Gamma Knife surgery for skull base meningiomas

Clinical article

Restricted access


Skull base meningiomas are challenging tumors owing in part to their close proximity to important neurovascular structures. Complete microsurgical resection can be associated with significant morbidity, and recurrence rates are not inconsequential. In this study, the authors evaluate the outcomes of skull base meningiomas treated with Gamma Knife surgery (GKS) both as an adjunct to microsurgery and as a primary treatment modality.


The authors performed a retrospective review of a prospectively compiled database detailing the outcomes in 255 patients with skull base meningiomas treated at the University of Virginia from 1989 to 2006. All patients had a minimum follow-up of 24 months. The group comprised 54 male and 201 female patients, with a median age of 55 years (range 19–85 years). One hundred nine patients were treated with upfront radiosurgery, and 146 patients were treated with GKS following resection. Patients were assessed clinically and radiographically at routine intervals following GKS. Factors predictive of new neurological deficit following GKS were assessed via univariate and multivariate analysis, and Kaplan-Meier analysis and Cox multivariate regression analysis were used to assess factors predictive of tumor progression.


Meningiomas were centered over the cerebellopontine angle in 43 patients (17%), the clivus in 40 (16%), the petroclival region in 28 (11%), the petrous region in 6 (2%), and the parasellar region in 138 (54%). The median duration of follow-up was 6.5 years (range 2–18 years). The mean preradiosurgery tumor volume was 5.0 cm3 (range 0.3–54.8 cm3).

At most recent follow-up, 220 patients (86%) displayed either no change or a decrease in tumor volume, and 35 (14%) displayed an increase in volume. Actuarial progression-free survival at 3, 5, and 10 years was 99%, 96%, and 79%, respectively. In Cox multivariate analysis, pre-GKS covariates associated with tumor progression included age greater then 65 years (HR 3.41, 95% CI 1.63–7.13, p = 0.001) and decreasing dose to tumor margin (HR 0.90, 95% CI 0.80–1.00, p = 0.05).

At most recent clinical follow-up, 230 patients (90%) demonstrated no change or improvement in their neurological condition and the condition of 25 patients had deteriorated (10%). In multivariate analysis, the factors predictive of new or worsening symptoms were increasing duration of follow-up (OR 1.01, 95% CI 1.00–1.02, p = 0.015), tumor progression (OR 2.91, 95% CI 1.60–5.31, p < 0.001), decreasing maximum dose (OR 0.90, 95% CI 0.84–0.97, p = 0.007), and petrous or clival location versus parasellar, petroclival, and cerebellopontine angle location (OR 3.47, 95% CI 1.23–9.74, p = 0.018).


Stereotactic radiosurgery offers a high rate of tumor control and neurological preservation in patients with skull base meningiomas. After radiosurgery, better outcomes were observed for those receiving an optimal radiosurgery dose and harboring tumors located in a cerebellopontine angle, parasellar, or petroclival location.

Abbreviations used in this paper: FSRT = fractionated stereotactic radiotherapy; GKS = Gamma Knife surgery; SRS = stereotactic radiosurgery.

Article Information

Address correspondence to: Robert M. Starke, M.D., M.Sc., Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia 22908. email:

Please include this information when citing this paper: published online December 16, 2011; DOI: 10.3171/2011.11.JNS11530.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Kaplan-Meier progression-free survival.

  • View in gallery

    Kaplan-Meier progression-free survival in patients with and without a history of surgery.


  • 1

    Al-Mefty O: Clinoidal meningiomas. J Neurosurg 73:8408491990

  • 2

    Al-Mefty OFox JLSmith RR: Petrosal approach for petroclival meningiomas. Neurosurgery 22:5105171988

  • 3

    Arnautović KIAl-Mefty OHusain M: Ventral foramen magnum meninigiomas. J Neurosurg 92:1 Suppl71802000

  • 4

    Bassiouni HAsgari SStolke D: Tuberculum sellae meningiomas: functional outcome in a consecutive series treated microsurgically. Surg Neurol 66:37452006

  • 5

    Bindal RGoodman JMKawasaki APurvin VKuzma B: The natural history of untreated skull base meningiomas. Surg Neurol 59:87922003

  • 6

    Chi JHMcDermott MW: Tuberculum sellae meningiomas. Neurosurg Focus 14:6e62003

  • 7

    Condra KSBuatti JMMendenhall WMFriedman WAMarcus RB JrRhoton AL: Benign meningiomas: primary treatment selection affects survival. Int J Radiat Oncol Biol Phys 39:4274361997

  • 8

    Couldwell WTFukushima TGiannotta SLWeiss MH: Petroclival meningiomas: surgical experience in 109 cases. J Neurosurg 84:20281996

