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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 87-92

Intracranial meningiomas: Experience at a tertiary health-care center in India


1 Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
2 Department of Neurosurgery, Tata Main Hospital, Jamshedpur, Jharkhand, India

Date of Submission19-Apr-2020
Date of Acceptance29-Nov-2020
Date of Web Publication26-Dec-2020

Correspondence Address:
Dr. Anil Kumar
Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi - 834 009, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJNO.IJNO_5_20

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  Abstract 


Introduction: Intracranial meningioma is one of the most common primary intracranial tumors. It constitutes 10%–15% of all brain neoplasm across the globe, whereas in India, their occurrence varies from 11.6% to 21%. These tumors are neuroectodermal in origin and are believed to arise from arachnoid cap cells. These tumors are mostly histologically benign with <0.2% showing metastasis. Total excision of tumor is the treatment of choice.
Patients and Methods: The survey intended to study the incidence of meningioma among other intracranial tumors, the clinical profile of the patients, surgical outcomes, and long-term results. The study included all the cases of intracranial meningioma admitted in the Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, between the time period of January 2012–December 2015. All patients, irrespective of age and sex, who were diagnosed of intracranial meningioma based on clinical data, radiological evidence, and histopathology, were included in the study. A total of 106 patients were included in the study.
Results: The study revealed that the incidence of intracranial meningioma among other brain tumors is 14.45% and the disease shows a female preponderance. Meningiothelial meningioma is the most common histological variant reported during the study. Seizure and cranial nerve damage were the common complications observed among the patients during the follow-up study. Total excision of the tumor is the treatment of choice. Seventy-seven percent of the patients show good recovery with Glasgow Outcome Score of 5.
Conclusion: Intracranial meningiomas are common intracranial tumors. They affect people in fifth decade of their life and show a female preponderance. They commonly present with symptoms such as seizure and headache. Meningothelial meningioma is the most common histological subtype. Total excision of the tumor mass has been found effective in preventing reoccurrence. Microsurgical techniques give good results with minimum mortality.

Keywords: Epidemiology, intracranial meningiomas, risk factors, surgical outcomes


How to cite this article:
Besra SK, Harsh V, Kumar H, Mallik J, Sahay CB, Kumar A. Intracranial meningiomas: Experience at a tertiary health-care center in India. Int J Neurooncol 2020;3:87-92

How to cite this URL:
Besra SK, Harsh V, Kumar H, Mallik J, Sahay CB, Kumar A. Intracranial meningiomas: Experience at a tertiary health-care center in India. Int J Neurooncol [serial online] 2020 [cited 2021 Jan 17];3:87-92. Available from: https://www.Internationaljneurooncology.com/text.asp?2020/3/2/87/305065




  Background Top


Intracranial meningiomas are one of the most common primary intracranial tumors accounting for 10%–20% of all brain neoplasm occurring worldwide.[1],[2] Evidence proves that meningiomas were of interest to medical professionals since prehistoric times; however, it was only in 1614 that Felix Plater (University of Basel, Switzerland), first described them over the autopsy of the knight, Casper Bonecuritus, as round, fleshy, hard and full of holes.[3],[4] The oldest paleontologist evidence of intracranial meningioma was excavated in 1933 near Steinheim (Baden-Württemberg, Germany). The characteristic feature of meningioma to cause hyperostosis of the overlying bone helped in the identification and diagnosis of meningioma in this 365,000-year-old Steinheim skull.[5] Since the beginning of documentation of meningioma, it has been given various names such as fungoid duraematis, sarcoma, cylindroma, endothelioma, and fibroma, but it was in 1922 that Harvey Cushing coined the term “Meningioma.”


  Introduction Top


Intracranial meningiomas are mostly benign tumors originating from the meninges surrounding the brain.[1] They are neuro-ectodermal in origin arising from the arachnoid cells of the leptomeninges.[4] Although these tumors rarely show metastatic changes, it is the location of these which possess life-threatening consequences to the patients. Since most tumors are slow growing, a large number of cases go undiagnosed. Tumors in the silent areas of the brain are usually insidious and are not expressed until they are large and cause increased intracranial pressure Majority of cases are of incidental finding during autopsy or when patients present with other symptoms due to site affected by the location of the brain.[1] The incidence of intracranial meningioma among the general population ranges from 1.3 to 7.8 per 100,000.[6],[7],[8] Despite equal susceptibility of males and females to intracranial tumors, intracranial meningioma shows a female preponderance.[6],[9],[10] Study by Wiemels et al. stated that male preponderance may be observed in cases of atypical and malignant meningioma.[10],[11] Meningiomas are rare in children accounting for 1%–2% of all brain tumors.[12] These intracranial meningiomas are reported in all age groups, but people in their sixth and seventh decade of life are most vulnerable to it.[7],[11] Similar finding was seen in the study by Tomasello which states that the people above the age of 70 were 3.5 times more susceptible to developing intracranial meningioma than those below 70 years.[13] The development of intracranial meningioma was also seemed to be related to the ethnicity of the patients. A study conducted in Los Angeles concluded that meningiomas were most common among African Americans, followed by Caucasians and lowest amongst Asians.[1],[10],[14] This study is a 3-year institutional study intending to determine the incidence of intracranial meningioma in eastern India. The study provides useful information regarding the probable risk factors that may be associated with the disease as well as accounts epidemiology, clinical profile, histopathology, and surgical outcomes of patients.


