Probabilistic MRI Maps for the Presentation and Management of Intracranial Meningiomas

Purpose To develop a voxel-based, MRI-derived atlas of intracranial meningiomas and assess the voxelwise associations of location with clinical presentation, management strategy, and malignancy grade. Materials and Methods This single-center retrospective study (January 2000-December 2024) included adults with intracranial meningioma and preoperative MRI scans. Lesions were manually segmented and normalized to the Montreal Neurological Institute 152 template space and analyzed with volume-adjusted permutation testing and false discovery rate correction. Results The final cohort comprised 1333 patients (mean age, 58 years ± 13 [SD], 1064 female [79.8%] and 269 male [20.2%] patients) with 1676 intracranial meningiomas. Density analysis revealed a cluster in the anterior or middle skull base. Symptomatic presentation was localized to the bilateral motor and premotor cortex, deep frontobasal regions, and anteromedial skull base (26ߙ141 voxels; maximum z score [max z] = 7.70; q < .05). Symptom-specific clusters included focal deficits in the left precentral and anteromedial junction of the skull base (3163 voxels; max z = 9.26; q < .05), epilepsy in the bilateral premotor region including supplementary motor area and middle frontal gyrus (929 voxels; max z = 5.89; q < .05), and radioclinical signs of elevated intracranial pressure in the deep right frontal and left cerebellar regions (19 066 voxels; max z = 7.62; q < .05). The resection probability was clustered in the anterior skull base, middle skull base, bilateral supplementary motor area, left precentral gyrus, and deep frontobasal regions (56 649 voxels; max z = 9.50; q < .05). Among resected tumors with available histology, tumors with a higher World Health Organization grade (grade 2-3) were localized to a right frontal cluster along the superior and middle frontal gyri (97 voxels; max z = 5.76; q < .05). Conclusion The voxelwise maps of 1676 meningiomas revealed that tumor location was associated with symptoms, resection probability, and malignancy grade. Keywords: Intracranial Meningioma, MRI Mapping, Brain Atlas, Skull Base, Neurosurgery Supplemental material is available for this article. © RSNA, 2026 See also commentary by Todea in this issue.