2026 Proffered Presentations
S264: TRIGEMINAL NERVE OUTCOMES IN PETROCLIVAL MENINGIOMAS: IMPACT OF TUMOR BURDEN AND SURGICAL STAGING
Hithardhi Duggireddy, MS; J. Manuel Revuelta-Barbero, MD, PHD; Rommi Kashlan, BS; Thomas McCaffery, BS; Karen Salmeron-Moreno, MD; Karthik Papisetty, BA; Gustavo Pradilla, MD; Tomas Garzon-Muvdi, MD, MSc; Emory University
Background: Petroclival meningiomas often compromise parts of the trigeminal nerve (CN V), leading to pain, numbness, or sensory disturbances that can impair quality of life. While tumor burden and clinical status often inform the decision to pursue staged resection, the impact of surgical strategy and tumor burden on trigeminal outcomes remains poorly characterized.
Objective: To compare trigeminal nerve involvement and symptoms between single and two-staged resections, assess symptom-volume relationships, and evaluate predictors of trigeminal complications.
Methods: We retrospectively analyzed 47 consecutive patients. 39 patients underwent single-staged resection (83.0%) and 8 underwent two-staged resection (17.0%). Baseline variables included age, sex, Karnofsky Performance Status (KPS), 5-item Modified Frailty Index (mFI-5), and preoperative tumor volume. Trigeminal endpoints were: (1) CN V involvement, (2) trigeminal pain presence, and (3) pain severity assessed by the Barrow Neurological Institute (BNI) score at baseline, 3, 6, and 12 months. Group differences were assessed using Mann-Whitney U and Fisher’s exact tests. A multivariable logistic regression (predictors: two-stage approach, age, sex, log-standardized tumor volume) modeled a composite “trigeminal complication” (CN V involvement or pain), with receiver operating characteristics (ROC) and calibration metrics (Brier score) to assess performance.
Results: Two-staged resection patients had substantially larger tumors (71.5±58.1 vs 23.0±22.6 cm³; p=0.002), worse functional status (KPS median 70 [70–72.5] vs 90 [80–90]; p<0.001), and higher frailty (mFI-5 median 2 [1–2] vs 0 [0–1]; p<0.001). Preoperative CN V involvement was more frequent in two-staged patients (87.5% vs 41.5%; odds ratio [OR] 9.88; p=0.023). Prevalence of trigeminal pain did not differ (12.5% vs 27.5%; OR 0.38; p=0.659), and baseline BNI severity was comparable (p=0.316). Across approaches, tumor volume showed only weak, non-significant associations with CN V involvement (logit-slope p=0.531) and BNI severity (1-stage slope p=0.076; 2-stage p=0.298). Mean BNI scores improved modestly by 6 months in both groups and partially rebounded by 12 months. Complete pain resolution (BNI = 1) was uncommon overall (3.2% 1-stage vs 33.3% 2-stage). In multivariable modeling, the two-stage approach remained independently associated with the composite trigeminal complication (OR 15.75; 95% CI 1.44–172.75; p=0.024), whereas age, sex, and standardized tumor volume were not significant. Model fit and discrimination were modest (pseudo-R² 0.113; AIC 67.8). Internal ROC performance varied by approach (AUC 0.575 for single-stage; 1.000 for two-stage, likely reflecting small n and class imbalance); overall calibration was fair (Brier 0.216).
Conclusions: Compared with single-staged cases, two-stage patients presented with larger tumors, lower KPS, and greater frailty, and they had markedly higher odds of preoperative CN V involvement. While pain severity and trajectories were similar across groups, the staged cohort had higher overall trigeminal complication risk. Tumor volume alone did not robustly predict trigeminal pain or involvement, with surgical strategy emerging as the dominant predictor of trigeminal complications. These findings support the integration of frailty, tumor anatomy, and operative strategy into preoperative risk stratification and counseling to guide patient expectations accordingly.
