:Acta
Acta Neurochir (Wien) (1990) 107:47-55
N urochirurgica 9 by Springer-Verlag1990
Treatment of lntracranial Meningiomas in Patients over 70 Years Old C. Arienta, M. Caroli, F. Crotti, and R. Villani Neurosurgical Clinic, University of Milan, Milan, Italy
Summary
this category are represented in various studies 7' 10, 12
The neurosurgeon often finds himself in the position to having to decide whether or not to operate on an elderly patient suffering from intracranial meningioma. The decision is rarely easy and the results often disappointing. We studied 46 cases of intracranial meningioma in patients over 70 years of age, 34 patients were operated on while 12 patients were not, although both groups were subjected to long term follow-up. The operative mortality rate was 12%, a rate which increased to 20% at 3 months follow-up. Various unfavourable prognostic factors were taken into consideration, the most significant of which were: poor overall clinical condition, peritumoural oedema, the presence of diabetes mellitus and the duration of surgery. A scored grading system was created to standardize surgical indications in elderlypatients with cerebral meningioma. An analysis of the grading system, when applied to patients submitted to surgery, showed that the deceased patients within 3 months of surgery had a score which varied from 7 to 12, with a mean score of 10. The surviving patients had a score averaging from 10 to 16 with a mean of 13. The patients with the lowest scores (7-9) had a 100% mortality rate while those in the upper ranges (13-16) demonstrated a mortality rate of 0%. Among the conservatively treated patients the worst outcome was seen in patients with a grading equal to or less than 12.
I m p r o v e d c o n d i t i o n s o f life a n d the increased m e a n age in the general p o p u l a t i o n a c c o u n t for the m o r e frequent incidence of elderly patients in good general health who
Keywords: IntracraniaI meningioma; elderly patients; clinicaIradiological grading.
Introduction M e n i n g i o m a s are rightly considered to be b e n i g n b r a i n t u m o u r s whose radical r e m o v a l allows complete recovery of the patient. Biological recovery does n o t however always c o r r e s p o n d to clinical recovery a n d there exists a certain m o r b i d i t y (hemiplegia, seizures, etc.) a n d the possibility of recurrence 2~9, 12, 14, 16 I n the literature we find m a n y studies of i n t r a c r a n i a l m e n i n g i o m a s ; less interest has been accorded however to i m m e d i a t e a n d l o n g - t e r m operative results in the t r e a t m e n t of m e n i n g i o m a s in patients over 70 years of age ~, 3, 4, 5, 6, 11, 13 even t h o u g h patients who fall within
suffer from i n t r a c r a n i a l m e n i n g i o m a s , T h e present day decrease in the operative death rate further p r o m p t s c o n s i d e r a t i o n o f the surgical r e m o v a l o f m e n i n g i o m a s in elderly patients. Does there exist a n age limit in the surgical t r e a t m e n t of this type o f biologically b e n i g n t u r n o u t ? Will the p a t i e n t truly benefit from the surgery? Will the patient's quality of life a n d chances of survival improve? Is the surgical risk greater or less t h a n the s u b s e q u e n t risks of n o t operating? Should all elderly patients free of a g g r a v a t i n g pathological c o m p l i c a t i o n s such as hypertension, diabetes, ischaemic heart a n d b r a i n diseases, a n d acute or chronic respiratory diseases, a u t o m a t i c a l l y be selected for surgery? These are i m p o r t a n t questions a n d they m u s t be answered in order to determine the p r o p e r indications for surgical t r e a t m e n t of m e n i n g i o m a s in the elderly patient.
Clinical Materials and Methods Only cases of intracranial meningiomas were taken into consideration in this study, excludingcases of intraorbital and spinal meningiomas. No cases of recurrent meningiomas were included in this group selected for study. The group includes 46 patients, 15 men and 31 women between 70 and 80 years of age, who were admitted and operated on in our clinic between 1980 and 1986. Thirty four patients underwent radical surgical removal of the meningioma. The remaining 12 were not operated on for varying reasons: lack of consent on the part of the patient or relatives, the extremely small dimensions of the meningioma or the generally poor condition of the patient. There does not exist a histological comparison in the nonsurgical cases of course, but the densimeter characteristics of the CT scan with contrast medium allowed for a presumed diagnosis.