  • 9

    Davidson LFishback DRussin JJWeiss MHYu CPagnini PG: Postoperative Gamma Knife surgery for benign meningiomas of the cranial base. Neurosurg Focus 23:4E62007

  • 10

    DeMonte FSmith HKal-Mefty O: Outcome of aggressive removal of cavernous sinus meningiomas. J Neurosurg 81:2452511994

  • 11

    DiBiase SJKwok YYovino SArena CNaqvi STemple R: Factors predicting local tumor control after gamma knife stereotactic radiosurgery for benign intracranial meningiomas. Int J Radiat Oncol Biol Phys 60:151515192004

  • 12

    Dufour HMuracciole XMétellus PRégis JChinot OGrisoli F: Long-term tumor control and functional outcome in patients with cavernous sinus meningiomas treated by radiotherapy with or without previous surgery: is there an alternative to aggressive tumor removal?. Neurosurgery 48:2852962001

  • 13

    Duma CMLunsford LDKondziolka DHarsh GR IVFlickinger JC: Stereotactic radiosurgery of cavernous sinus meningiomas as an addition or alternative to microsurgery. Neurosurgery 32:6997051993

  • 14

    Eustacchio STrummer MFuchs ISchröttner OSutter BPendl G: Preservation of cranial nerve function following Gamma Knife radiosurgery for benign skull base meningiomas: experience in 121 patients with follow-up of 5 to 9.8 years. Acta Neurochir Suppl 84:71762002

  • 15

    Feigl GCSamii MHorstmann GA: Volumetric follow-up of meningiomas: a quantitative method to evaluate treatment outcome of gamma knife radiosurgery. Neurosurgery 61:2812872007

  • 16

    Flannery TJKano HLunsford LDSirin STormenti MNiranjan A: Long-term control of petroclival meningiomas through radiosurgery. Clinical article. J Neurosurg 112:9579642010

  • 17

    Flickinger JCKondziolka DMaitz AHLunsford LD: Gamma knife radiosurgery of imaging-diagnosed intracranial meningioma. Int J Radiat Oncol Biol Phys 56:8018062003

  • 18

    Ganz JC: Gamma knife radiosurgery and its possible relationship to malignancy: a review. J Neurosurg 97:5 Suppl6446522002

  • 19

    Ganz JCReda WAAbdelkarim K: Gamma Knife surgery of large meningiomas: early response to treatment. Acta Neurochir (Wien) 151:182009

  • 20

    Goldsmith BJWara WMWilson CBLarson DA: Postoperative irradiation for subtotally resected meningiomas. A retrospective analysis of 140 patients treated from 1967 to 1990. J Neurosurg 80:1952011994

  • 21

    Han JHKim DGChung HTPark CKPaek SHKim CY: Gamma knife radiosurgery for skull base meningiomas: long-term radiologic and clinical outcome. Int J Radiat Oncol Biol Phys 72:132413322008

  • 22

    Harrison MJal-Mefty O: Tentorial meningiomas. Clin Neurosurg 44:4514661997

  • 23

    Hasegawa TKida YYoshimoto MKoike JIizuka HIshii D: Long-term outcomes of Gamma Knife surgery for cavernous sinus meningioma. J Neurosurg 107:7457512007

  • 24

    Haselsberger KMaier TDominikus KHoll EKurschel SOfner-Kopeinig P: Staged gamma knife radiosurgery for large critically located benign meningiomas: evaluation of a series comprising 20 patients. J Neurol Neurosurg Psychiatry 80:117211752009

  • 25

    Hudgins WRBarker JLSchwartz DENichols TD: Gamma Knife treatment of 100 consecutive meningiomas. Stereotact Funct Neurosurg 66:Suppl 11211281996

  • 26

    Ichinose TGoto TIshibashi KTakami TOhata K: The role of radical microsurgical resection in multimodal treatment for skull base meningioma. Clinical article. J Neurosurg 113:107210782010

  • 27

    Igaki HMaruyama KKoga TMurakami NTago MTerahara A: Stereotactic radiosurgery for skull base meningioma. Neurol Med Chir (Tokyo) 49:4564612009

  • 28

    Iwai YYamanaka KIkeda H: Gamma Knife radiosurgery for skull base meningioma: long-term results of low-dose treatment. Clinical article. J Neurosurg 109:8048102008

  • 29

    Iwai YYamanaka KNakajima H: The treatment of skull base meningiomas—combining surgery and radiosurgery. J Clin Neurosci 8:5285332001

  • 30

    Jääskeläinen J: Seemingly complete removal of histologically benign intracranial meningioma: late recurrence rate and factors predicting recurrence in 657 patients. A multivariate analysis. Surg Neurol 26:4614691986

