ACTA NEUROCHIRURGICA 9 by Springer-Verlag 1983

Acta Neurochirurgica 67,195--204 (1983)

Neurosurgical Division, Regional General Hospital, Ancona, Italy

Intracranial Meningiomas in the Elderly in the CT Scan Era By I. P a p o

Summary Intracranial meningiomas diagnosed and operated upon in similar five-year periods before and after CT scan are analysed. In the latter period the overall number of meningiomas and the average age of the patients have increased-tumours from 77 to 186, and average age from 50 to 56. All patients but.one from the first group were operated on, while only 155 from the second group underwent surgery. Operation was rejected in 31 patients for different reasons. In the pre-CT scan epoch 25% of patients who were operated on were over 60 and 9% were over 65, whereas in the CT scan era these rates have risen to 35 and 210/0 respectively. Mortality and good recovery rate were the same in both groups up to 65 years of age. After 65, postoperative complications and mortality increased steeply: of the patients over 65 in whom the growth was excised 55~ died. The radical surgery of intracranial meningiomas in geriatric patients over 65 still remains a tremendous challenge despite all the advances in operative technique, neuroanaesthesia and intensive care. On these grounds, in such patients surgical indications should be carefully evaluated.

Keywords: Brain oedema; computed assisted tomography; intracranial meningiomas.

The introduction of CT scan as a screening procedure on unselected patients has profoundly modified the overall neurosurgical diagnostic outlook. In particular, the incidence of intracranial meningiomas seems to have definitely increased. In actual fact, a number of small tumours are disclosed by CT scans performed for trivial symptoms, such as atypical headache, dizziness, mild psychic disorders, and so forth, which are often unrelated to the intracranial growth. However, the relevant increase of intracranial meningiomas depends to a greater extent on the fact that in a number of elderly people who exhibit mental deterioration, hemiparesis, or epileptic fits, and who previously would have been considered as having 0001-6268/83/0067/0195/$ 02.00

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vascular or degenerative diseases, benign intracranial space-occupying lesions are now easily detected. On these grounds, the problem of making surgical decisions in geriatric patients with intracranial meningiomas has become a matter of everyday routine. In the classical neurosurgical literature, it was unanimously established, on the basis of the largest series, that the peak incidence of intracranial meningiomas was in middle age, between 40 and 60 years. Even recently, in Garibi's series of 201 patients, 640/0 were in the fifth and in the sixth decades. In Cushing's 2 clinical material, the average age was 46 years (52 for males and 43 for females), while in Ziilch's 7 it was even lower: 44 for males and 43 for females. Nevertheless, years ago Russell and Rubinstein 5, even though they agreed that intracranial meningiomas are more commonly detected in the middle-aged, stressed that such tumours are more frequent in the elderly than was generally supposed. To support this statement, they quoted Wood's 6 study on intracranial tumours found incidentally at necropsy: of 300 tumours 100 were meningiomas. The peak incidence of these was in the seventh decade. In order to approach the management of intracranial meningiomas more rationally in geriatric patients we have reviewed our personal series. O w n Material

Overall Data In the 5-year period just before the introduction of CT scan only 77 meningiomas were diagnosed. Operation was discarded solely in one patient, a 66-year-old woman with a bifrontal hyperostosing meningioma and mild non-evolutive symptomatoXogy. The ages of the patients who underwent surgery are given in Table 1. Altogether 570/0 of patients were in the fifth and the sixth decade, while only 260/o were over 60 and 10~ over 65. The average age in the whole group was 50 years. The overall operative mortality was 14~ (11 patients); in the patients under 65 it was 13~ Of the 7 patients over 65, 2 died, while 2 additional patients remained severely disabled. In the 5-year period after the introduction of CT scan as a screening procedure on unselected cases, mostly in the out-patient department, 186 intracranial meningiomas were detected. Ten of these were of small size (less than 3 cm diameter). Multiple meningiomas were disclosed in four patients. The ages in the whole group are given in Table 2:470/0 were in the fifth and in the sixth decades, while 430/0 were over 60, and 31~ were over 65. The average age

Intracranial Meningiomas in the Elderly in the CT Scan Era Table 1. Ages of Patients with Intracranial Meningiomas (pre-CT-scan era) Years 0-10