C. Arienta et al.: Treatment of Intracranial Meningiomas in Patients over 70 Years Old
48
Results
30
Surgical P a t i e n t s B o t h o p e r a t i v e m o r t a l i t y ( w i t h i n 30 d a y s f o l l o w i n g surgery) and mortality
up to 3 months
following sur-
g e r y w e r e c o n s i d e r e d i n a n a l y z i n g t h e r e s u l t s o f t h e 34
20
[] []
Females 31 Males 15
N
Table 2. Clinical History and Mortality in Surgical and Nonsurgical
Patients 10
(a) Surgical Patients (n. 34)
_ 9
70
,
71
9
72
|
73
74
76
80
Onset of symptoms
Surviving patients
Operative mortality
Dead within 3 months
< 1 month 1-6 months < 6 months
10 6 i1
1 1 2
1 1 1
Length of survival
Age Fig. 1. Sex and age of elderly patients with intracranial meningioma
Table 1. Incidence of Symptoms and Signs at Time of Admission Symptoms and signs
Surgical patients
Nonsurgical patients
Total %
Hemiparesis Seizures Headache Dysphasia or aphasia Papilloedema Cranial nerve palsies Psychical deterioration Nausea and vomiting Visual impairment
21 12 8 6 7 6 5 3 3
3 3 1 3 2 1
52 33 17 15 15 19 15 6 8
The long-term follow-up varied from 1 to 5 years (average 2) and was carried out by means of a telephone conversation with the patient concerned or a close relative, along with a questionnaire. The age and sex o f the patients are summarized in Fig. 1. The mean age was 72 years. The most important symptoms and clinical signs are illustrated in Table 1. Epileptic seizures were present in 33% of the cases. Seven patients suffered from the intracranial hypertension syndrome, representing 15% of all cases studied. In all of these patients except one peritumoural oedema was identifiable by CT scan. The diagnosis in all cases was obtained by cerebral CT scan with contrast medium. Sixteen patients underwent an angiographic study in additon to CT scan. Our data were submitted to statistical analysis using T-student test. A P value was calculated for each comparison with significance assumed at the 0.05 level.
(b) Nonsurgical Patients (n. 12) Onset of symptoms
Surviving patients
Dead
< 1 month 1-6 months > 6 months
3 3
1
3 months
5
3 years 3 years 3 years 18 months 12 years
Table 3. Tumour Sites and Size and Mortality in Surgical Patients (a) Tumour Site and Mortality Location
Number
Operative mortality
Dead within 3 months
Convexity Falx Sphenoid ridge Parasagittal Olfactory groove Pontocerebellar angle Tuberculum sellae Falcotentorial Multiple (convexity)
9 8 6 3 4 1 1 1 1
2 1 1 -
1 2 -
(b) Tumour Size and Mortality Size
Number
Operative mortality
Dead within 3 months
>6cm 4-6 cm 5 hours < 5 hours
Size
Site
> 6 can %
4-6 cm %
< 4 cm %
Convexity %
Midline %
Base %
73 65
18 22
9 13
27 30
27 35
46 35
C. Arienta et al.: Treatment of Intracranial Meningiomas in Patients over 70 Years Old 3" 100 -
e
[]
51
1 O0 []
[]
90
90
2*
o 8O
8
r"
[]
3*
70 ,0 r
8O
[]
70
60
E
Go
50
40
I
I
I
Admission
Discharge
Follow-up
Fig, 3. Changes in the Karnofsky scale at follow-up of the 22 surviving operated patients. AII surviving patients demonstrated improved clinical conditions whatever their original Karnofsky scale score. * Represents the number of patients with the same Karnofsky scale score. A mean score was utilized for each group
the surgery. The present neurological conditions of the remaining 22 living patients confirm additional improvement in their grading level over the scores initially recorded following surgery (Fig. 3).
Patients Treated Conservatively [Nonsurgical] The clinical profiles of the 12 patients suffering from intracranial meningiomas (diagnosed by CT scan) who did not undergo surgery are summarized in Table 10. Included are symptoms and clinical signs, onset of symptoms, the initial Karnofsky scale grading and the reason for the decision not to operate. The quality and length of survival in these unoperated patients was established by long-term follow-up controls. The meningioma was located at the convexity in 6 cases, at the base in 4 and at the midline in the remaining 2 cases. Long-term control (2 years average) verified that the cases of unoperated meningioma located at the base demonstrated a mortality rate of 75%, those at the midline a mortality rate of 50% and the meningiomas located at the convexity one of 33%. The length of clinical history, which varied from 15 days to 10 years, had a bearing on mortality. The controls clearly demonstrate that a higher mortality rate was present in the patients with the longest clinical histories, (Table2b) but this correlation is not statistically significant. The Karnofsky scale gradings of the nonsurgical cases (the evaluation method also adopted for the surgical cases) varied between 50 and 80. Observation of
40
I
i
Follow-up Fig.4. Changesin the Karnofskyscale at follow-upcontrol of the 6 survivingunoperatedpatients. *Represents the numberofpatients with the sameKarnofskyscalescore. A meanscorewas utilizedfor each group. Admission
mortality at the long-term follow-up control shows that mortality is also present in the nonsurgical patients with the highest Karnofsky scale gradings. It is primarily the size of the meningioma, and more importantly the presence of peritumoural oedema confirmed by CT scan, which influence eventual long-term outcome. Indeed all 3 of the patients who presented the characteristic of peritumoural oedema with shift died. The presence of diabetes, as in the case of the surgical patients, severely compromised patient survival; in fact the only nonsurgical patient suffering from diabetes had the shortest length of survival. The Karnofsky index was unchanged in 2 cases and lowered in the other 4 surviving patients (Fig. 4). Discussion
Surgical indications and prognosis for elderly patients with intracranial meningiomas depend on various factors: general condition, the presence of neurological deficit or intracranial hypertension, the tumour size and location of the meningioma, the duration of surgery, the presence of peritumoural oedema, diabetes mellitus and other concomitant diseases. The general and the neurological conditions seemed to considerably influence the final outcome in these cases. In addition, it seems that while the size of the meningioma must be taken into consideration when determining surgical indications, the location proves even more critical. An accurate prediction of the duration of surgery, hypothetically calculated according
52
C. Arienta et al.: Treatment of Intracranial Meningiomas in Patients over 70 Years Old
Table 10. Treated Conservatively (Nonsurgical) No.
