar
  • 74 Wong RH, Wong AK, Vick N, Farhat HI. Natural history of multiple meningiomas. Surg Neurol Int 2013; 4: 71
    CrossrefPubMedGoogle Scholar
  • 75 Spille DC, Hess K, Bormann E. et al. Risk of tumor recurrence in intracranial meningiomas: comparative analyses of the predictive value of the postoperative tumor volume and the Simpson classification. J Neurosurg 2020; 134 (06) 1764-1771
    CrossrefPubMedGoogle Scholar
  • 76 Voß KM, Spille DC, Sauerland C. et al. The Simpson grading in meningioma surgery: does the tumor location influence the prognostic value?. J Neurooncol 2017; 133 (03) 641-651
    CrossrefPubMedGoogle Scholar
  • 77 Schwartz TH, McDermott MW. The Simpson grade: abandon the scale but preserve the message. J Neurosurg 2020; DOI: 10.3171/2020.6.JNS201904.
    CrossrefPubMedGoogle Scholar
  • 78 El-Hajj VG, Pettersson-Segerlind J, Fletcher-Sandersjöö A, Edström E, Elmi-Terander A. Current knowledge on spinal meningiomas epidemiology, tumor characteristics and non-surgical treatment options: a systematic review and pooled analysis (Part 1). Cancers (Basel) 2022; 14 (24) 6251
    CrossrefPubMedGoogle Scholar
  • 79 Wang N, Osswald M. Meningiomas: overview and new directions in therapy. Semin Neurol 2018; 38 (01) 112-120
    Article in Thieme ConnectPubMedGoogle Scholar
  • 80 Mair MJ, Berghoff AS, Brastianos PK, Preusser M. Emerging systemic treatment options in meningioma. J Neurooncol 2023; 161 (02) 245-258
    CrossrefPubMedGoogle Scholar
  • 81 Choudhury A, Magill ST, Eaton CD. et al. Meningioma DNA methylation groups identify biological drivers and therapeutic vulnerabilities. Nat Genet 2022; 54 (05) 649-659
    CrossrefPubMedGoogle Scholar
  • 82 Lynes J, Flores-Milan G, Rubino S. et al. Molecular determinants of outcomes in meningiomas. Front Oncol 2022; 12: 962702
    CrossrefPubMedGoogle Scholar
  • 83 Shahbandi A, Shah DS, Hadley CC, Patel AJ. The role of pharmacotherapy in treatment of meningioma: a systematic review. Cancers (Basel) 2023; 15 (02) 483
    CrossrefPubMedGoogle Scholar
  • 84 Ibraheem A, Pillai C, Okoye I. et al. Cancer clinical trials in Africa - an untapped opportunity: recommendations from AORTIC 2019 conference special interest group in clinical trials. JCO Glob Oncol 2021; 7: 1358-1363
    CrossrefPubMedGoogle Scholar
  • 85 Simpson D. The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry 1957; 20 (01) 22-39
    CrossrefPubMedGoogle Scholar
  • 86 Aizer AA, Bi WL, Kandola MS. et al. Extent of resection and overall survival for patients with atypical and malignant meningioma. Cancer 2015; 121 (24) 4376-4381
    CrossrefPubMedGoogle Scholar
  • 87 Yuzawa S, Nishihara H, Tanaka S. Genetic landscape of meningioma. Brain Tumor Pathol 2016; 33 (04) 237-247
    CrossrefPubMedGoogle Scholar
  • 88 Seliger C, Meier CR, Becker C. et al. Metabolic syndrome in relation to risk of meningioma. Oncotarget 2017; 8 (02) 2284-2292
    CrossrefPubMedGoogle Scholar
  • 89 Meng Y, Tang C, Yu J, Meng S, Zhang W. Exposure to lead increases the risk of meningioma and brain cancer: a meta-analysis. J Trace Elem Med Biol 2020; 60: 126474
    CrossrefPubMedGoogle Scholar
  • 90 Lee KS, Zhang JJY, Kirollos R, Santarius T, Nga VDW, Yeo TT. A systematic review and meta-analysis of the association between cyproterone acetate and intracranial meningiomas. Sci Rep 2022; 12 (01) 1942
    CrossrefPubMedGoogle Scholar
  • 91 Nanda A, Bir SC, Maiti TK, Konar SK, Missios S, Guthikonda B. Relevance of Simpson grading system and recurrence-free survival after surgery for World Health Organization Grade I meningioma. J Neurosurg 2017; 126 (01) 201-211
    CrossrefPubMedGoogle Scholar