Number

~

1

1

11-20 21-30 31-40 41-50 51-60 61-70 Over 70

3 2 6 20 24 16 4

4 3 8 26 32 21 5

Total

76

Table 2. Ages of Patients with Intracranial Meningiornas (CT-scan era) Years

Number

~

21-30 31-40 41-50 51-60 61-70 Over 70

8 11 46 41 58 22

4 6 25 22 31 12

Table 3. Locations of Meningiornas (CT-scan series) Tumour location

Number

~

Parasagittal Falx Convexity Sphenoid ridge Olfactory groove Infratentorial Middle fossa Sylvian fissure Anterior fossa Tuberculum sellae Hyperostosing (vault) Tentorium (supratentorial) Falcotentorial Intraventricular Optic sheath

47 11 30 32 15 17 8 7 5 5 3 2 2 1 1

25 6 16 17 8 9 4 4 3 3 2

Total 14

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was 56 years. T h e l o c a t i o n s o f the t u m o u r s are s u m m a r i z e d in T a b l e 3. O p e r a t i o n was n o t p e r f o r m e d on 31 p a t i e n t s f o r d i f f e r e n t reasons which are listed in T a b l e 4. T e n o f these p a t i e n t s w e r e f o l l o w e d u p f o r eight m o n t h s to f o u r y e a r s : one d e t e r i o r a t e d t w o y e a r s Table 4. Reasons for not Performing Surgery on 31 Patients Patients under 60

Cavernous sinus tumours Severe arterial hypertension and diabetes (brain infarct unrelated to the tumour) Operation refused

2 1 2

Patients over 60

Age over 72 Well-controlled seizures, no oedema on CT Hyperostosing non-evolutive tumour Cavernous sinus tumour Severe diabetes--mild neurological symptoms Heart failure Operation refused

12 3 2 1 2 3 3

Total

31 Table 5. Overall Results of Surgery According to the Ages of Patients

Age in years Good recovery Moderate disability Severe disability Death Total

< 60

61-65

66-70

Over 70

(75~ (70/0) (40/0) (14~

15 (71~ 1 -5 (24~

10 (400/0)** 2 *** 1 12 (48~

1 (13~ -3 (37%) 4 (50~

101 (65%)

21 (14~

25 (16~

8 (50/0)

76 7 4 14

* One patient with a clivus meningioma was only shunted, and died from heart failure. ':'::" Three patients were only shunted (infratentorial meningiomas). *** One patient was only shunted (pineal region meningioma). a f t e r diagnosis. O n e a d d i t i o n a l p a t i e n t , a 7 3 - y e a r - o l d m a n w i t h a large f a l x m e n i n g i o m a was o p e r a t e d on elsewhere a n d d i e d f r o m e x t r a c e r e b r a l c o m p l i c a t i o n s a few d a y s a f t e r the u n e v e n t f u l r e m o v a l o f the t u r n o u t . T h e o v e r a l l surgical results a c c o r d i n g to t h e ages o f the p a t i e n t s are r e p o r t e d in T a b l e 5. T h e r e w a s o n l y one d e a t h ( f r o m r e n a l f a i l u r e

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after an otherwise u n e v e n t f u l course) in the patients u n d e r 40. Conversely, m o r t a l i t y reached 5 5 % in the patients over 65 in w h o m the g r o w t h was excised. Finally, the causes of postoperative death d u r i n g the hospital stay are listed in Table 6. Table 6. Causes of Postoperative Death During the Hospital Stay Patients over 60 Mortality 40% (44~ in case of tumour excision)

Patients under 60 Mortality 14%

Preoperative deep coma

1

Early complications

2 1 1 1

Massive swelling Brain infarction Thalamic haemorrhage DIC (intraoperative) Pulmonary embolism Heart failure

2 1 1 2 1 I

Progressive deterioration Pulmonary embolism Pontine haemorrhage Meningitis Heart failure

Early complications Massive swelling Brain infarction Pulmonary embolism Acute heart failure

Late complications Brain infarction Brain abscess Meningitis Heart failure Pulmonary embolism Renal failure

2 1 2 2 1 1

Late complications 6 3 1 1 1

Post-mortem examination was carried out in all cases. Table 7. Symptoms and Signs in the Elderly Patients (80 cases) Psychical deterioration Epileptic seizures Hemiparesis Headache Gait disturbances Deficit of cranial berves Skull hyperostosis Papilloedema

45 31 27 20 16 6 4 1

(56o/o)

(39~ (34%) (25o/o) (20~ ,)