S e x / Location age
Onset, duration, evolution of symptoms
Neurological and clinical conditions
Karnofsky scale
Grading (C.R.G.S.)
1
m/70 clivus and right apical petrous bone
1 year, right facial paraesthaesias
right impaired V, VI, VII, cerebellarsyndrome, hypertension, left bundle branch block
80
11
2
f/71
tuberculum sellae
2 years, visual impairment
bilateral amaurosis, asthma, hypertension, sinus node disease
60
10
3
f/70
posterior fossa, cerebellar convexity
2 years, bilateral impaired hearing
mild left hemiparesis, respiratory failure, atelectasis of the lung
70
14
4
m/70 left parietal parasagittal
3 months, psychological deterioration, insteady gait
wide-basedgait, left ventricular hypertrophy respiratory failure
80
15
5
m/70 clivus, right pontocerebellar a n g l e
1 month, psychological deterioration
confused, paranoiac, hypertension atrial fibrillation
60
11
6
f/72
left fronto-temporal convexity
10 years, seizures
left bundle branch block, pulmonary atelectasis
70
14
7
1"/78
left fronto-parietal convexity
10 years, seizures
negative neurological findings, heart failure
70
12
8
m/73 right frontal convexity
1 year, psychical deterioration
left ventricular hypertrophy, acute bronchitis
70
14
9
f/70
left middle fossa
7 months, transient aphasia, seizures
lobectomy of left pulmonary apex due to TBC
70
11
10
I"/72
falx
15 days, seizures
uncontrolled diabetes, hypertension, heart and respiratory failure
50
11
11
m/80 right fronto-parietal convexity
7 months, left hemiparesis
left hemiparesis, cerebrovascular disease
60
11
12
1"/70 right parietal-occipital convexity
1 month, left hemiparesis
mild left hemiparesis, cerebrovascular disease
80
14
to the t u m o u r size, the critical location o f the mening i o m a and the experience o f the surgeon, is very imp o r t a n t to the final prognosis, because longer surgical procedures are very often a c c o m p a n i e d by mediocre results. It has been reported that meningiomas with severe peritumoural o e d e m a have a faster growth rate ~5, and it has been demonstrated iv that such meningiomas are histologically hypercellular and hypervascularized with vascular proliferation. O u r data show that meningiomas with severe peritumoural o e d e m a in elderly patients do n o t necessarily correlate with shorter clinical histories, nor are they m o r e frequently associated with
intracranial hypertension. T h e y are, however, more often accompanied by severe neurological deficit and this, combined with the fact o f increased surgical risk, strongly suggests that peritumoural o e d e m a should" be adequately treated prior to the surgical intervention. O u r study reveals in fact that severe o e d e m a is related to a high operative mortality rate (33%) and to a very high post-operative h a e m a t o m a rate as well (25%). This was verified in 3 cases: 2 patients were also suffering f r o m diabetes and in all 3 the m e n i n g i o m a was associated with severe peritumoural oedema. The conc o m i t a n t diabetes mellitus, especially when decompensated by pre- and post-operative steroid therapy, sig-
C. Arienta et al.: Treatment of Intracranial Meningiomas in Patients over 70 Years Old
53
Size
Oedema
Reason for not operating
Length and type of survival
Interval from onset of symptos and cause of death
large
no
extension of lesion
2 years, self-sufficient
after 3 years, ictus
large
no
non-consent of relatives
fair for 6 months, then hemiparesis and patient bedridden
after 3 years, unrelated conditions
small
no
slightly symptomatic, modest dimensions
fair for 4 years, mild left hemiparesis, not completely self-sufficient
alive
small
no
no complaint
good for 3 years
alive
large
no
general and neurological conditions
4 years, continued psychological disorders, not self-sufficient, renal failure
alive
large
no
non-consent of patient
good for 3 years, size unchanged (CT), pacemaker
alive
large
severe
non-consent of patient and relatives
2 years with deterioration of neurological condition
after 12 years, IICP
medium
no
initially postponed due to infection, then non-consent of patient
3 years, right amaurosis
alive
medium
severe
negative neurological findings
good for l year, then hemiparesis and aphasia
after 3 years, bronchopneumonia
large
no
poor condition
2 months in poor condition
after 3 mor/ths, diabetic coma
large
severe
non-consent of relatives due to advanced age
worsening of hemiparesis, not self-sufficient
after 1.5 years, bronchopneumonia
medium
no
non-consent of relatives
good for 2 years, size unchanged (CT)
alive
nificantly increased the mortality rate, a rate which reached 50% in our patients suffering from diabetes. In this series of 34 elderly patients who underwent radical removal of an intracranial meningioma the overall operative mortality rate was 12% (4 patients), a rate higher than that of meningiomas in general, which in recent studies typically varies form 4 to 5%. It is necessary to look at both operative and short-term mortality. Indeed when we consider the mortality rate within 3 months of surgery we see that it increases to 20% (7 patients). In his series of 30 patients over 70 years old Djindjian shows an operative mortality rate of 23% which increases to 37% at 3 month follow-up3.
