Research Article

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International Journal of Science Academic Research

Vol. 05, Issue 03, pp.7100-7104, March, 2024

Available online at http://www.scienceijsar.com

ISSN: 2582-6425

Research Article

DOES THE LOCATION OF MENINGIOMA HAVE ANY IMPACT ON POSTOPERATIVE

OUTCOMES? – A PROSPECTIVE COHORT STUDY

*Dr. Areeba Tariq, Dr. Uzair Ahmed Siddiqui, Asma Riaz, Noem Najam Syed and Salman Yousuf Sharif

�

Liaquat�National�Hospital,�Stadium�Road,�Karachi,�74800,�Pakistan�

Received 16th January 2024; Accepted 10th February 2024; Published online 18th March 2024

Abstract

Meningioma is a CNS tumour with a moderate growth rate that arises from the meninges. (1) Meningiomas are produced by arachnoid cells that

are situated on the inner surface of the dura. Meningiomas are the most common primary CNS tumour, accounting for about 36% of cases and

53% of nonmalignant CNS tumours, with an incidence of 7.86 cases per 100,000 people each year (2, 3). In addition to symptoms from the mass

effect of the central nervous system, such as headache, patients with meningiomas also experience a variety of neurologic symptoms brought on

by the compression of surrounding central nervous system components. As a result, the type of symptoms is directly influenced by the tumour's

location. Meningiomas can develop in places where there are arachnoid cells, and their locations range from the para-sagittal region to the spine.

(4, 5). The management decisions depend on the particular characteristics of each area(6). For instance, patients with convexity meningiomas are

more likely to present with seizures as a baseline symptom compared to skull base meningiomas which result in a higher frequency of headaches,

anosmia, ocular deficits, and auditory deficits(7). The surgical care of these tumours has changed to demonstrate better results and decrease

mortality and surgical morbidity, but it is still linked to significant morbidity and problems. Microsurgical methods and surgical approaches to

these tumours have also improved. (8) The purpose of this prospective study is to investigate how the anatomical location of meningioma affects

the postoperative outcomes after its excision. Intriguing, in our opinion, is the analysis of the clinical outcomes of meningioma patients in a

setting of developing countries.

Keywords: Meningioma, Outcome , Location of meningioma, KPS.

INTRODUCTION

A meningioma is a CNS tumor with a moderate growth rate

that arises from the meninges. (1) Meningiomas are produced

by arachnoid cells situated on the dura's inner surface.

Meningiomas are the most common primary CNS tumor,

accounting for about 36% of cases and 53% of nonmalignant

CNS tumors, with an incidence of 7.86 cases per 100,000

people each year(2,3). In addition to symptoms from the mass

effect of the central nervous system, such as headache, patients

with meningiomas also experience a variety of neurologic

symptoms brought on by the compression of surrounding

central nervous system components. As a result, the type of

symptoms is directly influenced by the tumor's location.

Meningiomas can develop anywhere where there are arachnoid

cells, and their locations range from the para-sagittal region to

the spine. (8)(4) The management decisions depend on the

particular characteristics of each area. (5) For instance, patients

with convexity meningiomas are more likely to present with

seizures as a baseline symptom compared to skull base

meningiomas which result in a higher frequency of headaches,

anosmia, ocular deficits, and auditory deficits (6). The surgical

care of these tumors has changed to demonstrate better results

and decrease mortality and surgical morbidity, but it is still

linked to significant morbidity and problems. Microsurgical

methods and surgical approaches to these tumors have also

improved. (7) This retrospective study aims to investigate how

the anatomical location of meningioma affects the

postoperative outcomes after its excision. Intriguing, in our

opinion, is the analysis of the clinical outcomes of meningioma

patients in a setting of developing countries.

*Corresponding Author: Dr. Areeba Tariq,

Liaquat National Hospital, Stadium Road, Karachi, 74800, Pakistan

MATERIALS AND METHODS

Pre-operative data from 182 patients were obtained from the

patient records at Liaquat national hospital. Every patient who

underwent meningioma resection at Liaquat national hospital a

minimum of 6 months before the commencement of the study

was included. This was done to allow sufficient time for any

postoperative outcomes to be clinically apparent. All patients

who fit the inclusion criteria were followed up via phone call

to assess any improvement or worsening in their functional

capabilities after the surgery. If the patient could not be

contacted, their postoperative data were obtained from the

follow-up clinic files. Every patient whose postoperative data

could not be obtained or whose pre-operative data was

incomplete was excluded from the study, leaving us with a

final pool of 105 patients. 10 patients with spinal meningioma

were further excluded during the final analysis: making the

final study group of 95 patients. The Karnofsky Performance

Scale (KPS) in Figure 1 was used to evaluate a patient's

functional capabilities. Apart from biodata, the pre-operative

data provided us with the presenting symptoms to calculate the

presenting KPS and the anatomical location of the tumor,

which was assessed using MRI. An arbitrary classification for

the various anatomical locations on the brain was created

according to each part's relation to the cranial vault. Spinal

meningiomas were excluded from the study. The anatomical

classification of meningiomas used in this study and the

frequency of each type of meningioma is provided in Figure 2.