  Patients and Methods Top


This was a retrospective study performed at the Department of Neurosurgery at Rajendra Institute of Medical Sciences, Ranchi, from January 2012 to December 2015. All the patients, irrespective of age and sex, who were diagnosed with intracranial meningioma on the basis of clinical data, radiological evidence, and histopathological studies, were included in the study. All the patients were evaluated on the basis of their history, signs and symptoms, and investigation which included both radiological tests and blood tests. Routine blood test and urine test were done. Radiological investigations such as chest X-ray, skull X-ray, noncontrast computed tomography (CT), contrast-enhanced CT, and magnetic resonance (MR) imaging were performed to come to a diagnosis. Cerebral angiography was performed in selected cases to define the relation of blood vessels with the tumor. MR spectroscopy was also done. The patients who opted out of the surgery were managed conservatively. Ventriculoperitoneal (VP) shunt was performed in few patients to decrease the intracranial pressure at the time of tumor evacuation. Radiation therapy was suggested for patients undergoing partial resection of a meningioma. The patients were kept for postoperative stay to manage the immediate complications after surgery. All the patients were called for follow-up after a period of 2 months–2 years. They were looked for any recurrence or postsurgical complications.


  Results Top


During the study, 734 patients of brain tumor were admitted in the department of neurosurgery out of which, 106 patients (14.45%) were confirmed cases of intracranial meningioma. There was a female preponderance with male:female ratio of 1:1.46. Majority of the patients belonged to the 4th–6th decade of the life [Figure 1]. The mean of presentation was 42.9 years. The youngest patient was 9 years old, whereas the oldest was 72 years old. Twenty-nine patients presented with the history of trauma. Patients with meningioma present with various clinical symptoms. Headache is the most common symptom present in 66.98% cases, followed by seizures (in 34.1%) and vomiting along with headache (in 32%). Altered sensorium, visual impairment, and memory impairment were other clinical presentations [Figure 2]. While most of the patients had single tumor, only two patients presented with multiple tumors; Type-II neurofibromatosis (NF 2) was reported among two patients. CT scan study revealed that parasagittal/parafalcine is the most common location of the tumor (24.52%), followed by cerebral convexity (20.75%) and sphenoid wing (16.98%) [Figure 3]. Histopathological examination showed that meningothelial meningioma is the most common histological variant seen in 72.90% of cases, followed by transitional meningioma (10.4%) and fibroblastic meningioma (8.3%) [Figure 4]. Surgery was the mainstay of treatment. Ninety-six patients were operated, whereas ten patients who opted out of the surgery were managed conservatively. VP shunt was performed on six patients. Radiation therapy was suggested for patients undergoing partial resection of a meningioma. The patients were kept for postoperative stay for 10–50 days (mean: 11.3 days). The Glasgow Coma Scale (GCS) score showed that 77% of the patients showed good recovery, whereas 8.3% of patients showed recovery with moderate disability. Severe disability was seen in only 4.2% of the cases. Seizures, cranial nerve damage, meningitis, and cerebrospinal fluid (CSF) leak are some of the common postoperative complications presented among operated cases. The patients were called for a follow-up study after 2 months–2 years to check for reoccurrence of meningioma. It was observed that during the course of the study, eight patients died (mortality: 8.3%), whereas only one showed recurrence.
Figure 1: Line graph showing the age distribution

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Figure 2: Bar graph showing the clinical presentation

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Figure 3: Bar graph showing the location of tumor

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Figure 4: Bar graph showing histological variation