Summary of the Elderly Patients (Over 60) Clinical Features T h e most i m p o r t a n t clinical features observed in the w h o l e g r o u p of 80 patients are s u m m a r i z e d in Table 7. 14,

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Psychical deterioration, which was present in 56% of patients, was by far the most common evidence of intracranial meningiomas in the elderly. By contrast only 25% complained of headache, while frank intracranial hypertension was quite rare. Gait disturbances associated with mentation disorders with no evidence of intracranial hypertension mimicked the so-called "normal pressure hydrocephalus" in eight cases. In four of these patients with huge ventricular dilatation and periventricular lucency on CT scan, long-term ICP recording was carried out. In one case ICP attained 35 m m H g , whereas in the remainder lower values (12-15, 15-20, and 18-25 m m H g respectively) were recorded, but all tracings were unstable with broad pulsation. Table 8. Perifocal Oederna on CT Scan (Kazner's Grading) (73 supratentorial tumours) Grade 0 (no oedema) Grade 1 (mild oedema) Grades 2 and 3 (severe oedema)

36 (49~ 13 (18%) 24 (33~

Three of these patients had large infratentorial meningiomas and in the last the tumour lay astride the tentorial notch in the pineal region. In a further patient with a cerebellopontine meningioma with moderate ventricular dilatation ICP was recorded, and normal values were encountered.

CT Appearance (PerifocaI Oedema) The perifocal oedema was evaluated according to Kazner's 4 grading in 73 patients with supratentorial tumours (Table 8). Clinical features were correlated with CT findings in the patients with the most severe grades of brain oedema: in 18 cases out of 24 (75%) severe mental deterioration was observed. In 12 of these patients mental disturbances were rapidly evolutive. Conversely, no definite correlation was found between oedema and outcome after surgery: mortality was 35% in the patients with severe oedema and 32O/o in those with mild or no oedema.

Outcome Versus Location of Tumours The location of turnouts versus operative mortality is analysed in Table 9. It appears that outcome was particularly poor in the patients with sphenoidal ridge and infratentorial tumours. While

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201

in the former vascular complications and progressive deterioration often occurred, the latter deserve some comment. Oddly enough, two patients succumbed to uncontrollable bleeding due to disseminated intravascular coagulation (DIC) which set in at the moment of the wound closure after very easy removal of superficial tumours. The last two patients had very stormy postoperative courses and died some weeks after surgery from pulmonary embolism and meningitis respectively. Table 9. Location of Tumours Versus Operative Mortality (53 cases) Locations of tumours

Number

Dead

Parasagittal Falx Convexity Sylvian fissure Anterior fossa Olfactory groove Sphenoid ridge Tuberculum sellae Tentorium Infratentorial

16 4 7 2 1 4 8 1 2* 7*

4 -2 1 1 2 5 1 1 4

* The survivor (pineal region tumour) was only shunted. ** All the survivors were only shunted.

The results in the four patients who were submitted to CSF shunting only were as follows: in three patients (two with infratentorial and one with pineal region tumour) the ventricular size as well as the ICP values became normal. The clinical condition improved definitely in all patients, but the patient with the pineal tumour continued to complain of severely disabling dizziness. One of these patients died six months after shunting from heart failure, and a further case fared quite well for four years but subsequently deteriorated with progressive symptoms and signs of brain-stem dysfunction. Finally, in the last patient, a 69-year-old woman with a huge angioblastic tentorial meningioma, severe intracranial hypertension, and very poor general and neurological condition, ICP became normal but the size of the ventricles and the periventricular lucency were not affected. Clinical condition improved somewhat for some months but subsequently the patient exhibited progressive signs of brain-stem damage.

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Comment

The most impressive data to be singled out from our series seem to be the following: 1. In our as well as in other series, the average age of patients with intracranial meningiomas has definitely increased since the introduction of CT scan as a screening procedure. Thus, nowadays more and more geriatric patients with benign intracranial turnouts are referred to neurosurgical units. 2. Mental disorders followed by epileptic seizures and hemiparesis were the most common clinical features in our elderly patients. By contrast, marked intracranial hypertension was fairly rare. 3. Psychical disorders were particularly frequent and rapidly evolutive in patients with grades 2 and 3 peritumoural oedema. 4. The overall mortality was 15~ in the patients under 65. Good recovery rate ( > 70~ was quite acceptable. 5. Conversely, mortality rate increased very steeply after 65, attaining 48~ Yet, if we consider that 4 patients underwent CSF shunting only, we see that in the patients in whom the growth was excised mortality reached 55~ In the same group good recovery rate was only 28% . 6. The results of surgery were particularly disappointing in the patients over 70 inasmuch as only one of them made a satisfactory recovery. 7. As far as the causes of postoperative death are concerned, pulmonary embolism proved particularly troublesome. Altogether, of the last 97 patients over 60 on whom we have operated for different non-malignant intracranial lesions, 8 (8o/0) died of this complication, while in the whole group of patients over 40, mortality from pulmonary embolism was 2~ and there were no deaths in patients under 40. In patients with intracranial meningiomas intracerebral haemorrhages unrelated to the operative fields took place solely in elderly patients. However, the most impressive fact is that six patients, after faring well during the first week after operation, deteriorated eventually, either from the general or the neurological point of view, and died from trivial respiratory complications some weeks later.