The symptoms obtained through the follow-up calls were used

to assess the postoperative KPS, and the main outcome was

evaluated as the change in KPS before and after the surgery. A

positive change represents an improvement, while a negative

change represents worsening functional capabilities. Further

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outcomes investigated independent of the KPS were the

resolution of the patient’s presenting complaints, recurrence of

the meningioma, or death. The data was analyzed using the

IBM SPSS software for a confidence interval of 95%.

Therefore, a P-value of less than 0.05 was considered to be

significant. Paired samples t-test was used to compare any

significant differences between the mean presenting KPS and

the mean postoperative KPS. ANOVA was used to compare

any significant difference between the various anatomical

categories relative to the change in KPS and the presenting

KPS. Fisher’s exact test was used for non-numeric outcomes,

including recurrence, resolution of presenting complaints, and

death.

Characteristics

Score

Normal no complaints; no evidence of disease

100

Able to carry on regular activity; minor signs or

symptoms of the disease

Normal activity with effort; some signs or

symptoms of the disease

Cares for self; unable to carry on a regular activity

or to do active work

Requires occasional assistance, but can care for

most of his personal needs

Requires considerable assistance and frequent

medical care

Disabled; requires special care and assistance

Severely disabled; hospital admission is indicated,

although death is not imminent

Very sick; hospital admission necessary; active,

supportive treatment necessary

Moribund; fatal processes progressing rapidly

Dead

Fig 1. KPS scale

Fig 2. Frequency of meningioma by location

Figure 3. Demographics as per location

Figure 4. Who grade as per meningioma location

Figure 5. Improvement in kps

Figure 6. Post-surgical outcomes as per location

RESULTS

Figures 3, 4,5, and 6 are representative of the prevalence of

non-numeric outcomes in our study population. Results of the

Fisher’s exact test (Table 1) show that there is no significant

relationship anatomical location of the meningioma does not

have a significant relationship to recurrence (P=0.808),

resolution of presenting complaints (P=0.104), and death

(P=1.000). Although the results of the paired samples t-test

(Table 2) reveal an overall statistically significant difference

between the mean values of the presenting KPS against the

postoperative KPS (P=0.000), the ANOVA results (Table 3)

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show that there is no significant difference in the change in

KPS between the different anatomical classes of the tumor

(P=0.126). Although this is not an outcome, our results show a

significant difference between the presenting KPS of the

various anatomical classes of meningiomas (Table 3)

(P=0.001). A posthoc analysis of the presenting KPS ANOVA

results (Table 4) displays that in our sample population, the

mean presenting KPS of spinal meningiomas (45.00) is

significantly worse compared to the means of all the other

classifications (P<0.05) barring posterior cranial fossa

meningioma (P=0.053).

Table 1. Fischer’s test:

P-value

Recurrence

0.808

Resolution of presenting complaints 0.104

Death

1.000

Table 2. Paired T-test:

Mean

Standard deviation P-value

Presenting KPS-Post

operative KPS

- 15. 14 23.94

0.000

Table 3. ANOVA

Mean Standard

deviation

Degrees of

freedom

F-

value

P-

value

Presenting KPS

63.14 14.432

4.511

0.001

Change in KPS

15.14 23.944

1.770

0.126

DISCUSSION

Meningiomas are the most common brain tumors. They are

classified based on histology into 15 different types (9) as well

as via grades from 1 to grade 4(10) and location (11). it is

generally thought that tumors inaccessible locations have a

better prognosis than those at the base of the skull (12).

Similarly, meningiomas in eloquent areas are more likely to be

symptomatic than non-eloquent meningiomas (13). Clinical

presentation of meningioma differs by location (14).

