Review Reports - Giant Right Sphenoid Wing Meningioma as a Reversible Frontal Network Lesion: A Pseudo-bvFTD Case with Venous-Sparing Skull-Base Resection

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The authors report an inteerting case illustrating the possibility of a non-dominant sphenoid wing meningioma to result in a pseudo-degenerative frontal syndrome and its potential for reversal if recognized as a network lesion and treated with tailored, venous-sparing skull-base surgery. Contrast enhanced imaging and routine frontal testing in atypical "dementia" presentations may aid in identifying additional patients with potentially surgically remediable cases.

This is an interesting case that could be considerered for differntial diagnosis of frontal syndromes and surgical implications to solve this clinical situation, improving the clinical and diagnostic pathway of oncological patients.

Author Response

Dear Esteemed Academic Reviewer,

We are grateful for your thoughtful and encouraging assessment of our manuscript. We greatly appreciate the time you dedicated to reviewing our work and for highlighting the clinical relevance of this case, particularly its implications for the differential diagnosis of frontal syndromes and the potential reversibility of pseudo-degenerative presentations when recognized as surgically remediable network lesions.

Your comments strongly align with the central intention of our report: to illustrate how a giant non-dominant sphenoid wing meningioma can mimic a primary neurodegenerative disorder, and how the integration of detailed neurobehavioral phenotyping, contrast-enhanced imaging, and vascular-aware skull base microsurgery can lead to measurable functional recovery.

We are very thankful for your collegial and supportive review, which helped us sharpen the manuscript’s practical message and multidisciplinary relevance. We hope that the revised version now communicates even more clearly how careful clinical quantification combined with contrast-enhanced imaging and tailored venous-sparing skull base surgery may uncover and treat similarly deceptive but reversible frontal network syndromes.

With profound respect!!!

Reviewer 2 Report

Comments and Suggestions for Authors

This is an exceptionally detailed and well-constructed case report that successfully transcends the limitations of a traditional single-case narrative by integrating network neuroscience, granular neuropsychological phenotyping, multimodal imaging, and tailored skull-base microsurgical strategy into a coherent and clinically instructive framework.

Major Strengths

Conceptual originality

The manuscript convincingly reframes a giant non-dominant sphenoid wing meningioma as a reversible frontal network lesion, rather than a simple space-occupying mass.

The “pseudo-bvFTD” construct is not merely asserted but quantitatively demonstrated, which substantially strengthens its credibility.

Depth and rigor of clinical phenotyping

The use of multiple standardized cognitive, behavioral, and functional scales (MoCA, FAB, NPI, IADL, Barthel, Tinetti, NIHSS, mRS, CFS) is exemplary.

Serial assessments allow the reader to appreciate staged, domain-specific recovery, rather than vague postoperative improvement.

Imaging–behavior correlation

The detailed mapping of edema and mass effect onto fronto-striato-thalamo-cortical and corticospinal pathways provides a compelling mechanistic explanation for the clinical syndrome.

The integration of venographic and angiographic findings into operative planning is particularly strong and educational.

Surgical narrative and rationale

The operative description is meticulous yet purposeful, clearly tied to venous preservation and network recovery rather than technical virtuosity alone.

The authors appropriately avoid overstating novelty, instead demonstrating how established skull-base principles, when applied deliberately, can yield profound functional recovery.

High educational value

The manuscript serves as a practical model for neurosurgeons, neurologists, and cognitive specialists evaluating atypical dementia presentations.

It has relevance beyond neurosurgery, particularly for clinicians in geriatrics, psychiatry, and cognitive neurology.

Suggestions for Minor Improvement

Conciseness in selected sections

While the detail is largely justified, modest condensation of the operative description (particularly repetitive anatomic confirmations) could improve readability without sacrificing rigor.

Early framing of key messages

A brief bullet-point summary at the end of the Introduction or beginning of the Discussion highlighting the three core contributions (phenotype, network mechanism, surgical strategy) may help orient non-surgical readers.

Limitations statement

Although implicitly acknowledged, a short explicit paragraph noting the inherent limitations of single-case generalizability would further strengthen the manuscript’s balance.

Author Response

Dear Esteemed Academic Reviewer,

We would like to express our gratitude for your thoughtful, detailed, and generous evaluation of our manuscript. We are deeply appreciative of the time and expertise you invested in assessing our work, and we are encouraged by your recognition of the manuscript’s conceptual framework and clinical–anatomical integration. Your comments were particularly valuable in helping us further strengthen clarity, balance, and accessibility for a multidisciplinary readership.

Below, we provide a point-by-point response to each of your suggestions and outline the specific revisions implemented in the manuscript.