Proposed Clinici~l-RadioIogiealGrading System ( CRSG ) Taking into account the various factors which can negatively affect the prognosis of these patients (size, location, neurological conditions, initial Karnofsky scale grading, oedema, diabetes and other concomitant diseases), we have adopted a scored grading system which is summarized in Table 11. The size of the meningioma was subdivided into three categories: small (< 4 cm), medium (4~6 cm) and large (> 6 cm). The location was considered critical, taking into account that surgery may be difficult or at risk when the tumour
C. Arienta et al.: Treatment of Intracranial Meningiomas in Patients over 70 Years Old
54
Table 11. Clinieal-Radiological Grading System (C,R.G.S.) Size
( > 6 cm) 1
(4-6 can) 2
( < 4 cm) 3
Neurological conditions
irrecoverable deficit 1
progressive or recoverable deficit 2
no deficit or only seizures 3
Karnofsky scale
up to 50 1
60-80 2
90-100 3
Critical location
highly 1
moderately 2
not critical 3
Peritumoural oedema
severe 1
moderate 2
absent 3
Concomitant diseases
decompensated 1
compensated 2
absent 3
is attached to a venous sinus or when the tumour is in proximity to major cerebral arteries, cranial nerves or the brain stem. About the neurological conditions we considered the presence of irrecoverable, progressive or recoverable deficits. The best score was attributed to patients without neurological deficit or with only seizures. An analysis of this grading system shows that the patients deceased within 3 months of surgery had a score which varied from 7 to 12, with a mean score of 10. The surviving patients on the other hand had a score averaging from 10 to 16 with a mean score of 13 (Fig. 5). If we consider the patients with the lowest scores (7-9) we note the extremely disappointing operative results and prognosis (100% mortality rate). Among the patients with a score between 10 and 12
t
de~l within 30 d ~
we find 8 surviving and 3 dead, 2 of whom died within 3 months of surgery (37% mortality rate). Patients with a score higher than 12 demonstrate excellent results (0 mortality). Differences among these three groups of patients are statistically significant (P < < 0.05). When this grading system is applied to the patients treated conservatively the resulting scores are between 10 and 15 (Fig. 6). Certain aspects of these 12 (nonsurgical) cases bear closer examination. Six patients judged to be candidates for surgery refused to undergo the operation. The clinical conditions of these patients allowed for surgery while the size and location of the meningioma, and in 2 cases the presence of severe oedema, strongly recommended it. Three of these (nonsurgical) patients died within 2 years of the above diagnosis, 2 are currently in good health and one case has worsened. The other 6 nonsurgical cases were not judged to be candidates for surgery due to: failing general con-
de~ within 3 months 0
Q o
16 15 14 13 12 11 I0 9 8
alive
[]
9
de~l
O O O 0 O
O
O
O
O
O
O
O
O O
O O
0
0
e
[] []
[]
[]
13
7
o
16 15 14 13 12 11 10 9
[] o
O
[]
[]
9
9
9
9
[]
9
9
8
7
Fig. 5. C.R.G.S. and mortality in 34 surgical patients. In the group of patients with a score between 7 and 9 the mortality rate was 100%. In the group of patients with a score between 10 and 12 the mortality rate was 37%. In the group of patients with a score between 13 and 16 the mortality rate was 0%
Fig. 6. C.R.G.S. and mortality in 12 nonsurgical patients. The deceased patients all belonged to the group with a score equal to or less than 12
C. Arienta et aL: Treatment of Intracranial Meningiomas in Patients over 70 Years Old
dition (dead 2 months after diagnosis), severe psychological problems unrelated to the meningioma (currently alive), the extremely small dimensions of the meningioma (2 cases - currently alive), and the extension of the meningioma which was consequently judged irremovable in toto (dead 2 years after diagnosis). In the remaining case the patient presented a meningioma of the left middle fossa with negative neurological findings and associated peritumoural oedema. The patient avoided periodic follow-up, subsequently developed focal symptoms and eventually showed an unfavourable outcome (dead 2 years after diagnosis). The mean score of the deceased patients was 11, while that of the alive patients proved to be 14. All of the nonsurgical and deceased patients had a score of less than or equal to 12. The difference between these two groups of patients is statistically significant (P
Acta Neurochir (Wien) (1990) 107:47-55
N urochirurgica 9 by Springer-Verlag1990
