Factors contributing to surgical complexity in giant parasagittal and falcine meningiomas: a case-based review

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Introduction: Giant parasagittal and falcine meningiomas are surgically challenging due to their frequent involvement of the superior sagittal sinus (SSS), proximity to eloquent cortex, and complex venous anatomy. Although these tumors carry a high operative risk, detailed analyses of surgical difficulty remain limited in the literature. Objective: This narrative review of published case reports and series aims to delineate the key determinants of surgical complexity in giant parasagittal and falcine meningiomas, including tumor size, sinus involvement, anatomical constraints, and intraoperative decision-making while emphasizing the balance between surgical radicality and patient safety. Methods: A narrative review and multicase synthesis were performed, analyzing 22 published reports (19 case reports and 3 case series) describing the microsurgical management of giant parasagittal and falcine meningiomas. Studies were included based on the PICOS framework, focusing on tumors ≥5 cm with original surgical and outcome data. Extracted variables included demographics, tumor size, location, SSS involvement, histology, surgical technique, and clinical outcomes. Results: A total of 36 patients were identified. Most tumors were parasagittal (52.8%), involved the middle third of the SSS (38.9%), and demonstrated SSS invasion (78.6%), with complete occlusion in 64.3% of cases. Gross total resection was achieved in 75.7% of cases. Pediatric patients (11.1%) were more frequently associated with high-grade histology and intraoperative complications. Tumors involving the middle third of the SSS and those with parasagittal location were consistently associated with increased technical difficulty, venous bleeding, and postoperative deficits. Overall, 72.2% of patients experienced favorable recovery, while 11.1% had poor outcomes, including tumor recurrence or death. Conclusion: Surgical management of giant parasagittal and falcine meningiomas is technically demanding, particularly in pediatric cases and when tumors involve the parasagittal region or the middle third of the SSS. Careful preoperative venous evaluation and individualized strategies are crucial for optimizing the resection while minimizing complications.

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