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  Discussion Top


Despite high annual incidence of 2–7 per 100,000 for women and 1–5 for men,[1] the etiological factors for intracranial meningioma remain uncertain. Various studies have put forth various hypotheses suggesting the etiological factors for meningioma. Earlier studies had considered head trauma as the main risk factor for developing intracranial meningioma.[15] Even, repeated head blows in sports like boxing were thought to be associated with the development of intracranial meningioma. However, recent studies concluded no significant relation between head trauma and development of meningioma.[16] Other factors such as high exposure to ionization radiation have also been studied.[1],[14] Although prolonged exposure to cell phones was not seen associated with meningioma, frequent dental X-rays were considered to be a risk factor for it.[1],[6],[8],[14] The higher incidence of meningioma in females has correlated with high level of estrogen and progesterone in them. The frequent association of meningioma with breast cancer and changes in size of meningioma during pregnancy indicates toward a relation between meningioma and high level of estrogen and progesterone in the body.[1] Females undergoing natural or surgical menopause were found to be at greater risk for developing meningioma as compared to premenopausal females.[17] The genetic composition of a person may also predispose a person to develop meningioma. The mutation of chromosome 22 inactivating NF2 gene is most commonly seen associated with meningioma. Studies suggest that AKT1, MN1, PTEN, and BRIP1 are some other genes whose mutation appears to be linked to meningioma.[10],[18] Chromosomal defects in 1p, 6q, 10, 14q (MEG3 and NDRG2), and 18q were seen in atypical meningioma. The environmental factors such as the occupation and lifestyle habits were considered as the risk factors.[19],[20] Infection with certain viruses such as Simian virus-40 and Inoue-Melnick virus is suspected to be associated as a risk factor for meningioma.[21]

The sociodemographic profile of our institution-based study depicts that the incidence of meningioma in our area is 14.45% which is comparatively higher as compared to other studies in the past [Table 1]. This high incidence could be due to the presence of radioactive uranium mines in the state causing high exposure to radiation or presence of high iron content which indirectly affects the estrogen metabolism and produces cancer-causing property.[20] Our study shows a female predominance to the disease with female:male ratio of 1.46:1. This ratio, however, is less as compared to other studies [Table 2]. The majority of the patients belonged to 4th–6th decade of their life with a mean age presentation of 42.9 years. The mean age in other studies was significantly higher as compared to our study [Table 2]. This less mean age could be due to the relatively young population in the area. The mean age in our study roughly corresponds to the study of Deshpande et al. (1978). Headaches and seizures were the most common clinical presentation observed with 67% and 34.9% of total patients, respectively. This percentage was, however, very high when compared with other studies in past [Table 3]. The most common site tumor formation was parasagittal/parafalcine (24.5%), followed by convexity (20.7%) and sphenoid wing (16.9%). These data are similar to studies conducted by Rohringer et al.[24] and MacCarty and Taylor[29] The study showed that meningothelial meningioma was the most common histological variant, seen in 72.9% of cases. This percentage is very high compared to previous studies [Table 4]. Complete surgical excision was the treatment of choice. Besides that, radiosurgery is considered as a good option for treating the tumors in high-risk locations or in the removal of left out tumor masses after surgical resection.[30] The outcome of the patients with intracranial meningioma depends on factors such as preoperative condition, location and size of tumor, and histology of tumor. Recurrence was seen in only one patient. A study by Bumrungrachpukdee et al. has shown that headache presentation, histological variant, and extent of resection may be associated with the recurrence of meningioma.[31] Studies have shown that recurrence can occur even after radiosurgery.[32] Such cases require re-radiosurgery or surgical excision to remove the tumor growing back. The postoperation complications appear to reduce overtime [Table 5], but our study showed higher incidence of postoperative complications (22%), which included seizure, cranial nerve damage, CSF leak, etc. The mortality too seems to fluctuate in various studies depending on the postoperative care and better facility available to the patients [Table 6]. Seventy-seven percent of patients show good recovery as per Glasgow outcome score (GOS). Moderated disability (GOS = 4) in our study was very less (8.3%) as compared other studies [Table 7]. A study by Kotecha et al. showed that 25% of cases reported moderate to severe disability. This disability was more commonly in patients with tumors located in the base of the skull.[40]
Table 1: Incidence of intracranial meningioma

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Table 2: Male: female ratio of intracranial meningioma and mean age of presentation

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Table 3: Clinical presentation in intracranial meningioma

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Table 4: Histology of intracranial meningioma

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Table 5: Postoperation complication rate

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Table 6: Mortality observed

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Table 7: Outcome comparison

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  Conclusion Top


The study concludes that the intracranial meningioma is one of the most common brain tumors with female preponderance. It commonly affects people in their fifth decade of life. The disease has various risk factors whose association with occurrence requires further study. The protection from susceptible risk factors, early presentation, adequate medical care, and proper surgical techniques can help to reduce the incidence of the disease. Proper postoperative care may help to reduce the mortality and morbidity. Studies with greater sample sizes are required to come to definitive conclusions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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