  • 31

    Jung HWYoo HPaek SHChoi KS: Long-term outcome and growth rate of subtotally resected petroclival meningiomas: experience with 38 cases. Neurosurgery 46:5675752000

  • 32

    Kollová ALiscák RNovotný J JrVladyka VSimonová GJanousková L: Gamma Knife surgery for benign meningioma. J Neurosurg 107:3253362007

  • 33

    Kondziolka DFlickinger JCLunsford LD: The principles of skull base radiosurgery. Neurosurg Focus 24:5E112008

  • 34

    Kondziolka DMathieu DLunsford LDMartin JJMadhok RNiranjan A: Radiosurgery as definitive management of intracranial meningiomas. Neurosurgery 62:53602008

  • 35

    Kreil WLuggin JFuchs IWeigl VEustacchio SPapaefthymiou G: Long term experience of gamma knife radiosurgery for benign skull base meningiomas. J Neurol Neurosurg Psychiatry 76:142514302005

  • 36

    Lee JYNiranjan AMcInerney JKondziolka DFlickinger JCLunsford LD: Stereotactic radiosurgery providing long-term tumor control of cavernous sinus meningiomas. J Neurosurg 97:65722002

  • 37

    Linskey MEDavis SARatanatharathorn V: Relative roles of microsurgery and stereotactic radiosurgery for the treatment of patients with cranial meningiomas: a single-surgeon 4-year integrated experience with both modalities. J Neurosurg 102:Suppl59702005

  • 38

    Lo SSCho KHHall WAKossow RJHernandez WLMc-Collow KK: Single dose versus fractionated stereotactic radiotherapy for meningiomas. Can J Neurol Sci 29:2402482002

  • 39

    Loeffler JSNiemierko AChapman PH: Second tumors after radiosurgery: tip of the iceberg or a bump in the road?. Neurosurgery 52:143614422003

  • 40

    Lunsford LD: Contemporary management of meningiomas: radiation therapy as an adjuvant and radiosurgery as an alternative to surgical removal?. J Neurosurg 80:1871901994

  • 41

    Maire JPCaudry MGuérin JCélérier DSan Galli FCausse N: Fractionated radiation therapy in the treatment of intracranial meningiomas: local control, functional efficacy, and tolerance in 91 patients. Int J Radiat Oncol Biol Phys 33:3153211995

  • 42

    Mendenhall WMMorris CGAmdur RJFoote KDFriedman WA: Radiotherapy alone or after subtotal resection for benign skull base meningiomas. Cancer 98:147314822003

  • 43

    Metellus PRegis JMuracciole XFuentes SDufour HNanni I: Evaluation of fractionated radiotherapy and gamma knife radiosurgery in cavernous sinus meningiomas: treatment strategy. Neurosurgery 57:8738862005

  • 44

    Minniti GAmichetti MEnrici RM: Radiotherapy and radiosurgery for benign skull base meningiomas. Radiat Oncol 4:422009

  • 45

    Natarajan SKSekhar LNSchessel DMorita A: Petroclival meningiomas: multimodality treatment and outcomes at long-term follow-up. Neurosurgery 60:9659812007

  • 46

    Nicolato AForoni RAlessandrini FMaluta SBricolo AGerosa M: The role of Gamma Knife radiosurgery in the management of cavernous sinus meningiomas. Int J Radiat Oncol Biol Phys 53:99210002002

  • 47

    Nutting CBrada MBrazil LSibtain ASaran FWestbury C: Radiotherapy in the treatment of benign meningioma of the skull base. J Neurosurg 90:8238271999

  • 48

    Otani NMuroi CYano HKhan NPangalu AYonekawa Y: Surgical management of tuberculum sellae meningioma: role of selective extradural anterior clinoidectomy. Br J Neurosurg 20:1291382006

  • 49

    Pollock BEStafford SL: Results of stereotactic radiosurgery for patients with imaging defined cavernous sinus meningiomas. Int J Radiat Oncol Biol Phys 62:142714312005

  • 50

    Pollock BEStafford SLUtter AGiannini CSchreiner SA: Stereotactic radiosurgery provides equivalent tumor control to Simpson Grade 1 resection for patients with small- to medium-size meningiomas. Int J Radiat Oncol Biol Phys 55:100010052003

  • 51

    Roberti FSekhar LNKalavakonda CWright DC: Posterior fossa meningiomas: surgical experience in 161 cases. Surg Neurol 56:8212001

  • 52

    Rowe JGrainger AWalton LSilcocks PRadatz MKemeny A: Risk of malignancy after gamma knife stereotactic radiosurgery. Neurosurgery 60:60662007

  • 53

    Salvati MFrati ARusso NCaroli EPolli FMMinniti G: Radiation-induced gliomas: report of 10 cases and review of the literature. Surg Neurol 60:60672003

