Binary 5-Aminolevulinic Acid Classification Integrated With Simpson Grading in Meningioma Surgery: A Single-Center Retrospective Series of 265 Cases

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Publication Details

Journal
Neurosurgery
Published
2026-09-11
DOI
https://doi.org/10.1227/neu.0000000000004209
Primary Topic
Meningioma and schwannoma management
Type
article
Field-Weighted Citation Impact
0.00
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article

Binary 5-Aminolevulinic Acid Classification Integrated With Simpson Grading in Meningioma Surgery: A Single-Center Retrospective Series of 265 Cases

Maurício Coelho Neto, Erasmo Barros da Silva, Guilherme Ramina Montibeller, Ricardo Ramina et al.
Neurosurgery
Meningioma and schwannoma management
article

Binary 5-Aminolevulinic Acid Classification Integrated With Simpson Grading in Meningioma Surgery: A Single-Center Retrospective Series of 265 Cases

Maurício Coelho Neto, Erasmo Barros da Silva, Guilherme Ramina Montibeller, Ricardo Ramina, Jerônimo Buzetti Milano, Gustavo Simiano Jung, Henrique Orefice Farah
article en

Abstract

BACKGROUND AND OBJECTIVE: Strategies to improve extent of resection (EOR) in meningioma surgery have evolved since Simpson grading. While 5-aminolevulinic acid (5-ALA) fluorescence-guided surgery is standard in malignant gliomas, its systematic integration into meningioma Simpson grading remains undefined. We aimed to characterize intraoperative fluorescence patterns in a large single-center series and evaluate a simple, binary 5-ALA classification to complement the Simpson grade. METHODS: We retrospectively analyzed 265 meningiomas (244 patients, 2018-2025) with 5-ALA fluorescence-guided surgery. Intraoperative fluorescence was dichotomized. For 5-ALA-positive tumors, the resection cavity was classified as "5-ALA tumor-free" or "5-ALA residual mass" (visible nodular fluorescence, including dura presenting as a mass). Surrounding structures were classified as "tissue-free" or "residual fluorescent tissue" (visible fluorescence on macroscopically normal tissue). Associations with 5-ALA status, Simpson grade, MRI-based EOR, World Health Organization grade, location, and recurrence were assessed. RESULTS: Overall, 254 of 265 meningiomas (95.8%) were 5-ALA-positive. The tumor bed was 5-ALA tumor-free in 216 of 254 cases (85.0%) and showed residual fluorescent mass in 38 of 254 cases (15.0%). Residual fluorescent tissue in surrounding structures was observed in 157 of 254 tumors (61.8%), predominantly in convexity, parasagittal/falx, and posterior fossa/tentorial locations. 5-ALA residual mass was independent of World Health Organization grade but strongly associated with Simpson grade (7.5% of Simpson I-II vs 80.8% of Simpson III-IV resections) and MRI-based EOR (7.0% of MRI-complete vs 81.5% of MRI-incomplete resections, both P < .0001). Nineteen recurrences were observed. CONCLUSION: These observations suggest a simple, binary 5-ALA classification (residual fluorescent mass and residual tissue fluorescence) can be incorporated as a descriptive adjunct to the Simpson grade. It provides a structured intraoperative EOR description suitable for routine documentation and future prospective validation.

Neurosurgery
Instituto de Neurologia de Curitiba (BR)
Good health and well-being
Openalex Percentile: Top 10%
Meningioma and schwannoma management
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