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Meningioma

Brain Tumor Meningioma

Meningioma refers to one oR many tumors that arise in very close contact to the meninges. The meninges are the membranous layers that cover the brain and spinal cord.


Presentation

Symptoms of meningioma are produced via different mechanisms. By irritating the underlying cortex, they can cause seizures. Headaches, weakness, dysphasia, and apathy are some of the symptoms seen due to compression by the tumors. They may also produce symptoms relative to their position, e.g. a tumor in the foramen magnum will produce paraparesis and sphincteric trouble while one in the olfactory groove will produce symptoms like anosmia. If the meningiomas are located in the skull base, they may occlude the cerebral arteries and present as strokes or transient ischemic attacks. This is however rare [8].

Fatigue
  • Side effects during/soon after treatment (Early or ‘acute’ side effects) General – Fatigue is quite common in the second half of treatment and is very variable between patients. Fatigue may persist for several weeks after treatment.[targetingcancer.com.au]
  • We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: May 13, 2019[patientslikeme.com]
  • Meningiomas that arise over the surface of the frontal, temporal, parietal or occipital lobes may cause a variety of symptoms including headache, seizures, visual loss, double vision, weakness, fatigue, difficulty walking, confusion and personality changes[pacificneuroscienceinstitute.org]
  • Full recovery usually takes several weeks and the patient may feel fatigued during this time.[arcticspine.com]
Anosmia
  • In contrast, symptoms persisted in 60% of patients with anosmia, sensory changes, or frontal, temporal, or cerebellar symptoms.[ncbi.nlm.nih.gov]
  • Additional features may include headache, seizures, gradual personality changes (apathy and dementia), anosmia, impaired vision, exophthalmos, hearing loss, ataxia, dysmetria, hypotonia, nystagmus, and rarely spontaneous bleeding.[orpha.net]
  • They may also produce symptoms relative to their position, e.g. a tumor in the foramen magnum will produce paraparesis and sphincteric trouble while one in the olfactory groove will produce symptoms like anosmia.[symptoma.com]
  • Paresis that begins in the ipsilateral arm and progresses to the ipsilateral leg, then to the contralateral leg and arm Sometimes Lhermitte sign Cranial nerve deficits (eg, dysphagia, dysarthria, nystagmus, diplopia, facial hypoesthesia) Olfactory groove Anosmia[merckmanuals.com]
Nausea
  • We describe a 66-year-old female who presented with headache, nausea, and vomiting. Magnetic resonance imaging scan showed that there were 2 primary intracranial tumors occurring simultaneously at adjacent sites of the right cerebral hemisphere.[ncbi.nlm.nih.gov]
  • If headaches, nausea and/or vomiting occur during treatment, corticosteroid medication may be used to reduce the swelling around the tumour, which usually improves symptoms. Pain medications and anti-nausea medications are prescribed if needed.[targetingcancer.com.au]
Diplopia
  • A 33-year-old female patient presented with diplopia and left eye ptosis 26 weeks into her first pregnancy. No investigation was conducted at the time and her symptoms subsided 4 weeks post partum.[ncbi.nlm.nih.gov]
  • Foramen magnum Ipsilateral suboccipital pain Paresis that begins in the ipsilateral arm and progresses to the ipsilateral leg, then to the contralateral leg and arm Sometimes Lhermitte sign Cranial nerve deficits (eg, dysphagia, dysarthria, nystagmus, diplopia[merckmanuals.com]
Headache
  • Postoperatively, the patient's headaches improved significantly and his right-sided visual changes resolved.[ncbi.nlm.nih.gov]
  • These types of posterior fossa meningiomas can cause headaches, seizures, and difficulty walking.[mountsinai.org]
Seizure
  • These types of posterior fossa meningiomas can cause headaches, seizures, and difficulty walking.[mountsinai.org]
  • Few studies focus on seizure outcomes after resections of meningiomas.[epilepsy.com]
  • General symptoms General symptoms from the tumor pressing on the brain or spinal cord: Seizures. Motor seizures, also called convulsions, are sudden involuntary movements of a person’s muscles.[cancer.net]
  • The first patient was a 64-year-old man presenting to the emergency department with seizures and loss of consciousness.[ncbi.nlm.nih.gov]
Dizziness
  • Cavernous sinus meningiomas can cause double vision, dizziness and facial pain. Clival meningiomas are located on the underside of the cerebrum within the posterior cranial fossa.[mountsinai.org]
  • CASE DESCRIPTION: A 21-year-old man presented with generalized headache and dizziness for the past 6 months and worsening of symptoms for the past 2 months.[ncbi.nlm.nih.gov]
Confusion
  • Extradural meningiomas tend to show more aggressive features than intradural meningiomas and are often confused with malignant neoplasms.[ncbi.nlm.nih.gov]
  • Also, the variety of symptoms associated with meningiomas can lead to confusion regarding the cause, since many of the effects can also be due to other medical conditions.[brainsciencefoundation.org]
  • Meningiomas that arise over the surface of the frontal, temporal, parietal or occipital lobes may cause a variety of symptoms including headache, seizures, visual loss, double vision, weakness, fatigue, difficulty walking, confusion and personality changes[pacificneuroscienceinstitute.org]
Focal Neurologic Deficit
  • The patient was asymptomatic, without focal neurologic deficits. In 2016, the patient reported new-onset pain in the neck and left upper extremity.[ncbi.nlm.nih.gov]
  • Symptoms of a convexity meningioma are seizures, focal neurological deficits, or headaches.[brighamandwomens.org]