  • 54

    Sanna MBacciu AFalcioni MTaibah APiazza P: Surgical management of jugular foramen meningiomas: a series of 13 cases and review of the literature. Laryngoscope 117:171017192007

  • 55

    Schick UBleyen JBani AHassler W: Management of meningiomas en plaque of the sphenoid wing. J Neurosurg 104:2082142006

  • 56

    Sekhar LNSwamy NKJaiswal VRubinstein EHirsch WE JrWright DC: Surgical excision of meningiomas involving the clivus: preoperative and intraoperative features as predictors of postoperative functional deterioration. J Neurosurg 81:8608681994

  • 57

    Shamisa ABance MNag STator CWong SNorén G: Glioblastoma multiforme occurring in a patient treated with gamma knife surgery. Case report and review of the literature. J Neurosurg 94:8168212001

  • 58

    Sheehan JPWilliams BJYen CP: Stereotactic radiosurgery for WHO grade I meningiomas. J Neurooncol 99:4074162010

  • 59

    Shrivastava RKSen CCostantino PDDella Rocca R: Sphenoorbital meningiomas: surgical limitations and lessons learned in their long-term management. J Neurosurg 103:4914972005

  • 60

    Snell JWSheehan JStroila MSteiner L: Assessment of imaging studies used with radiosurgery: a volumetric algorithm and an estimation of its error. Technical note. J Neurosurg 104:1571622006

  • 61

    Stafford SLPerry ASuman VJMeyer FBScheithauer BWLohse CM: Primarily resected meningiomas: outcome and prognostic factors in 581 Mayo Clinic patients, 1978 through 1988. Mayo Clin Proc 73:9369421998

  • 62

    Stafford SLPollock BEFoote RLLink MJGorman DASchomberg PJ: Meningioma radiosurgery: tumor control, outcomes, and complications among 190 consecutive patients. Neurosurgery 49:102910382001

  • 63

    Starke RMNguyen JHRainey JWilliams BJSherman JHSavage J: Gamma Knife surgery of meningiomas located in the posterior fossa: factors predictive of outcome and remission. Clinical article. J Neurosurg 114:139914092011

  • 64

    Steiner LSheehan JLindquist CStroila MSteiner MGamma surgery in cerebral vascular lesions, malformations, tumors, and functional disorders. Schmidek HHRoberts DW: Schmidek & Sweet's Operative Neurosurgical Techniques: Indications Methods and Results ed 5PhiladelphiaWB Saunders2006. 530576

  • 65

    Subach BRLunsford LDKondziolka DMaitz AHFlickinger JC: Management of petroclival meningiomas by stereotactic radiosurgery. Neurosurgery 42:4374451998

  • 66

    Sughrue MEKane AJShangari GRutkowski MJMcDermott MWBerger MS: The relevance of Simpson Grade I and II resection in modern neurosurgical treatment of World Health Organization Grade I meningiomas. Clinical article. J Neurosurg 113:102910352010

  • 67

    Takanashi MFukuoka SHojyo ASasaki TNakagawara JNakamura H: Gamma knife radiosurgery for skull-base meningiomas. Prog Neurol Surg 22:961112009

  • 68

    Torres RCFrighetto LDe Salles AAGoss BMedin PSolberg T: Radiosurgery and stereotactic radiotherapy for intracranial meningiomas. Neurosurg Focus 14:5e52003

  • 69

    Van Havenbergh TCarvalho GTatagiba MPlets CSamii M: Natural history of petroclival meningiomas. Neurosurgery 52:55642003

  • 70

    Voss NFVrionis FDHeilman CBRobertson JH: Meningiomas of the cerebellopontine angle. Surg Neurol 53:4394472000

  • 71

    Williams BJYen CPStarke RMBasina BNguyen JHRainey J: Gamma Knife surgery for parasellar meningiomas: long-term results including complications, predictive factors, and progression-free survival. Clinical article. J Neurosurg 114:157115772011

  • 72

    Yaşargil MG: Meningiomas. Microneurosurgery: Microneurosurgery of CNS Tumors Vol IVB New YorkThieme1996

  • 73

    Yu JSYong WHWilson DBlack KL: Glioblastoma induction after radiosurgery for meningioma. Lancet 356:157615772000

  • 74

    Zachenhofer IWolfsberger SAichholzer MBertalanffy ARoessler KKitz K: Gamma-knife radiosurgery for cranial base meningiomas: experience of tumor control, clinical course, and morbidity in a follow-up of more than 8 years. Neurosurgery 58:28362006




All Time Past Year Past 30 Days
Abstract Views 501 501 93
Full Text Views 234 234 5
PDF Downloads 152 152 4
EPUB Downloads 0 0 0


Google Scholar