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Intracranial meningioma

Excluding autopsy data, meningiomas comprise approximately 22% of primary intracranial tumors. If autopsy data are included, the overall incidence of meningiomas is 2.3-5.5 cases per 100,000 persons.


Natural History


Extracranial meningioma metastases (EMM) occur in 0.1% of intracranial meningioma patients and are more commonly seen in those with atypical and anaplastic histologies. While the lungs and pleura are the most common site of EMM, intraspinal and vertebral EMM also occur and are not well described in the literature. Although the presence of EMM can worsen prognosis, no standard of care has been established for EMM management. All patients treated for recurrent atypical/anaplastic meningiomas between January 1985 and July 2014 at Memorial Sloan Kettering Cancer Center were screened for intraspinal and vertebral EMM. Of these patients, 2 were identified as having recurrent meningioma complicated by vertebral or intraspinal EMM. A review of the literature was also conducted. The PubMed database was screened for intraspinal and vertebral EMM cases reported in the literature from 1985 to 2015. Nineteen articles were identified from the literature and included 24 individual cases with a total of 34 vertebral or intraspinal EMM. Forty-two percent (10/24) of patients with vertebral or intraspinal EMM had WHO Grade I tumors. Furthermore, 25% (6/24) of vertebral and intraspinal EMM occurred after the primary tumor but prior to any recurrence. This paper highlights that vertebral and intraspinal EMM can occur in patients with WHO Grade I meningiomas and can occur before tumor recurrence. This challenges the notion that EMM are seen primarily in high-grade atypical and anaplastic meningiomas 1).

Clinical features

Neurocognitive functions

Meningioma patients are characterised by long term deficits in neurocognitive functioning that can partly be attributed to the use of antiepileptic drugs and tumour location but not to the use of radiotherapy 2).

Current recommendations stress the need for cognitive parameters to be integrated in the evaluation of outcomes for intracranial meningioma surgery.

Patients with skull base (anterior and middle fossa) and convexity (anterior and posterior) meningiomas (n = 54) underwent neuropsychological examination prior to and 1 year after surgery. A control group (n = 52) of healthy volunteers matched for age, sex, and education underwent the same examination. Assessments included executive funtions, memory, and motor functions with standardized testing. Patients with convexity meningiomas were clinically assessed for parietal association cortex functions.

All patients performed significantly worse (p < 0.05) in most neurocognitive domains than controls. The skull base group showed more disturbances in memory than the convexity group (p < 0.05). The anterior convexity group showed more deficits in executive function than the posterior convexity group, which presented with parietal association cortex deficits. Verbal deficits were more pronounced in the left hemisphere than in the right hemisphere. Patients with a large tumor (> 4 cm) had more severe neurocognitive deficits than those with a small tumor (< 4 cm). Postoperatively, patients showed no deterioration in neurocognitive function. Instead, significant improvement (p < 0.05) was observed in some executive, motor, and parietal association cortex functions.

According to the authors' findings, intracranial meningiomas may cause neurocognitive deficits in patients. Surgery does not cause a deterioration in cognitive function; instead, it may lead to improvements in some functions. Permanent neuropsychological postoperative deficits should be interpreted as tumor-induced rather than due to surgery 3).




Conventional open surgery of large meningiomas has proven to be challenging even in experienced hands. Intense retraction and dissection around neurovascular structures increase morbidity and mortality.

Large size of tumors, difficulties in resection and preexisting conditions are primary causes of a high rate of operative morbidity in elderly patients receiving meningioma removal 4).

Postoperative hematoma (POH)

Removal of an intracranial meningioma carries a higher risk of post-operative hemorrhage compared to surgery for other intracranial neoplasms.

21 patients (7.1 %) of 296 patients developed a post-operative intracranial hematoma requiring surgical evacuation. Age was significantly higher in the hematoma group 62.4 +/- 14.0 years compared to patients without post-operative hematoma 56.1 +/- 12.0 (p < 0.05; t-test). Patients older than 70 years had a six-fold increased risk to develop a post-operative hematoma (Chi2 test, 95% CI 1.949-13.224). Patients with post-operative hemorrhage had significant lower post-operative prothrombin time, fibrinogen and platelets immediately after surgery and lower platelets at day 1. None of the other parameters, including pre-operative routine coagulation values, differed significantly between patients with and without post-operative hemorrhage. Three patients with post-operative hematoma showed platelet dysfunction and three patients showed decreased FXIII activity. Of those patients with post-operative hemorrhage at three months follow up three patients (13%) succumbed from reasons not directly related to hemorrhage, one patient remained GOS 2 (4.3%), four patients (17.4%) were GOS 3 and 15 (65.4%) patients had favorable outcome (GOS 4 [one patient] and GOS5 [14 patients]). Meningioma surgery carries a higher risk for post-operative hematoma in the elderly. Thrombocytopenia and other hemostatic disorders were frequently associated with post-operative hemorrhage after meningioma surgery, while no surgical factors could be defined. Extending coagulation tests and specific replacement therapy may prevent hematoma formation and improve the patients outcome 5).