Treatment of lntracranial Meningiomas in Patients over 70 Years Old C. Arienta, M. Caroli, F. Crotti, and R. Villani Neurosurgical Clinic, University of Milan, Milan, Italy
Summary
this category are represented in various studies 7' 10, 12
The neurosurgeon often finds himself in the position to having to decide whether or not to operate on an elderly patient suffering from intracranial meningioma. The decision is rarely easy and the results often disappointing. We studied 46 cases of intracranial meningioma in patients over 70 years of age, 34 patients were operated on while 12 patients were not, although both groups were subjected to long term follow-up. The operative mortality rate was 12%, a rate which increased to 20% at 3 months follow-up. Various unfavourable prognostic factors were taken into consideration, the most significant of which were: poor overall clinical condition, peritumoural oedema, the presence of diabetes mellitus and the duration of surgery. A scored grading system was created to standardize surgical indications in elderlypatients with cerebral meningioma. An analysis of the grading system, when applied to patients submitted to surgery, showed that the deceased patients within 3 months of surgery had a score which varied from 7 to 12, with a mean score of 10. The surviving patients had a score averaging from 10 to 16 with a mean of 13. The patients with the lowest scores (7-9) had a 100% mortality rate while those in the upper ranges (13-16) demonstrated a mortality rate of 0%. Among the conservatively treated patients the worst outcome was seen in patients with a grading equal to or less than 12.
I m p r o v e d c o n d i t i o n s o f life a n d the increased m e a n age in the general p o p u l a t i o n a c c o u n t for the m o r e frequent incidence of elderly patients in good general health who
Keywords: IntracraniaI meningioma; elderly patients; clinicaIradiological grading.
Introduction M e n i n g i o m a s are rightly considered to be b e n i g n b r a i n t u m o u r s whose radical r e m o v a l allows complete recovery of the patient. Biological recovery does n o t however always c o r r e s p o n d to clinical recovery a n d there exists a certain m o r b i d i t y (hemiplegia, seizures, etc.) a n d the possibility of recurrence 2~9, 12, 14, 16 I n the literature we find m a n y studies of i n t r a c r a n i a l m e n i n g i o m a s ; less interest has been accorded however to i m m e d i a t e a n d l o n g - t e r m operative results in the t r e a t m e n t of m e n i n g i o m a s in patients over 70 years of age ~, 3, 4, 5, 6, 11, 13 even t h o u g h patients who fall within
suffer from i n t r a c r a n i a l m e n i n g i o m a s , T h e present day decrease in the operative death rate further p r o m p t s c o n s i d e r a t i o n o f the surgical r e m o v a l o f m e n i n g i o m a s in elderly patients. Does there exist a n age limit in the surgical t r e a t m e n t of this type o f biologically b e n i g n t u r n o u t ? Will the p a t i e n t truly benefit from the surgery? Will the patient's quality of life a n d chances of survival improve? Is the surgical risk greater or less t h a n the s u b s e q u e n t risks of n o t operating? Should all elderly patients free of a g g r a v a t i n g pathological c o m p l i c a t i o n s such as hypertension, diabetes, ischaemic heart a n d b r a i n diseases, a n d acute or chronic respiratory diseases, a u t o m a t i c a l l y be selected for surgery? These are i m p o r t a n t questions a n d they m u s t be answered in order to determine the p r o p e r indications for surgical t r e a t m e n t of m e n i n g i o m a s in the elderly patient.
Clinical Materials and Methods Only cases of intracranial meningiomas were taken into consideration in this study, excludingcases of intraorbital and spinal meningiomas. No cases of recurrent meningiomas were included in this group selected for study. The group includes 46 patients, 15 men and 31 women between 70 and 80 years of age, who were admitted and operated on in our clinic between 1980 and 1986. Thirty four patients underwent radical surgical removal of the meningioma. The remaining 12 were not operated on for varying reasons: lack of consent on the part of the patient or relatives, the extremely small dimensions of the meningioma or the generally poor condition of the patient. There does not exist a histological comparison in the nonsurgical cases of course, but the densimeter characteristics of the CT scan with contrast medium allowed for a presumed diagnosis.