Reviewer Comment: Conciseness in selected sections

“While the detail is largely justified, modest condensation of the operative description (particularly repetitive anatomic confirmations) could improve readability without sacrificing rigor.”

Response:
We are grateful for this constructive suggestion and fully agree that improved concision increases readability, particularly in a case report that contains a high density of clinical, imaging, and surgical detail. In response, we carefully revised the Case Presentation and operative narrative to remove redundant anatomic confirmations and repetitive interpretive phrasing, while intentionally preserving all clinically relevant quantitative metrics, imaging features, and operative steps that support the mechanistic “network lesion” argument. We believe this revision substantially improves manuscript flow and allows the key messages to remain clear without dilution.

Reviewer Comment: Early framing of key messages

“A brief bullet-point summary at the end of the Introduction or beginning of the Discussion highlighting the three core contributions (phenotype, network mechanism, surgical strategy) may help orient non-surgical readers.”

Response:
We appreciate this suggestion, as we agree that explicitly signposting the manuscript’s “three-pillar” contribution can help non-surgical readers quickly interpret how the clinical phenotype, network-level mechanism, and vascular-aware skull base strategy align within a single framework. In response, we added a short bullet-point summary at the end of the Introduction highlighting the three core contributions you identified. We believe this improves accessibility without changing the scientific density of the manuscript.

Reviewer Comment: Limitations statement

“Although implicitly acknowledged, a short explicit paragraph noting the inherent limitations of single-case generalizability would further strengthen the manuscript’s balance.”

Response:
We fully agree with this important point and appreciate the emphasis on maintaining an appropriately balanced tone. Although we intended the manuscript to remain cautious in its conclusions, we recognize that an explicit limitations paragraph improves transparency and strengthens interpretive discipline. Accordingly, we added a short limitations statement emphasizing the inherent constraints of a single case, including the inability to infer prevalence, typical recovery trajectories, or causal attribution of specific perioperative variables. We also acknowledged that advanced functional network measures (e.g., resting-state connectivity analysis or quantitative tractography) were not performed and might have further refined mechanistic interpretation. We maintained a humble framing, emphasizing that the case is hypothesis-generating, while still highlighting its potential clinical value as an integrated illustrative framework.

Once again, we are grateful for your collegial and insightful review. Your feedback substantially improved the manuscript’s clarity, balance, and readability, and we believe the revisions meaningfully strengthen its value for both surgical and non-surgical audiences. We respectfully hope that the revised manuscript now addresses your concerns and meets the expected standards for publication.

With warm appreciation and respect!!!

Reviewer 3 Report

Comments and Suggestions for Authors

The authors present a detailed and clinically instructive case of a giant right sphenoid wing meningioma presenting as a pseudo–behavioral variant frontotemporal dementia (bvFTD) syndrome, with marked cognitive and functional recovery following venous-sparing skull-base resection. The topic is highly relevant to neurosurgeons, neurologists, and imaging specialists, particularly in the context of atypical dementia presentations and large skull-base tumors. The longitudinal clinical documentation and close clinicoradiologic correlation are notable strengths.

Major comments

Surgical strategy and reproducibility
The venous-sparing, skull-base–flattening pterional approach is well described and appears well suited to this patient’s anatomy. However, from a neurosurgical perspective, it would be helpful to more explicitly delineate which aspects of the surgical strategy were case-specific (e.g., non-encasing tumor, preserved venous drainage, absence of sinus invasion) versus which principles might be broadly applicable to similar sphenoid wing meningiomas. This distinction would improve the practical transferability of the surgical lessons.

Extent of resection and decision-making at venous interfaces
The manuscript emphasizes conservative management at medial venous interfaces, including acceptance of thin capsular remnants when venous risk was deemed high. Clarifying how this approach was reconciled with the reported Simpson Grade I resection—particularly in the context of parasagittal venous structures—would strengthen the surgical discussion and avoid potential ambiguity for readers.

Preoperative planning and alternative strategies
The role of preoperative vascular imaging is clearly highlighted. From a neurosurgical standpoint, a brief comment on alternative strategies (e.g., staged surgery, subtotal resection with adjuvant radiotherapy, or a more conservative approach in frailer patients) would help contextualize why aggressive resection was favored in this specific clinical scenario.

Neurosurgical outcomes beyond cognition
While cognitive and functional recovery are extensively documented, traditional neurosurgical outcomes (visual function, cranial nerve status, seizure control) are discussed more briefly. A concise summary of these outcomes, even if normal or unchanged, would provide a more complete surgical outcome profile.

Minor comments

• The operative description is technically sound but could be modestly condensed without loss of instructional value. • Clarifying whether intraoperative neurophysiological monitoring was used (or not) would be of interest to practicing neurosurgeons. • A short comment on follow-up duration and surveillance strategy for recurrence would further strengthen the surgical perspective.

