Introduction: The surgery of giant intracranial meningioma [GIM] is unique and technically challenging due to its large size,prominent vascularity,limited visualisation and entangling of various neurovascular structures and severe cerebral edema.The study reports the authors surgical experience of 80 GIM cases,the operative challenges as well as surgical outcome and various factors influencing survival.

Methods: A retrospective analysis of 80 patients of histologically proven meningioma of size 5cm who underwent surgical treatment at LSU Health Sciences Center,Shreveport,Louisiana,USA over twenty year period is presented.The clinical and radiological data were collected and the tumours were categorised into histological groups according to WHO classification.

Results: The study included 27 males[33.8%] and 53 females [66.3%].The mean age of the cohort was 56 years.The mean size of the tumor was 56.4 mm with a range from 50 mm to 84 mm.Skull base was the most common location[57 patients, 71.3%].Simpson Grade 1 excision was achieved in 9 patients [11.3%] whereas Grade 2 excision was achieved in 57 patients [71.3%].80% of the tumors belonged to WHO grade 1.The operative mortality was seen in 4 patients [5%].Regression analysis showed age, sex, location of the tumor,neuronavigation,Simpson grade of excision and histology of tumor were the factors which significantly affected the recurrence free survival[RFS].

Conclusions: The surgery for GIM is unique in different ways due to various reasons.The surgical outcome of GIM is worse when compared to non-GIM tumors.As surgery for GIM is formidable,radiological characteristics can be useful adjuncts for planning an effective and safe surgical strategy.Safe-maximal resection should be the goal especially for GIM located at skullbase. The factors such as young age, male sex, use of neuronavigation and skullbase location positively influence RFS while Simpson Grade of excision [Grade 3/Grade 4] and poor histological grade adversely influence the survival.A careful pre-operative evaluation, understanding of the risk factors,effective surgical approach and judicious use of intra-op adjuncts are the key factors which play a pivotal role in GIM resection.

Patient Care: The article provides an overview on the latest nuances in the resection of GIM and associated technical challenges. It helps in gross total resection of the lesion with minimal post-op neurologic deficits.

Learning Objectives: 1. Advanced surgical nuances vs technical challenges in Giant intracranial meningioma resection. 2. Prognostic factors of GIM tumors.

References: 1. 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(1):201-211. 2. Bir SC, Konar SK, Maiti TK, Thakur JD, Guthikonda B, Nanda A. Utility of Neuronavigation in Intracranial Meningioma Resection: A Single-Center Retrospective Study. World Neurosurg. 2016;90:546-555. 3. Sekhar LN, Swamy NK, Jaiswal V, Rubinstein E, Hirsch WE, Wright DC. Surgical excision of meningiomas involving the clivus: preoperative and intraoperative features as predictors of postoperative functional deterioration. J Neurosurg. 1994;81(6):860-868.