C. Arienta et al.: Treatment of Intracranial Meningiomas in Patients over 70 Years Old
48
Results
30
Surgical P a t i e n t s B o t h o p e r a t i v e m o r t a l i t y ( w i t h i n 30 d a y s f o l l o w i n g surgery) and mortality
up to 3 months
following sur-
g e r y w e r e c o n s i d e r e d i n a n a l y z i n g t h e r e s u l t s o f t h e 34
20
[] []
Females 31 Males 15
N
Table 2. Clinical History and Mortality in Surgical and Nonsurgical
Patients 10
(a) Surgical Patients (n. 34)
_ 9
70
,
71
9
72
|
73
74
76
80
Onset of symptoms
Surviving patients
Operative mortality
Dead within 3 months
< 1 month 1-6 months < 6 months
10 6 i1
1 1 2
1 1 1
Length of survival
Age Fig. 1. Sex and age of elderly patients with intracranial meningioma
Table 1. Incidence of Symptoms and Signs at Time of Admission Symptoms and signs
Surgical patients
Nonsurgical patients
Total %
Hemiparesis Seizures Headache Dysphasia or aphasia Papilloedema Cranial nerve palsies Psychical deterioration Nausea and vomiting Visual impairment
21 12 8 6 7 6 5 3 3
3 3 1 3 2 1
52 33 17 15 15 19 15 6 8
The long-term follow-up varied from 1 to 5 years (average 2) and was carried out by means of a telephone conversation with the patient concerned or a close relative, along with a questionnaire. The age and sex o f the patients are summarized in Fig. 1. The mean age was 72 years. The most important symptoms and clinical signs are illustrated in Table 1. Epileptic seizures were present in 33% of the cases. Seven patients suffered from the intracranial hypertension syndrome, representing 15% of all cases studied. In all of these patients except one peritumoural oedema was identifiable by CT scan. The diagnosis in all cases was obtained by cerebral CT scan with contrast medium. Sixteen patients underwent an angiographic study in additon to CT scan. Our data were submitted to statistical analysis using T-student test. A P value was calculated for each comparison with significance assumed at the 0.05 level.
(b) Nonsurgical Patients (n. 12) Onset of symptoms
Surviving patients
Dead
< 1 month 1-6 months > 6 months
3 3
1
3 months
5
3 years 3 years 3 years 18 months 12 years
Table 3. Tumour Sites and Size and Mortality in Surgical Patients (a) Tumour Site and Mortality Location
Number
Operative mortality
Dead within 3 months
Convexity Falx Sphenoid ridge Parasagittal Olfactory groove Pontocerebellar angle Tuberculum sellae Falcotentorial Multiple (convexity)
9 8 6 3 4 1 1 1 1
2 1 1 -
1 2 -
(b) Tumour Size and Mortality Size
Number
Operative mortality
Dead within 3 months
>6cm 4-6 cm 5 hours < 5 hours
Size
Site
> 6 can %
4-6 cm %
< 4 cm %
Convexity %
Midline %
Base %
73 65
18 22
9 13
27 30
27 35
46 35
C. Arienta et al.: Treatment of Intracranial Meningiomas in Patients over 70 Years Old 3" 100 -
e
[]
51
1 O0 []
[]
90
90
2*
o 8O
8
r"
[]
3*
70 ,0 r
8O
[]
70
60
E
Go
50
40
I
I
I
Admission
Discharge
Follow-up
Fig, 3. Changes in the Karnofsky scale at follow-up of the 22 surviving operated patients. AII surviving patients demonstrated improved clinical conditions whatever their original Karnofsky scale score. * Represents the number of patients with the same Karnofsky scale score. A mean score was utilized for each group
the surgery. The present neurological conditions of the remaining 22 living patients confirm additional improvement in their grading level over the scores initially recorded following surgery (Fig. 3).
Patients Treated Conservatively [Nonsurgical] The clinical profiles of the 12 patients suffering from intracranial meningiomas (diagnosed by CT scan) who did not undergo surgery are summarized in Table 10. Included are symptoms and clinical signs, onset of symptoms, the initial Karnofsky scale grading and the reason for the decision not to operate. The quality and length of survival in these unoperated patients was established by long-term follow-up controls. The meningioma was located at the convexity in 6 cases, at the base in 4 and at the midline in the remaining 2 cases. Long-term control (2 years average) verified that the cases of unoperated meningioma located at the base demonstrated a mortality rate of 75%, those at the midline a mortality rate of 50% and the meningiomas located at the convexity one of 33%. The length of clinical history, which varied from 15 days to 10 years, had a bearing on mortality. The controls clearly demonstrate that a higher mortality rate was present in the patients with the longest clinical histories, (Table2b) but this correlation is not statistically significant. The Karnofsky scale gradings of the nonsurgical cases (the evaluation method also adopted for the surgical cases) varied between 50 and 80. Observation of
40
I
i
Follow-up Fig.4. Changesin the Karnofskyscale at follow-upcontrol of the 6 survivingunoperatedpatients. *Represents the numberofpatients with the sameKarnofskyscalescore. A meanscorewas utilizedfor each group. Admission
mortality at the long-term follow-up control shows that mortality is also present in the nonsurgical patients with the highest Karnofsky scale gradings. It is primarily the size of the meningioma, and more importantly the presence of peritumoural oedema confirmed by CT scan, which influence eventual long-term outcome. Indeed all 3 of the patients who presented the characteristic of peritumoural oedema with shift died. The presence of diabetes, as in the case of the surgical patients, severely compromised patient survival; in fact the only nonsurgical patient suffering from diabetes had the shortest length of survival. The Karnofsky index was unchanged in 2 cases and lowered in the other 4 surviving patients (Fig. 4). Discussion
Surgical indications and prognosis for elderly patients with intracranial meningiomas depend on various factors: general condition, the presence of neurological deficit or intracranial hypertension, the tumour size and location of the meningioma, the duration of surgery, the presence of peritumoural oedema, diabetes mellitus and other concomitant diseases. The general and the neurological conditions seemed to considerably influence the final outcome in these cases. In addition, it seems that while the size of the meningioma must be taken into consideration when determining surgical indications, the location proves even more critical. An accurate prediction of the duration of surgery, hypothetically calculated according
52
C. Arienta et al.: Treatment of Intracranial Meningiomas in Patients over 70 Years Old
Table 10. Treated Conservatively (Nonsurgical) No.
