Microsurgical treatment for central gyrus region meningioma with epilepsy as primary symptom

Preoperative tumor-associated epilepsy in patients with supratentorial meningioma: factors influencing seizure outcome after meningioma surgery

OBJECTIVE

Both pre- and postoperative seizures comprise common side effects that negatively impact patient quality of life in those suffering from intracranial meningioma. Therefore, seizure freedom represents an important outcome measure in meningioma surgery. In the current study the authors analyzed their institutional database to identify risk factors for postoperative seizure occurrence after surgical meningioma therapy in patients with preoperative symptomatic epilepsy.

METHODS

Between February 2009 and April 2017, 187 patients with preoperative seizures underwent resection of supratentorial meningioma at the authors' institution. Seizure outcome was assessed retrospectively 12 months after tumor resection according to the International League Against Epilepsy (ILAE) classification and stratified into favorable (ILAE class I) versus unfavorable (ILAE classes II-VI). A univariate and multivariate analysis was performed to identify factors influencing seizure outcome.

RESULTS

Overall 169 (90%) of 187 patients with preoperative seizures achieved favorable outcome in terms of seizure freedom after meningioma resection. Multivariate analysis revealed peritumoral edema > 1 cm in maximal diameter and WHO grade II and III tumors, as well as a low extent of resection (Simpson grades III-V) as independent predictors for postoperative unfavorable seizure outcome.

CONCLUSIONS

Surgery is highly effective in the treatment of seizures as common side effects of supratentorial meningioma. Furthermore, the present study identified several significant and independent risk factors for postoperative seizure occurrence, enabling one to select for high-risk patients that require special attention in clinical and surgical management.

Predictors of postoperative motor function in rolandic meningiomas

OBJECTIVE

Resection of supratentorial meningiomas is generally considered a low-risk procedure, but tumors involving the rolandic cortex present a unique challenge. The rate of motor function deterioration associated with resecting such tumors is not well described in the literature. Thus, the authors sought to report the rates and predictors of postoperative motor deficit following the resection of rolandic meningiomas to assist with patient counseling and surgical decision-making.

METHODS

An institution's pathology database was screened for meningiomas removed between 2000 and 2017, and patients with neuroradiological evidence of rolandic involvement were identified. Parameters screened as potential predictors included patient age, sex, preoperative motor severity, tumor location, tumor origin (falx vs convexity), histological grade, FLAIR signal (T2-weighted MRI), venous involvement (T1-weighted MRI with contrast), intratumoral hemorrhage, embolization, and degree of resection (Simpson grade). Variables of interest included preoperative weakness and postoperative motor decline (novel or worsened permanent deficit). The SPSS univariate and bivariate analysis functions were used, and statistical significance was determined with alpha < 0.05.

RESULTS

In 89 patients who had undergone resection of convexity (80.9%) or parasagittal (19.1%) rolandic meningiomas, a postoperative motor decline occurred in 24.7%. Of 53 patients (59.6%) with preoperative motor deficits, 60.3% improved, 13.2% were unchanged, and 26.4% worsened following surgery. Among the 36 patients without preoperative deficits, 22.2% developed new weakness. Predictors of preoperative motor deficit included tumor size (41.6 vs 33.2 cm3, p = 0.040) and presence of FLAIR signal (69.8% vs 50.0%, p = 0.046). Predictors of postoperative motor decline were preoperative motor deficit (47.2% vs 22.2%, p = 0.017), minor (compared with severe) preoperative weakness (25.6% vs 21.4%, p < 0.001), and preoperative embolization (54.5% vs 20.5%, p = 0.014). Factors that trended toward significance included parafalcine tumor origin (41.2% vs 20.8% convexity, p = 0.08), significant venous involvement (44.4% vs 23.5% none, p = 0.09), and Simpson grade II+ (34.2% vs 17.6% grade I, p = 0.07).

CONCLUSIONS

Resection of rolandic area meningiomas carries a high rate of postoperative morbidity and deserves special preoperative planning. Large tumor size, peritumoral edema, preoperative embolization, parafalcine origin, and venous involvement may further increase the risk. Alternative surgical strategies, such as aggressive internal debulking, may prevent motor decline in a subset of high-risk patients.

Focused review on seizures caused by meningiomas

BACKGROUND

Meningiomas belong to the most common intracranial neoplasms in adults. One of the most common symptoms patients with meningioma experience is seizures. However, it remains unclear whether prophylactic preoperative anticonvulsant treatment is worthwhile. Furthermore, it is not clear which patients are likely to experience seizures in the course of the disease. In recent years, many studies and meta-analyses addressed this question with particular contradictory results. Therefore, we aimed to identify the most important risk factors for seizures in patients with meningiomas.

METHODS

For the search terms "meningioma and seizure", "meningioma and epilepsy", and "Simpson and seizure" Medline query identified 865 articles. After applying inclusion and exclusion criteria, 20 papers were chosen for further study. The papers were analyzed for all risk factors for pre- and postoperative risk factors for seizures.

