Decoding calvarial lesions: Contemporary neurosurgical management integrating radiological and histopathological features.

Introduction: Calvarial lesions range from benign tumors to malignant processes and pose diagnostic and surgical challenges due to their rarity and heterogeneous imaging features. Research question: Which clinical and radiological features distinguish benign from malignant calvarial lesions, and how do they influence neurosurgical management and outcomes? Material and methods: We performed a retrospective study of patients undergoing neurosurgical treatment for calvarial lesions between 2013 and 2025. Clinical, radiological, surgical, and histopathological data were analyzed. Functional outcomes (KPS, GOS, mRS), comorbidity measures (ASA classification, BMI), and frailty (modified 5-Item Frailty Index) were assessed. Imaging evaluation included CT-based bone morphology and MRI. Results: A total of 174 patients were included; 66.1% had benign and 33.9% malignant lesions. Malignant lesions were associated with older age, higher frailty, and comorbidity burden. The most common diagnoses were meningioma and metastases. Multiple osteolytic lesions on CT were associated with malignancy and remained the strongest independent predictor (OR: 5.34; 95% CI: 2.35-12.14). Gross total resection was achieved in 82.8% of cases (83.5% in benign vs. 81.3% in malignant lesions, p = 0.8), with significant postoperative functional improvement (KPS), particularly in benign lesions (p < 0.0001). Overall, recurrence occurred in 3.4% of patients and was more frequent in malignant than benign lesions (6.8% vs. 1.7%, p = 0.2). Discussion and conclusion: Multiple osteolytic lesions represent a key radiological marker of malignancy and support preoperative risk stratification. Distinguishing benign from malignant lesions is essential, as it informs surgical strategy and the extent of resection, enabling individualized patient management.