S e x / Location age
Onset, duration, evolution of symptoms
Neurological and clinical conditions
Karnofsky scale
Grading (C.R.G.S.)
1
m/70 clivus and right apical petrous bone
1 year, right facial paraesthaesias
right impaired V, VI, VII, cerebellarsyndrome, hypertension, left bundle branch block
80
11
2
f/71
tuberculum sellae
2 years, visual impairment
bilateral amaurosis, asthma, hypertension, sinus node disease
60
10
3
f/70
posterior fossa, cerebellar convexity
2 years, bilateral impaired hearing
mild left hemiparesis, respiratory failure, atelectasis of the lung
70
14
4
m/70 left parietal parasagittal
3 months, psychological deterioration, insteady gait
wide-basedgait, left ventricular hypertrophy respiratory failure
80
15
5
m/70 clivus, right pontocerebellar a n g l e
1 month, psychological deterioration
confused, paranoiac, hypertension atrial fibrillation
60
11
6
f/72
left fronto-temporal convexity
10 years, seizures
left bundle branch block, pulmonary atelectasis
70
14
7
1"/78
left fronto-parietal convexity
10 years, seizures
negative neurological findings, heart failure
70
12
8
m/73 right frontal convexity
1 year, psychical deterioration
left ventricular hypertrophy, acute bronchitis
70
14
9
f/70
left middle fossa
7 months, transient aphasia, seizures
lobectomy of left pulmonary apex due to TBC
70
11
10
I"/72
falx
15 days, seizures
uncontrolled diabetes, hypertension, heart and respiratory failure
50
11
11
m/80 right fronto-parietal convexity
7 months, left hemiparesis
left hemiparesis, cerebrovascular disease
60
11
12
1"/70 right parietal-occipital convexity
1 month, left hemiparesis
mild left hemiparesis, cerebrovascular disease
80
14
to the t u m o u r size, the critical location o f the mening i o m a and the experience o f the surgeon, is very imp o r t a n t to the final prognosis, because longer surgical procedures are very often a c c o m p a n i e d by mediocre results. It has been reported that meningiomas with severe peritumoural o e d e m a have a faster growth rate ~5, and it has been demonstrated iv that such meningiomas are histologically hypercellular and hypervascularized with vascular proliferation. O u r data show that meningiomas with severe peritumoural o e d e m a in elderly patients do n o t necessarily correlate with shorter clinical histories, nor are they m o r e frequently associated with
intracranial hypertension. T h e y are, however, more often accompanied by severe neurological deficit and this, combined with the fact o f increased surgical risk, strongly suggests that peritumoural o e d e m a should" be adequately treated prior to the surgical intervention. O u r study reveals in fact that severe o e d e m a is related to a high operative mortality rate (33%) and to a very high post-operative h a e m a t o m a rate as well (25%). This was verified in 3 cases: 2 patients were also suffering f r o m diabetes and in all 3 the m e n i n g i o m a was associated with severe peritumoural oedema. The conc o m i t a n t diabetes mellitus, especially when decompensated by pre- and post-operative steroid therapy, sig-
C. Arienta et al.: Treatment of Intracranial Meningiomas in Patients over 70 Years Old
53
Size
Oedema
Reason for not operating
Length and type of survival
Interval from onset of symptos and cause of death
large
no
extension of lesion
2 years, self-sufficient
after 3 years, ictus
large
no
non-consent of relatives
fair for 6 months, then hemiparesis and patient bedridden
after 3 years, unrelated conditions
small
no
slightly symptomatic, modest dimensions
fair for 4 years, mild left hemiparesis, not completely self-sufficient
alive
small
no
no complaint
good for 3 years
alive
large
no
general and neurological conditions
4 years, continued psychological disorders, not self-sufficient, renal failure
alive
large
no
non-consent of patient
good for 3 years, size unchanged (CT), pacemaker
alive
large
severe
non-consent of patient and relatives
2 years with deterioration of neurological condition
after 12 years, IICP
medium
no
initially postponed due to infection, then non-consent of patient
3 years, right amaurosis
alive
medium
severe
negative neurological findings
good for l year, then hemiparesis and aphasia
after 3 years, bronchopneumonia
large
no
poor condition
2 months in poor condition
after 3 mor/ths, diabetic coma
large
severe
non-consent of relatives due to advanced age
worsening of hemiparesis, not self-sufficient
after 1.5 years, bronchopneumonia
medium
no
non-consent of relatives
good for 2 years, size unchanged (CT)
alive
nificantly increased the mortality rate, a rate which reached 50% in our patients suffering from diabetes. In this series of 34 elderly patients who underwent radical removal of an intracranial meningioma the overall operative mortality rate was 12% (4 patients), a rate higher than that of meningiomas in general, which in recent studies typically varies form 4 to 5%. It is necessary to look at both operative and short-term mortality. Indeed when we consider the mortality rate within 3 months of surgery we see that it increases to 20% (7 patients). In his series of 30 patients over 70 years old Djindjian shows an operative mortality rate of 23% which increases to 37% at 3 month follow-up3.