Overall recommendation — Minor revision

This is a thoughtful and well-executed case report that effectively illustrates how a giant sphenoid wing meningioma can produce a reversible, dementia-like frontal syndrome when conceptualized and treated as a network-disrupting lesion. Minor revisions aimed at clarifying surgical decision-making, reproducibility of the approach, and neurosurgical outcome reporting would further enhance the manuscript’s value for a surgical readership.

Author Response

Dear Esteemed Academic Reviewer,

We are grateful for the time, expertise, and thoughtful attention you devoted to evaluating our manuscript. We greatly appreciate your generous appraisal of the clinical relevance and educational value of this case, as well as your recognition of the longitudinal clinical documentation and clinicoradiologic correlation. Your comments were exceptionally constructive and have helped us strengthen the manuscript’s neurosurgical clarity, reproducibility, and completeness. We have carefully revised the text in accordance with each of your suggestions, as detailed below.

General Response

We thank you for highlighting the importance of atypical dementia presentations and the need for neurosurgical awareness when frontal syndromes arise from large skull-base lesions. In response to your recommendations, we refined the operative description for improved readability while preserving its instructional value, clarified decision-making at venous interfaces and its relationship to Simpson grading, expanded the discussion of surgical strategy to distinguish case-specific anatomical factors from broadly applicable skull-base principles, contextualized the rationale for maximal safe resection by briefly addressing alternative strategies, and added a concise report of traditional neurosurgical outcomes and postoperative surveillance plans.

Major Comments
1) Surgical strategy and reproducibility

Reviewer comment: The surgical approach is well described; however, it would be helpful to delineate which aspects were case-specific versus broadly applicable principles.

Response: We fully agree that this distinction improves practical transferability for a surgical readership. We have therefore added a dedicated paragraph explicitly separating case-specific anatomical features that favored maximal safe resection from broadly applicable principles relevant to large sphenoid wing meningiomas (e.g., skull-base flattening to reduce working distance, early devascularization, staged internal debulking, strict arachnoid-plane dissection, and a venous-preservation hierarchy at medial interfaces). These revisions are intended to clarify which lessons generalize and which were contingent upon favorable patient anatomy.

2) Extent of resection and decision-making at venous interfaces

Reviewer comment: The manuscript describes conservative capsular management at medial venous interfaces; please clarify how this approach was reconciled with the reported Simpson Grade I resection.

Response: We appreciate this important point and agree that it required greater precision to avoid ambiguity. We have revised the operative section to explicitly explain that, at critical parasagittal venous interfaces where a safe cleavage plane could not be established, a paper-thin capsular film was intentionally left adherent to venous adventitia as a protective “venous wrapper,” rather than risking venous injury, thrombosis, or infarction. We also clarified that this conservative strategy did not represent a nodular residual tumor burden: systematic cavity inspection revealed no macroscopic tumor, the skull-base attachment was treated with focal dural excision/coagulation in a Simpson-oriented manner, and no radiologic residual was detected on early postoperative imaging. We believe this revised description more accurately conveys how maximal oncologic intent was balanced against venous safety in a technically high-risk zone.

3) Preoperative planning and alternative strategies

Reviewer comment: Please include a brief comment on alternative strategies to contextualize the rationale for aggressive resection in this patient.

Response: We agree and have added a concise discussion of reasonable alternative management strategies, including staged surgery in selected cases, planned subtotal resection with adjuvant radiotherapy for residual tumor at high-risk vascular interfaces, and a more conservative approach in frailer patients or those with milder symptom burden.

4) Neurosurgical outcomes beyond cognition

Reviewer comment: Traditional neurosurgical outcomes (visual function, cranial nerves, seizure control) are only briefly discussed; a concise summary would strengthen the outcome profile.

Response: We appreciate this recommendation and have expanded the postoperative course section to include a clear summary of neurosurgical outcomes beyond cognition.

Minor Comments
1) Operative description length

Reviewer comment: The operative description could be modestly condensed.

Response: We fully agree. We have rewritten the operative description into a more structured and concise format, preserving all key surgical steps and principles while improving readability and avoiding repetition.

2) Intraoperative neurophysiological monitoring

Reviewer comment: Please clarify whether neurophysiological monitoring was used.

Response: Thank you for this suggestion. We have added an explicit statement indicating that intraoperative neurophysiological monitoring was not used in this case, and we clarified that safety was guided by strict arachnoid-plane microsurgical technique, continuous vessel visualization, and physiologic targets designed to support venous outflow.