Workup

  • Imaging studies are the mainstay and laboratory investigations have no use in screening for meningioma. Imaging studies include plain skull radiograph which may show hyperostosis, intracranial calcifications and increased vascular markings of the skull.
  • Plain cranial CT scan will show isoattenuating to slightly hyperattenuatingdural based tumors that enhance after injection of contrast. It will also show perilesional edema, hyperostosis and intratumoral calcification if present.
  • MRI will show edema better than a CT, the meningiomas also enhance more intensely and homogenously after injection of contrast.
  • Angiography is used pre-operatively to assess the vascular supply of the tumor and will show features like sun-burst appearance of the feeding arteries.
  • Histological assessment of the tumor will help to unequivocally diagnose meningioma.

Treatment

The gold standard for treatment for treatment of a benign meningioma surgical resection. Medical care is only used for perioperative medication or when other methods of treatment have failed considerably. Corticosteroid use for example greatly decreases the morbidity and mortality associated with resection. Antiepileptic drugs are also used pre and postoperatively in supratentorial surgery [9].

The general principles in surgical resection of meningiomas are: remove all involved and hyperostotic bone if possible. The dura involved with the tumor as well as its rim that is tumor free should be resected and a duroplasty performed. If dura tails are seen on MRI, they should be removed even if they are not involved with the tumor.

Radiotherapy therapy is used as primary treatment for some unresectable tumors. It is also used as adjuvant therapy for incompletely resected tumor and recurrent tumors.

Prognosis

The size of the tumor may have a role to play in determining the outcome. Studies have revealed permanent cranial nerve deficits is seen in up to 45.5% of patients who have tumors greater than 3cm. In patients with tumors less than 3cm, only about 6% show permanent cranial nerve deficits. If the neoplasm extends into the lower jugular foramen, there could be deficit of the lower cranial nerves.
The prognosis is generally excellent in patients who have had their meningiomas completely resected. However, if the tumors are incompletely resected, multiple or malignant, there is an increased likelihood of recurrence [7].

Etiology

The cause of these tumors have not been fully understood. They are believed to be familial but many cases have arisen randomly, arising sporadically. However, there appears to be an increased risk of developing meningioma in patients who have suffered brain injury or received radiation to the scalp. There is also an increased risk with heavy mobile phone use and with frequent dental x-rays [2].

Patients with neurofibromatosis type 2 also have an increased risk of developing meningioma. There are also genetic mutations that have been associated with meningioma [3].