Symptoms that are commonly seen are as follows: headache

(33.3–36.7%), focal cranial nerve deficit (28.8–31.3%), seizure

(16.9–24.6%), cognitive change (14.4%), weakness (11.1%),

vertigo/dizziness (9.8%), ataxia/gait change (6.3%),

pain/sensory change (5.6%), proptosis (2.1%), syncope (1.0%),

and asymptomatic (9.4%)(15-17). usually, skull base

meningiomas are more eliptogenic than non-skull base

meningiomas (18). Anterior cranial fossa meningiomas

(anterior falcine, olfactory groove, or orbitofrontal) are often

quite large at presentation and present with impaired vision

(54%), headache (48%), anosmia (40%), seizure (20%),

psychomotor symptoms, and behavioral disturbance with

personality disintegration (19-20). Parasagittal meningiomas

can grow considerably before being clinically evident and

mostly present with Jacksonian seizures of the lower limbs or

headaches. Anterior parasagittal meningiomas are

characteristically present with papilledema and homonymous

hemianopia. Tuberculum sellae meningiomas usually present

with insidious unilateral visual loss, followed by scotomatous

defects in the other eye. (21) Lateral sphenoid wing

meningiomas often present with painless unilateral

exophthalmos, followed by unilateral vision loss. Temporal

lobe meningiomas frequently presented with seizures.

Petroclival meningiomas can present with ataxia and cranial

nerve neuropathies such as trigeminal nerve impairment.

Clinoidal meningiomas are often present with a wide variety of

visual impairments, cranial nerve palsies, and exophthalmos.

Posterior cranial fossa meningiomas can develop obstructive

hydrocephalus and present with papilledema and early-

morning headache. Peritorcular meningiomas symptoms are

commonly caused by compression of the occipital lobe or the

cerebellum and present with a headache with occipital

localized pain, papilledema, and homonymous field deficits, as

well as ataxia, dysmetria, hypotonia, and nystagmus. Spinal

meningiomas, most common in the thoracic spine, present with

slowly progressive spastic paresis with or without radicular or

nocturnal pain. (19-20) Treatment of meningioma is mostly

surgical. The goal for surgery is GTR (Simpson I, GTR);

however, the ability to achieve this may be limited by various

factors, including tumor location, involvement of venous

sinuses and neurovascular tissue, and other patient factors

affecting the safety of surgery in general(21). These factors

influence the decision to pursue surgery, the surgical approach,

and the extent of resection (22). The extent of resection,

defined by the Simpson grade, heavily impacts the recurrence

rates for surgically treated meningioma of all WHO grades,

and so does the location (23). FIGURE 4 shows a case of

surgical management of meningioma.. currently, no

chemotherapeutic agent is approved for use in

meningioma(24), and radiotherapy is an adjunct to surgery

(25).

Figure 4. showing pre and post-operative images of convexity

meningioma

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There is a lack of information on the long-term functional

outcomes of meningioma patients, which is especially

concerning given the high incidence of meningiomas in routine

neurosurgical practice. This is in stark contrast to outcome

parameters such as the extent of resection (EOR),

complications, predictors of overall survival (OS), progression-

free survival (PFS), and EOR. Impaired health-related quality

of life (HrQoL) and functional disability (FD) in meningioma

patients are topics of considerable attention. According to the

World Health Organisation, the standard indicators of quality

of life (QoL) relate to the environment, education, leisure time,

and physical and mental health. Quality of life (QoL) is

multifactorial, taking into account the culture and value

systems in which patients live concerning their goals. Our

study aimed to find a relationship between the location of the

tumor and its impact on outcomes ( using the KPS score), if

present. It was seen that larger size correlated with increased

edema and mass effect (26)(27). a study done by Daniel

showed a correlation between the histology of the 15

histopathological varieties of meningiomas and the

predilection site of appearance as well as certain demographic

aspects, such as sex (28).

Meningiomas are more common in convexity and parasagittal

regions, where their growth patterns may be impacted by the

fact that there is only one plane of bone structures, although

they are not a limiting factor for growth or expansion.

Additionally, cortical gyri, sulcus, parenchyma, and vascular

structures are much more malleable to compression. This may

help explain why this tumor location is diagnosed later than the

skull base and/or spinal cord. The symptoms in these two

locations typically manifest earlier because bone structures

surround multiple anatomical planes, and structural

compression and parenchymal or nerve compromise occur

earlier. (29) Surprisingly, shorter space and bone structures act

as growth inhibitors for meningiomas of the skull base and

spinal cord. They might have a lower risk of non-benign

meningiomas because their oxygen supply may not be

compromised for a long enough period to allow for hypoxia

adaptation. According to a study by Hashimoto et al.,

meningioma tumors at the base of the skull grow more slowly

than those at other intracranial sites. (30) However, in our

study, tumor location didn't correlate with the recurrence rate,

outcome, mortality, or resolution of symptoms.

Conclusion

Even though meningioma resection seems to improve patients'

functional capabilities overall, the tumor's location does not

seem to play a significant role in this. Recurrence, resolution of

presenting complaints, and death after meningioma resection

do not seem to be impacted by the location of the tumor either.

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