Efficacy and safety of stereotactic radiosurgery for foramen magnum meningiomas: a systematic review and meta-analysis

INTRODUCTION: Managing foramen magnum meningiomas (FMMs) poses challenges due to their anatomical complexity. Surgical resection aimed at achieving gross total resection (GTR) is the primary therapeutic option; however, the proximity to nerves and arteries complicates resection and is associated with significant morbidity and mortality rates, reported to reach as high as 50% and 25%, respectively. Stereotactic radiosurgery (SRS) is a non-invasive radiotherapeutic modality that has been extensively used to treat intracranial meningiomas and is associated with high rates of favorable outcomes and low complications. This study aimed to evaluate the efficacy and safety of SRS for FMMs.EVIDENCE ACQUISITION: We searched the electronic databases from inception to October 24th, 2024. We included studies that evaluated the radiological and clinical outcomes of SRS application in FMMs. The risk of bias was assessed using the Risk of Bias in Non-Randomized Studies of Interventions tool. The R program was used to perform the meta-analyses, sensitivity analysis, and publication bias.EVIDENCE SYNTHESIS: Our study included five studies with a total of 174 patients. Our meta-analysis revealed that SRS resulted in a pooled local control (LC) rate of 99% (95% CI: 96-100%), an objective response (OR) rate of 49% (95% CI: 25-74%), a stable disease (SD) rate of 48% (95% CI: 25-71%), and a progressive disease (PD) rate of 1% (95% CI: 0-4%). Our results indicated a pooled clinical improvement rate of 43% (95% CI: 11-80%) and a clinical stability rate of 56% (95% CI: 21-87%). The meta-analysis showed that SRS had low heterogeneity (I2=0%, P=0.84) and a pooled adverse radiation effect rate (ARE) of 0% (95% CI: 0-1%).CONCLUSIONS: SRS is associated with promising clinical and radiological outcomes and low complication rates. It can be considered for use in asymptomatic or minimally symptomatic individuals with small- to medium-sized lesions, symptomatic individuals with significant comorbidities without brainstem compression, and those who are reluctant to undergo surgery.