Five hundred and five operations for intracranial meningiomas were complicated by 18 postoperative hematomas (POH)–3.56%. The POH were more frequently encountered in older patients and/or patients with atherosclerosis, arterial hypertension and diabetes. Longer lasting operations especially cases with intraoperative fall of blood pressure were more often complicated by POH. The POH were more frequently observed following total excision than partial removal and after convexity meningioma operations than other locations. The outcome of the operations complicated by POH was related to the time of their clinical manifestation and removal 6).

Postoperative seizures

Fourteen factors possibly correlated with early postoperative seizures in a cohort of 209 elderly patients who had undergone meningioma resection, as analyzed by multifactorial stepwise logistic regression. Phenobarbital sodium (0.1 g, intramuscularly) was administered to all 209 patients 30 min prior to undergoing surgery. All the patients had no previous history of seizures. The correlation of the 14 clinical factors (gender, tumor site, dyskinesia, peritumoral brain edema (PTBE), tumor diameter, pre- and postoperative prophylaxes, surgery time, tumor adhesion, circumscription, blood supply, intraoperative transfusion, original site of the tumor and dysphasia) was assessed in association with the risk for post-operative seizures. Tumor diameter, postoperative prophylactic antiepileptic drug (PPAD) administration, PTBE and tumor site were entered as risk factors into a mathematical regression model. The odds ratio (OR) of the tumor diameter was >1, and PPAD administration showed an OR >1, relative to a non-prophylactic group. A logistic regression equation was obtained and the sensitivity, specificity and misdiagnosis rates were 91.4, 74.3 and 25.7%, respectively. Tumor diameter, PPAD administration, PTBE and tumor site were closely correlated with early postoperative seizures; PTBE and PPAD administration were risk and protective factors, respectively 7).

Thromboembolic events

Meningiomas are associated with the highest postoperative rate of venous thromboembolic events (VTE) among all intracranial tumors.


Intraoperative leg-elevation, intermittent pneumatic compression (IPC), early heparin administration and low-molecular-weight heparin (LMWH) 8).

Recurrent meningioma

Case series


All histologically proven intracranial meningiomas that underwent resection in a single centre between April 2009 and April 2014 were reviewed and classified according to the 2016 edition of the Classification of the Tumours of the CNS. Only patients who had two pre-operative scans that were at least 3 months apart were included in the study. Two authors performed the volumetric measurements using the Slicer 3D software independently and the inter-rater reliability was assessed. Multiple regression analyses of factors affecting the VGR and VDE of meningiomas were performed using the R statistical software with p < 0.05 considered to be statistically significant.

Of 548 patients who underwent resection of their meningiomas, 66 met the inclusion criteria. Sixteen cases met the exclusion criteria (NF2, spinal location, previous surgical or radiation treatment, significant intra-osseous component and poor quality imaging). Forty-two grade I and 8 grade II meningiomas were included in the analysis. The VGR was significantly higher for grade II meningiomas. Using receiver-operator characteristic (ROC) curve analysis, the optimal threshold that distinguishes between grade I and II meningiomas is 3 cm3/year. Higher histological grade, high initial tumour volume, MRI T2-signal hyperintensity and presence of oedema were found to be significant predictors of higher VGR.

Reliable tools now exist to evaluate and monitor volumetric growth of meningiomas. Grade II meningiomas have significantly higher volumetric growth rate (VGR) compared with grade I meningiomas and growth of more than 3 cm3/year is strongly suggestive of a higher grade meningioma. A larger, multi-centre prospective study to investigate the applicability of velocity of growth to predict the outcome of patients with meningioma is warranted 9).


Park et al. present a retrospective case series of 5 females at our institutions (age ranged 21-72 years, mean 54.6 years) diagnosed with LD of an intracranial meningioma after surgery between 1998 and 2013. A database search revealed 45 cases with LD of meningioma in the English literature. Characteristic features were analyzed and compared.

The incidence rate at our institutions of LD of meningioma was 0.9% (5/534). World Health Organization (WHO) grade was distributed as follows: I : 2, II : 2, and III : 1. Time to LD ranged from 2.5 months to 6.9 years; the patient with WHO grade III had the shortest interval to LD. The patient with an intraventricular meningioma (WHO grade II) had the second shortest interval to LD (1.7 years), and simultaneously revealed both LD and extraneuronal metastases. Four of 5 patients showed a disease progression, with the survival ranging from 1 month to 3.8 years after LD. Based on the literature, the initial tumor was an intraventricular meningioma in 9 patients, and their time to LD was shorter on average (mean 1.9 years). Histologically, 26 of 45 (58%) were initially diagnosed with a WHO grade II or III meningioma, and 6 of 19 patients (32%) with WHO grade I revealed malignant transformation.

