Intracranial meningiomas are the most common benign central nervous system tumors, often managed with elective surgical resection. While outcomes are generally favorable, postoperative management remains variable, particularly regarding routine Intensive-Care Units (ICU) admission. Given increasing pressure on critical care resources, identifying patients who truly require ICU-level monitoring is essential.

To evaluate early postoperative complications after meningioma surgery and develop a practical risk-based score to guide ICU admission.

We performed a retrospective single-center study of 203 intracranial meningioma resections (2020–2022). Patients were included if they had scheduled surgery and at least one night of postoperative ICU monitoring. A composite endpoint defined ICU-relevant complications within 24 h, including seizures, new deficits, delayed awakening, reintubation, transfusion, intra-veinous (IV) antihypertensives, and urgent imaging or reoperation. Twenty-two clinical, radiological, and surgical factors were analyzed.

Postoperative complications requiring ICU-level care occurred in 19.2% of cases, mostly neurological (13.8%). Two-thirds of events occurred upon awakening or in the post-anesthesia care unit (PACU). Univariate analysis identified seven significant predictors: intracranial hypertension, falcine location, motor cortex involvement, operative time ≥3 h, blood loss >500 mL, osmotherapy use, and transfusion. A 10-item risk score demonstrated high sensitivity (92.3%) and negative predictive value (95.9%) using a cut-off of 1 or more points. Using this model, in our population, 36.5% of patients could have safely avoided ICU admission.

A risk-based approach to ICU admission after meningioma surgery appears both safe and feasible. Implementation of this score, combined with extended PACU monitoring, could optimize resource use without compromising patient safety. Prospective validation is warranted.