Proposed Clinici~l-RadioIogiealGrading System ( CRSG ) Taking into account the various factors which can negatively affect the prognosis of these patients (size, location, neurological conditions, initial Karnofsky scale grading, oedema, diabetes and other concomitant diseases), we have adopted a scored grading system which is summarized in Table 11. The size of the meningioma was subdivided into three categories: small (< 4 cm), medium (4~6 cm) and large (> 6 cm). The location was considered critical, taking into account that surgery may be difficult or at risk when the tumour
C. Arienta et al.: Treatment of Intracranial Meningiomas in Patients over 70 Years Old
54
Table 11. Clinieal-Radiological Grading System (C,R.G.S.) Size
( > 6 cm) 1
(4-6 can) 2
( < 4 cm) 3
Neurological conditions
irrecoverable deficit 1
progressive or recoverable deficit 2
no deficit or only seizures 3
Karnofsky scale
up to 50 1
60-80 2
90-100 3
Critical location
highly 1
moderately 2
not critical 3
Peritumoural oedema
severe 1
moderate 2
absent 3
Concomitant diseases
decompensated 1
compensated 2
absent 3
is attached to a venous sinus or when the tumour is in proximity to major cerebral arteries, cranial nerves or the brain stem. About the neurological conditions we considered the presence of irrecoverable, progressive or recoverable deficits. The best score was attributed to patients without neurological deficit or with only seizures. An analysis of this grading system shows that the patients deceased within 3 months of surgery had a score which varied from 7 to 12, with a mean score of 10. The surviving patients on the other hand had a score averaging from 10 to 16 with a mean score of 13 (Fig. 5). If we consider the patients with the lowest scores (7-9) we note the extremely disappointing operative results and prognosis (100% mortality rate). Among the patients with a score between 10 and 12
t
de~l within 30 d ~
we find 8 surviving and 3 dead, 2 of whom died within 3 months of surgery (37% mortality rate). Patients with a score higher than 12 demonstrate excellent results (0 mortality). Differences among these three groups of patients are statistically significant (P < < 0.05). When this grading system is applied to the patients treated conservatively the resulting scores are between 10 and 15 (Fig. 6). Certain aspects of these 12 (nonsurgical) cases bear closer examination. Six patients judged to be candidates for surgery refused to undergo the operation. The clinical conditions of these patients allowed for surgery while the size and location of the meningioma, and in 2 cases the presence of severe oedema, strongly recommended it. Three of these (nonsurgical) patients died within 2 years of the above diagnosis, 2 are currently in good health and one case has worsened. The other 6 nonsurgical cases were not judged to be candidates for surgery due to: failing general con-
de~ within 3 months 0
Q o
16 15 14 13 12 11 I0 9 8
alive
[]
9
de~l
O O O 0 O
O
O
O
O
O
O
O
O O
O O
0
0
e
[] []
[]
[]
13
7
o
16 15 14 13 12 11 10 9
[] o
O
[]
[]
9
9
9
9
[]
9
9
8
7
Fig. 5. C.R.G.S. and mortality in 34 surgical patients. In the group of patients with a score between 7 and 9 the mortality rate was 100%. In the group of patients with a score between 10 and 12 the mortality rate was 37%. In the group of patients with a score between 13 and 16 the mortality rate was 0%
Fig. 6. C.R.G.S. and mortality in 12 nonsurgical patients. The deceased patients all belonged to the group with a score equal to or less than 12
C. Arienta et aL: Treatment of Intracranial Meningiomas in Patients over 70 Years Old
dition (dead 2 months after diagnosis), severe psychological problems unrelated to the meningioma (currently alive), the extremely small dimensions of the meningioma (2 cases - currently alive), and the extension of the meningioma which was consequently judged irremovable in toto (dead 2 years after diagnosis). In the remaining case the patient presented a meningioma of the left middle fossa with negative neurological findings and associated peritumoural oedema. The patient avoided periodic follow-up, subsequently developed focal symptoms and eventually showed an unfavourable outcome (dead 2 years after diagnosis). The mean score of the deceased patients was 11, while that of the alive patients proved to be 14. All of the nonsurgical and deceased patients had a score of less than or equal to 12. The difference between these two groups of patients is statistically significant (P