This study shows that intraventricular location and histologically aggressive features seem to increase the chance of LD of meningioma 10).

Case reports

A 42-year-old man presented with occasional headache. Neurological examination was negative. CT scans showed a mass lesion located in temporal region with homogeneous hyperdensity and foci calcification. The patients MRI studies demonstrated the lesion was hypointense on T1-weighted and T2-weighted MR images. After administration of Gd-DTPA, the lesion revealed neither enhancement nor dural tail sign. After gross total excision of the lesion was accomplished, histopathological examination confirmed the diagnosis of hyalinedegeneration-rich fibrous meningioma, which represented a distinctive pathologic manifestation.

This report illustrates common meningiomas possess the rare occurrence of uncommon neuroimaging characteristics and pathological features. According to radiological and pathological features, the causes of rare imaging characteristics were discussed 11).

Singh R, Ryan C, Chohan MO, Tisnado J, Hadjigeorgiou GF, Bilsky MH. Intracranial meningioma with vertebral or intraspinal metastasis: report of 2 cases and review of the literature. J Neurosurg Spine. 2016 Jul 15:1-7. [Epub ahead of print] PubMed PMID: 27420397.
Dijkstra M, van Nieuwenhuizen D, Stalpers LJ, Wumkes M, Waagemans M, Vandertop WP, Heimans JJ, Leenstra S, Dirven CM, Reijneveld JC, Klein M. Late neurocognitive sequelae in patients with WHO grade I meningioma. J Neurol Neurosurg Psychiatry. 2009 Aug;80(8):910-5. doi: 10.1136/jnnp.2007.138925. Epub 2008 Jul 24. PubMed PMID: 18653549.
Liouta E, Koutsarnakis C, Liakos F, Stranjalis G. Effects of intracranial meningioma location, size, and surgery on neurocognitive functions: a 3-year prospective study. J Neurosurg. 2016 Jun;124(6):1578-84. doi: 10.3171/2015.6.JNS1549. Epub 2015 Dec 4. PubMed PMID: 26636380.
Zeng C, Wang S, Zhao YL, Zhang D, Wang R, Zhao JZ. [Ninety cases of postoperative complications in elderly patients after surgical removal of meningiomas]. Zhonghua Yi Xue Za Zhi. 2010 Feb 2;90(5):298-300. Chinese. PubMed PMID: 20368048.
Gerlach R, Raabe A, Scharrer I, Meixensberger J, Seifert V. Post-operative hematoma after surgery for intracranial meningiomas: causes, avoidable risk factors and clinical outcome. Neurol Res. 2004 Jan;26(1):61-6. PubMed PMID: 14977059.
Arnaudova V, Romansky K. Postoperative hematomas following 505 operations for intracranial meningiomas. Zentralbl Neurochir. 1989;50(2):99-100. PubMed PMID: 2624029.
Zhang BO, Wang D, Guo Y, Yu J. Clinical multifactorial analysis of early postoperative seizures in elderly patients following meningioma resection. Mol Clin Oncol. 2015 May;3(3):501-505. Epub 2015 Jan 22. PubMed PMID: 26137257.
Eisenring CV, Neidert MC, Sabanés Bové D, Held L, Sarnthein J, Krayenbühl N. Reduction of thromboembolic events in meningioma surgery: a cohort study of 724 consecutive patients. PLoS One. 2013 Nov 14;8(11):e79170. doi: 10.1371/journal.pone.0079170. eCollection 2013. PubMed PMID: 24244441; PubMed Central PMCID: PMC3828295.
Soon WC, Fountain DM, Koczyk K, Abdulla M, Giri S, Allinson K, Matys T, Guilfoyle MR, Kirollos RW, Santarius T. Correlation of volumetric growth and histological grade in 50 meningiomas. Acta Neurochir (Wien). 2017 Aug 9. doi: 10.1007/s00701-017-3277-y. [Epub ahead of print] PubMed PMID: 28791500.
Park KS, Kim KH, Park SH, Hwang JH, Lee DH. Intracranial meningioma with leptomeningeal dissemination : retrospective study with review of the literature. J Korean Neurosurg Soc. 2015 Apr;57(4):258-65. doi: 10.3340/jkns.2015.57.4.258. Epub 2015 Apr 24. PubMed PMID: 25932292; PubMed Central PMCID: PMC4414769.
Zhang Q, Wang X. A distinctive pathological meningioma completely without enhancement and dural tail sign on imaging findings. World Neurosurg. 2017 Feb 27. pii: S1878-8750(17)30272-3. doi: 10.1016/j.wneu.2017.02.099. [Epub ahead of print] PubMed PMID: 28254600.
intracranial_meningioma.txt · Last modified: 2018/05/25 16:52 by administrador