Concluding Remarks In the elderly patients with non-malignant lesions the criteria for making surgical decisions are not necessarily the same as in

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203

younger patients. As a matter of fact, in the elderly, due to their relatively limited life expectancy even in normal conditions, we should clearly distinguish the cases with severe and rapid deterioration which entails immediate danger of death or severe disability from those with mild smyptomatology and slow evolution. In the former, surgery appears to be the only issue while in the latter the surgical intervention is chiefly a prophylactic procedure to prevent further deterioration and to avoid the risks that delayed surgery implies. Therefore, the question arises as to which are the limits of age for safe and worthwhile early surgery. A further question to bring up is: in which bad risk patients can valuable results still be expected from surgery? On the basis of our series, it would appear that contraindications to surgery aiming at removing intracranial meningiomas are quite occasional, and dictated by general diseases or technical reasons, in patients under 65 years of age. On the other hand, it would also seem that patients over 70 years can seldom benefit from surgery, particularly if severe and long-standing deterioration is present: in the survivors the quality of life is generally poor. At any rate, in patients over 65 postoperative complications in general, whether intracranial or extracranial, are very common, even though it may be extremely difficult to predict which complication is more likely to occur in a given patient. Consequently, before undertaking any surgical procedures the pros and cons must be very carefully evaluated. In patients with progressive deterioration, particularly if brain oedema is detected on CT scan, there does not seem to be any alternative to surgery, although high mortality and relatively low good recovery rate are to be expected. Conversely, in cases with minor or non-evolutive disturbances, or both, such as well-controlled epileptic fits or mild psychical deterioration, with no oedema on CT scan, conservative management is probably to be preferred 2. Finally, valuable results may be achieved with CSF shunting procedures only in some patients with hydrocephalus, mostly from infratentorial tumour. On the whole, the surgical management of intracranial meningiomas in patients over 65 still remains a tremendous challenge, despite all the advances in neurosurgical technique, neuroanaesthesia and intensive care. On these grounds, we are now less aggressive than a few years ago when CT scan first disclosed an unexpectedly high number of intracranial meningiomas in elderly patients; we feel in fact that for some of such patients surgery is not necessarily the best solution.

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1. Carella, R. J., Ransohoff, J., Newall, J., Role of radiation therapy in the management of meningioma. Neurosurgery 10 (1982), 332--339. 2. Cushing, H., Eisenhardt, L., Meningiomas (their classification, regional behavior, life history and surgical results). Springfield-Baltimore: Ch. C Thomas. 1938. 3. Garibi, J., Igartua, A., Aramendi, A. D., Proceedings of the 96th meeting of the Society of British Neurological Surgeons. J. Neurol. Neurosurg. Psychiat. 44 (1981), 181. 4. Kazner, E., Steinhoff, H., Lanksch, W., Marguth, F., Computerized tomography using the high definition matrix (160 • 160) an early evaluation. In: Advances in neurosurgery 3 (Penholz, H., et aI., eds.), pp. 364--380. BerlinHeidelberg-New York: Springer. 1975. 5. Russell, D. S., Rubinstein, L. J., Pathology of tumours of the nervous system. (Third Edition.) London: E. Arnold. 1971. 6. Wood, M. W., White, R. J., Kernohan, J. W., One hundred intracranial meningiomas found incidentally as necropsy. J. Neuropath. exp. Neurol. 16 (1957), 337--340. 7. Ziilch, K. J., Brain tumors. Their biology and pathology. (Second Edition.) New York: Springer. 1965. Author's address: Prof. Dr. I. Papo, Ospedale Generale Regionale, Ancona, Italy.