Epidemiology

In the United States, the annual frequency of symptomatic meningioma is 2 in 100000. It accounts for 20% of all primary intracranial tumors. In Africa, it is responsible for 30% of all intracranial tumors. The morbidity and mortality is difficult to assess but the 5-year survival rate is assumed to be around 73 – 94%. They have a higher prevalence in Africans and African-Americans than in Caucasians. It is more commonly found in women than in men with a male to female ratio of up to 1 : 2.8. The incidence of meningioma increases with age from as low as 0.12 in patients younger than 19 years to as high as 18.89 in patients older than 85 [4, 5].

Sex distribution
Age distribution

Pathophysiology

These tumors may grow within the brain or within the spinal cord. They are widely thought to originate from the arachnoid cap cells which are in the arachnoid layer covering the external part of the brain. Most meningiomas are seen on the brain surface, either at the skull base or over the convexity of the brain. In rare occasions, the may have an intraosseous or intraventricular origin. Classifying meningiomas is problematic because arachnoid cells may exhibit both epithelial and mesenchymal features, and similar tumors may arise from other mesodermal structures.

The classification of all these tumors together is contentious. The current inclination is to separate tumors that are definitely meningiomas from other less well-defined or poorly defined neoplasms. It is however expected that with the advances in molecular biology, scientist will be able to identify the exact anomaly in a genome that is responsible for each specific tumor [6].

Prevention

There are no known ways to prevent this condition. Avoidable risk factors like heavy mobile phone use should however be prevented as much as possible [10].

Summary

Meningiomas are typically benign in nature with only a few percentage turning malignant. They are also asymptomatic in many instances and some individuals carry them their whole life without realizing. They are usually found when investigation for other conditions or during an autopsy [1].

Patient Information

Definition: Meningioma is used to define any of many tumors that grow very close to the meninges. The meninges are the covering of the brain and spinal cord. They are usually benign and many people live and die without knowing that they have it.

Cause: It is believed to have a genetic link but some cases arise randomly. Factors that could increase chances of getting this condition and increased exposure to radiation like mobile phones and dental x-rays. Also, patients who have had a brain injury have an increased risk of developing this condition.

Symptoms: The symptoms are numerous and are determined by the location of the tumor and/or the effect it is having on the brain. They range from the milder headaches and weakness to severe symptoms like paraparesis and stroke.

Diagnosis: This is mainly by the use of imaging tests like x-rays, CT scans and MRI. Some of the sample of the tumor will also be sent to the lab for histology.

Treatment: The main treatment is mainly surgical removal of the tumor. Drug treatment may be used to reduce the operative risk and postoperative complications.

References

Article

  1. Cushing, H, Eisenhardt, L. Meningiomas: Their Classification, Regional Behavior, Life History and Surgical End Results, Thomas, Springfield 1938.
  2. Claus EB, Calvocoressi L, Bondy ML, et al. Dental x-rays and risk of meningioma. Cancer 2012; 118:4530.
  3. Preston-Martin S, Yu MC, Henderson BE, Roberts C. Risk factors for meningiomas in men in Los Angeles County. J Natl Cancer Inst 1983; 70:863.
  4. Annegers JF, Schoenberg BS, Okazaki H, Kurland LT. Epidemiologic study of primary intracranial neoplasms. Arch Neurol 1981; 38:217.
  5. Ibebuike K, Ouma J, Gopal R. Meningiomas among intracranial neoplasms in Johannesburg, South. Afr Health Sci. Mar 2013;13(1):118-21.
  6. Weber DC, Lovblad KO, Rogers L. New pathology classification, imagery techniques and prospective trials for meningiomas: the future looks bright. Curr Opin Neurol 2010; 23:563.
  7. Lieu AS, Howng SL. Intracranial meningiomas and epilepsy: incidence, prognosis and influencing factors. Epilepsy Res 2000; 38:45.
  8. Hallinan JT, Hegde AN, Lim WE. Dilemmas and diagnostic difficulties in meningioma. Clin Radiol. Apr 25 2013;
  9. Liu Y, Li F, Zhu S, et al. Clinical features and treatment of meningiomas in children: report of 12 cases and literature review. Pediatr Neurosurg 2008; 44:112.
  10. Milham S. Meningioma and mobile phone use. Int J Epidemiol. Apr 22 2009;

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Last updated: 2019-07-11 22:34