RESULTS

Preoperative seizures were mostly associated with extensive brain edema, localization, and bigger tumor size. Even though data were sometimes very contradictory, higher postoperative seizure rate in patients with meningioma was associated with distinct localizations, preoperative seizures, tumor size, brain edema, extent of resection, tumor recurrence, and new neurological deficits. There were no randomized trials showing a prophylactic effect of anticonvulsant drugs.

CONCLUSIONS

There are relevant risk factors for seizures in patients with meningioma. There is the need for a double blind randomized trial for the prophylactic use of antiepileptic drugs (AEDs).

Effect of postoperative systemic antipsychotic therapy on psychiatric recurrence in patients with meningiomas

A number of patients with meningiomas and psychiatric disorders will suffer psychiatric symptom recurrence following tumorectomies. The present study reported a retrospective analysis regarding 42 cases of patients with meningiomas using complete clinical follow-up data from June 2005 to June 2013. The patients were divided into the systemic antipsychotic (SP) group (n=20) following 6months of postoperative SP therapy and the none-SP (NSP) group (n=22), who did not receive postoperative antipsychotic treatment. Patients were assessed using the Positive and Negative Syndrome Scale (PANSS) and Brief Psychiatric Rating Scale (BPRS) at the time points of prior to surgery, immediately following surgery, and 6 months, 12 months and 3 years following surgery. The effective rate, recurrence rate, rehospitalization rate and survival analysis were calculated. The BPRS score and PANSS scores (including PANSS positive, PANSS negative, PANSS general psychopathology and PANSS overall) in the SP group at 6 months, 12 months and 3 years following surgery were significantly decreased compared with the NSP group (P<0.05). The effective rate was 95, 90 and 90% at 6 months, 12 months and 3 years, respectively, in the SP group, whilst it was 68.2, 63.6 and 59%, respectively, in the NSP group, which was statistically significant (χ²=4.89, χ²=4.01 and χ²=5.12; P<0.05). The recurrence rate of the SP group was 0, 5 and 10% at 6 months, 12 months and 3 years, respectively, whilst in the NSP group it was 22.7, 31.8 and 54.5%, respectively, which was statistically significant (χ²=5.16, χ²=4.89 and χ²=9.34; P<0.05). The rehospitalization rate of the SP group was 0, 0 and 5% at 6 months, 12 months and 3 years, respectively, whilst in the NSP group it was 13.6, 22.7 and 36.4%, respectively, and the data at 12 months and 3 years was statistically significant (χ²=5.16 and χ²=6.12; P<0.05). Kaplan-Meier survival analysis indicated that the accumulative survival rates of recurrence and rehospitalization in the SP group were improved compared with the NSP group. The log-rank of recurrence was χ²=9.369 (P=0.002) and the log-rank of rehospitalization was χ²=6.330 (P=0.012). In conclusion, postoperative SP therapy is of great importance to the consolidation of mental symptoms in patients with meningiomas and psychiatric symptoms, and it may significantly reduce the recurrence and rehospitalization rates.

Central lobe epilepsy surgery - (functional) results and how to evaluate them

OBJECT

To evaluate whether central lobe epilepsy (CLE) surgery in the pericentral area implies inevitable function loss and to determine how postsurgical functional outcomes are perceived by the patient.

METHODS

We included all 22 people with epilepsy (PWE) who received central lobe epilepsy (CLE) surgery in the pre- and postcentral gyri between 1995 and 2015 in the University Medical Center Utrecht. We determined function loss and followed-up on quality of life (AQoL-8D), mobility (Rivermead Mobility Index RMI) and self-evaluation of the surgery. To compare this with the literature, a systematic review was conducted, with specific regard for studies that included functional outcome.

RESULTS

Our own cohort showed newly developed functional loss in 54.4% postoperatively. Follow-up questionnaires were returned by 11/19 PWE (the other 3 could not be contacted). The mean AQoL-8d score was 0.74 (SD 0.16) and the mean RMI score was 13.7 (SD 3.0). This mean AQoL-8d was slightly lower than the Western mean population scores (0.86 and 0.87 respectively). RMI scores and postoperative functional deficits were both significantly related to how well PWE scored on the AQoL-8d. 72.7% of the PWE became seizure free after surgery (Engel class 1A). All PWE were happy with the CLE surgery and would recommend this type of surgery to other PWE. Becoming seizure-free, gaining better functioning and having more energy were reported as the most important reasons. The literature provided 475 unique papers, of which 25 were selected for critical appraisal. Six studies were of adequate quality and provided sufficient information to extract results. Prevalence of postoperative neurological deficit varied between 0 and 50%. No information is given on patient's perceptions.

CONCLUSIONS

About half of central lobe resections do not result in new neurological deficits. The patient's perspective is important in CLE surgery, but neglected in the literature. PWE may report being satisfied with the results of surgery despite new deficits and impact on quality of life. Counseling in CLE surgery should take these findings into account. Neurologists and neurosurgeons should not by default refrain from CLE surgery and think a PWE will not accept a deficit.