Original Article Nepal Journal of Neuroscience 2020;17(2):16-25 Clinicopathological characteristics of intracranial meningiomas Rajiv Jha MCh1, Prakash Bista MCh2 1National Neurosurgical Referral Center, NAMS Bir Hospital, Kathmandu, Nepal, 2National Neurosurgical Referral Center, Bir Hospital, Kathmandu, Nepal Date of submission: 26th May 2020 Date of acceptance: 15th July 2020 Date of publication: 12th August 2020 Abstract Background: Meningioma comprises 25-30% of total central nervous system tumors detected. Ninety percent of meningiomas are benign, 6% are atypical, and 2% are malignant. Complete resection is often curative. Objectives: The objective of this study is to give ideas about the descriptive epidemiology, clinical presentation and histopathology of current scenario at National Neurosurgical Referral Center, Nepal. Methods: This is a prospective study from the period of January 2015 to September 2019 in the department of neurosurgery, National Academy of Medical Science, Bir Hospital. Inclusion criteria consists of all the histopathological proven cases of meningioma during the study period. Result: A total of 150 meningioma cases were operated during the study period. The average age of presentation was 42 years. Male to female ratio was 1:2. Most common affected age group was 30-50 years. The most common clinical symptoms for intracranial meningioma were headache followed by vomiting and paresis. Among intracranial meningioma, the most common location was convexity meningioma followed by sphenoid wing meningiomas and parasagittal meningiomas. Most common histopathological variety encountered was transitional meningioma, World health organization grade I. Conclusion: Meningiomas are slow growing, extra-axial tumor, usually benign which are most commonly located along convexities, sphenoid ridge and parasagittal area. Most are cured if completely removed, which is not always possible. Key words: Central nervous system tumor, Diagnosis, Histopathology, Meningioma Introduction Access this article online ntracranial meningiomas account for 25-30% of all Website: https://www.nepjol.info/index.php/NJN Iprimary intracranial tumors. They originate from the arachnoid cap cells and occur in middle-aged DOI: https://doi.org/10.3126/njn.v17i2.30181 adults. Women are affected twice as often as men. HOW TO CITE Jha R, Bista P. Clinicopathological characteristics of intracranial Meningiomas are mostly well-differentiated, benign, and meningiomas. NJNS. 2020;17(2):16-25 encapsulated lesions that indent the brain as they enlarge. Although most meningiomas are benign, they have a 1ORCID iD: https://orcid.org/0000-0002-2830-7835 2ORCID iD: https://orcid.org/0000-0002-4811-6964 surprisingly broad spectrum of clinical characteristics, Address for correspondence: and histologically distinct subsets are associated with a Dr. Rajiv Jha high risk of recurrence, even after seemingly complete Professor of Neurosurgery resection. In rare instances, meningiomas are malignant. National Neurosurgical Referral Center Most meningiomas are iso-intense to the brain on T1- and NAMS Bir Hospital T2-weighted images.1 Kathmandu, Nepal Meningioma accounted for more than a third of Contact number: +9779851039699 E-mail: [email protected] all primary central nervous system tumors reported Copyright © 2020 Nepalese Society of Neurosurgeons (NESON) in the US between 2006 and 2010, where the highest incidence rate (7.44 per 100,000) of the disease has ISSN: 1813-1948 (Print), 1813-1956 (Online) been recorded.2 Meningiomas usually grow slowly, with This work is licensed under a Creative Commons a long initial asymptomatic phase, and may remain Attribution-Non Commercial 4.0 International License. 16 Nepal Journal of Neuroscience, Volume 17, Number 2, 2020 Clinicopathological characteristics of intracranial meningiomas 3 silent until the patient’s sudden death. Only 3%–6% Paresis 45(30%) of clinically detected asymptomatic meningiomas later Visual impairment 42(28%) become symptomatic.4 When symptomatic, intracranial Ataxia 29(19%) meningiomas present a wide variety of symptoms arising Aphasia 25(17%) from the compression of adjacent structures, direct invasion of or reactive changes in the adjacent brain tissue, Personality change 23(15%) and obstruction of cerebrospinal fluid pathways, cortical Diplopia 22(14.6%) veins, or major venous sinuses.5 Symptoms and signs Vertigo 21(14%) may include seizure disorders, raised intracranial pressure Decreased level of consciousness 18(12%) sign, classic early morning headaches, focal neurological Decreased hearing 18(12%) deficits, such as motor and sensory disorders, ataxia, Table 1: Clinical Presentation of Intracranial Meningioma language dysfunction, cranial neuropathies, psychomotor 5 symptoms, and