Once again, we thank you for your careful review, encouraging assessment, and highly actionable feedback. We believe the revisions prompted by your comments substantially improve the manuscript’s clarity and surgical utility, particularly regarding reproducibility of strategy, venous interface decision-making, and comprehensive outcome reporting. We are grateful for the opportunity to refine the work under your guidance and hope the revised version meets your expectations.

With highest respect and appreciation!!!

Reviewer 4 Report

Comments and Suggestions for Authors

Dear Author,

This is an interesting case, however there are many unsupported "Network" Claims like "connectomics," "default-mode network," and "network lesion" throughout the text and title. However, no functional imaging (rs-fMRI) or tractography (DTI) was performed on this patient. The "network" mechanism is entirely hypothetical, inferred from the literature rather than observed data.

The Introduction and Discussion are bloated with general reviews of meningioma literature (Page 2, lines 53–101) rather than focusing on the specific case.

In current form it cannot be claimed that this is a "Connectomic" or "Network" case study (Abstract, Line 101; Discussion, Line 599) based solely on structural MRI and clinical observation.

Table 1 is not required as it adds no data to this specific patient. Citations can be moved to the text if absolutely necessary.

Please check for accuracy of references.

The paper is far too long for a single case report.

Comments on the Quality of English Language

Needs major editing

Author Response

Dear Esteemed Academic Reviewer,

We would like to express our gratitude for your careful, rigorous, and highly constructive critique of our manuscript. Your comments were particularly valuable because they identified several areas where our language could be interpreted as exceeding the strength of our patient-specific data, and where the overall presentation could be improved for balance, concision, and strict methodological clarity. We are grateful for the opportunity to revise the manuscript in response to these points, and we believe the revised version is substantially stronger as a result of your guidance.

Below we address each concern point-by-point and describe the corresponding revisions implemented.

1) “Unsupported ‘Network’ / ‘Connectomics’ claims without rs-fMRI or DTI; mechanism is hypothetical.”

Comment: You noted that terms such as “connectomics,” “default mode network,” and “network lesion” imply patient-specific functional network evidence, although no rs-fMRI or tractography was performed.

Response:
We fully agree with this critique and appreciate your emphasis on methodological precision.

2) “In current form it cannot be claimed this is a ‘Connectomic’ or ‘Network’ case study.”

Comment: You highlighted specific phrasing in the Abstract and Discussion (e.g., Abstract Line 101; Discussion Line 599) that overstates the evidence.

Response:
We agree and thank you for identifying these precise locations. We have revised these statements.

3) “The Introduction and Discussion are bloated with general reviews of meningioma literature.”

Comment: You noted that portions of the Introduction/Discussion read as a general review rather than a case-driven rationale.

Response:
We appreciate this point and agree that a case report should remain tightly focused on the specific clinical problem and what the present case adds. In response, we substantially revised the Introduction to reduce general review-style phrasing, increase case anchoring, and improve concision, while retaining the key supporting references that frame the clinical relevance of this unusual phenotype.

4) “Table 1 is not required; citations can be moved into the text.”

Comment: You recommended removing Table 1 because it does not add patient-specific data.

Response:
We appreciate this perspective and agree that Table 1 should not function as a general literature summary. To address this, we revised Table 1 to become a concise, case-anchored “evidence map” that directly supports the interpretation of our patient’s phenotype, the structural–network framework, and the operative strategy. The revised table is shorter, more focused, and explicitly linked to practice-relevant implications of this specific case. In parallel, we ensured that all cited points are also supported within the narrative text so that the table is not required for comprehension.

Comment: You noted a mismatch between the manuscript template date and the reference list chronology.

Response:
Thank you for catching this. We agree that it could create confusion.

6) “Please check for accuracy of references.”

Response:
We are very grateful for this reminder. We performed a full reference audit to ensure accuracy of author names, journal titles, publication dates, volume/issue/page numbers, and DOI formatting where required.

7) “The paper is far too long for a single case report.”

Comment: You emphasized that the manuscript length is excessive.

Response:
We fully understand this concern and appreciate the directness of your feedback. In response, we substantially condensed the Case Presentation, operative narrative by removing redundancies, tightening sentence structure, and eliminating explanatory repetition while preserving all quantitative clinical metrics, key imaging descriptors, and essential operative decision points. Our goal was to maintain the educational and mechanistic value of the case while bringing the manuscript closer to the expectations of a single-case format.

We would like to again express our appreciation for your rigorous and methodologically grounded critique. Your comments significantly improved the manuscript’s scientific discipline, clarity of claims, and overall readability. We hope the revised version now presents a more focused and appropriately cautious case report, while still conveying the clinical importance of recognizing structurally remediable tumor-related pseudo-degenerative syndromes and documenting objective staged recovery after venous-sparing skull base decompression.