Impact of Tumor Anatomic Location and Volumes on Visual Outcomes in Petroclival Meningiomas

BACKGROUND AND OBJECTIVES: We aimed to evaluate whether preoperative tumor volumetrics and compartmental dominance predict visual symptom presentation and recovery in petroclival meningiomas (PCMs) and delineate symptom-specific longitudinal trajectories following surgical resection. METHODS: We performed a single-center retrospective cohort (2000-2022) of 67 patients with PCM, 42 were surgically treated. Preintervention MRIs were segmented (3D Slicer) to obtain total, posterior-fossa, and middle-fossa volumes and the posterior/middle ratio. Visual symptoms (diplopia, visual acuity loss, visual field deficits) were assessed at baseline and 3, 6, and 12 months; resolution was defined as symptom absence at 12 months. Baseline comparisons used t-tests and Wilcoxon rank-sum tests. Univariable and multivariable logistic regression adjusted for age, sex, Karnofsky Performance Status, and 5-item Modified Frailty Index. McNemar testing evaluated paired temporal comparisons. ROC analysis estimated discriminative performance (area under the curve). RESULTS: Visual symptoms were present in 25/67(37.3%) patients at baseline. In the surgical subgroup, visual acuity loss (P = .023; odds ratio 1.07 per cm3, P = .032) and visual field deficits (P = .041; odds ratio 1.08, P = .060) were associated with larger tumor volumes; diplopia was not (P = .460). At 12 months, visual field deficits resolved in 100% (4/4), visual acuity in 57.1% (4/7), and diplopia in 55.6% (5/9). Symptom-specific resolution rates varied by domain; composite paired improvement did not reach significance (McNemar P = .386). Baseline tumor volume did not predict resolution (all P > .4). ROC analysis favored compartment-aware metrics over total volume: area under the curves were 0.683 (posterior/middle ratio), 0.650 (posterior), 0.633 (middle), and 0.600 (total volume). Multivariable models identified no independent predictors of recovery. CONCLUSION: In surgically treated PCMs, visual outcomes were dependent on symptom subtype and were anatomically driven. Visual acuity loss and visual field deficits correlate with tumor volume; diplopia reflects location rather than size. Visual field deficits are highly reversible; visual acuity and diplopia recovery is less predictable. Compartmental dominance offers a potential prognostic value than total volume, opening compartment-informed preoperative counseling and surgical planning.