behavioral disturbances. Common neurological examination findings were The purpose of our study was to evaluate the demographics, papilledema, paresis and cranial nerve deficit (Table 2). clinical presentation, radiological findings, extent of surgery, histological findings, overall outcome and Clinical findings Number of patients recurrence rates over the past 5 years at our institution. Papilledema 97(65%) Paresis 56(37%) Methods and Materials Cranial nerve deficit 47(31%) This is a prospective study of intracranial Memory impairment 33(22%) meningiomas, carried out at National Neurosurgical Visual field deficit 23(15%) Referral Center (NNRC), National Academy of Medical Decreased hearing 23(15%) Sciences (NAMS) Bir hospital. Institutional review Nystagmus 22(15%) board (IRB) approval was taken from the hospital for Paresthesia 18(12%) the study. Consent was taken from the patients if they Altered level of consciousness 18(12%) were able to communicate and from the next of kin if Normal finding 18(12%) they were not able to give consent. All histopathological Aphasia 17(12%) proven intracerebral meningioma in this department were Table 2: Clinical findings in Intracranial Meningioma included in this study. The duration of the study was from January 2015 to September 2019 (for 55 months). Age, Among intracranial meningioma, the most common sex, clinical presentations and neurological manifestations location was convexity meningioma followed by sphenoid were noted. Outcome measured on the basis of extent of wing meningiomas and parasagittal meningiomas (Table tumor excision, histopathological types, recurrence and 3). Glasgow Outcome Scale (GOS) at 6 months. Results Convexity 36(24%) Para-sagittal 29(19%) Total number of intracranial meningioma operated Sphenoid wing 28(19%) was 150. The average age of presentation was 42 years. Cerebellopontine angle 9(6%) Female were twice more affected than males. Most Tuberculum sella 8(5%) common affected age group was 30-50 years. Females Olfactory groove 8(5%) were involved at a slightly younger age compared to the Falx 7(4.6%) male. The most common clinical symptoms for intracranial Lateral ventricle 5(3%) meningioma were headache followed by vomiting and Tent 5(3%) paresis (Table 1). Petroclival 5(3%) Foramen magnum 3(2%) Clinical Presentation Number of patients Cerebellar convexity 3(2%) Headache 134(89%) Pineal Region 2(1%) Vomiting 96(64%) Intra orbital 2(1%) Seizure 46(31%) Table 3: Location of intracranial meningioma Nepal Journal of Neuroscience, Volume 17, Number 2, 2020 17 Jha et al Contrast enhanced CT scan and MRI Brain is the Ninety two percent (138 cases) of the meningiomas standard of diagnosis. In CT scan most meningioma were excised completely, and partially excised enhanced avidly and nearly all enhanced at least in part, meningiomas were further treated according to the even if heavily calcified. (Figure 1, Table 4) histopathology grade (Table 5). CT finding Number of patients Convexity All Simpson Grade I Excision Homogenous enhancement 88(59%) Para-sagittal Total Excision Heterogenous Enhancement 62(41%) Sphenoid wing Total Excision Calcification 68(45%) Tuberculum sella Total Excision Olfactory groove Total Excision Hyperostosis 52(35%) Lateral ventricle Total Excision Mass effect/Midline shift 122(81%) Tent Total Excision Table 4: CT scan findings in intracranial meningioma Cerebellopontine Total Excision angle On MRI, meningiomas were usually hypo- to Petroclival Total/Subtotal Excision isointense relative to the cerebral cortex on T1-weighted Foramen magnum Total Excision sequences and iso- to hyper intense on T2-weighted Intra orbital Total Excision sequences (Figure 2). Digital subtraction angiogram (DSA) remained a Cerebellar Convexity Total Excision useful tool in giant meningiomas not only to embolize Pineal Region Subtotal Excision the lesion but also to treat tumor associated vascular Falx Total Excision malformation and to achieve the full knowledge of Table 5: Extent of resection. Simpson grade I: Total vascular anatomy. (Figure 3) excision of tumor+Dura+bone, Total Excision: Total Although total removal can provide a cure for tumor excision and coagulation of dural attachment, meningioma, it is not always possible. The tumor location Subtotal excision: Not complete excision, debulking determines how much can be safely removed. Decision to extent of resection also depends on consistency and Neuro-navigation was used in all cases of convexity vascularity of the tumor (Figures 4, 5). and parasagittal meningiomas. If some tumor is left attached to arteries or nerves, There were mild to moderate disability in 4 percent radiation can treat the remainder. The risks of surgery (6 cases) of all operated cases but there were no surgical also