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Michael E. Sughrue, Ari J. Kane, Gopal Shangari, Martin J. Rutkowski, Michael W. McDermott, Mitchel S. Berger, and Andrew T. Parsa

Object

In 1957, Simpson published a seminal paper defining the risk factors for recurrence following surgical treatment of intracranial meningiomas. Given that Simpson's study was published more than 50 years ago, preceding image guidance technology and MR imaging, the authors reviewed their own experience with surgical treatment of Grade I meningiomas to determine if Simpson's grading scale is still relevant to modern neurosurgical practice.

Methods

From this cohort, the authors evaluated all patients undergoing craniotomy for resection of a histologically proven WHO Grade I meningioma as their initial therapy. Clinical information was retrospectively reconstructed using patient medical records and radiological data. Recurrence analysis was performed using the Kaplan-Meier method.

Results

The 5-year recurrence/progression-free survival for all patients receiving a Simpson Grade I, II, III, or IV resection was 95, 85, 88, and 81%, respectively (p = not significant, log-rank test). Kaplan-Meier analysis revealed no significant difference in recurrence-free survival between patients receiving a Simpson Grade I, II, III, or IV resection. Analysis limited to meningiomas arising from the skull base (excluding the cavernous sinus) similarly found no significant benefit to Simpson Grade I or II resection, and the survival curves were nearly superimposed.

Conclusions

In this study of a cohort of patients undergoing surgery for WHO Grade I meningiomas, the authors demonstrate that the benefit of more aggressive attempts to resect the tumor with dura and underlying bone was negligible compared with simply removing the entire tumor, or even leaving small amounts of tumor attached to critical structures. The authors believe that these data reflect an evolution in the nature of meningioma surgery over the past 2 decades, and bring into question the relevance of using Simpson's grading system as the sole predictor of recurrence.

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Michael E. Sughrue, Ari J. Kane, Gopal Shangari, Andrew T. Parsa, Mitchel S. Berger, and Michael W. McDermott

Object

The study of patients with multiple neoplasms can yield valuable insight into the common pathogenesis of both diseases, as well as identify more subtle risk factors that might not be as readily apparent otherwise. The authors present an analysis of the prevalence of previously diagnosed extracranial malignancies at the time of meningioma diagnosis in 1228 patients evaluated at a single institution.

Methods

All patients who underwent evaluation and/or treatment for meningioma between 1991 and 2007 at the authors' institution were identified. The intake history and physical were assessed for any history of extracranial malignancy. Using the National Cancer Institute data, the authors calculated an expected cancer prevalence for their meningioma patient population, and compared this derived value to the observed rate of these cancers in this population.

Results

There were 1228 patients included in this study. A total of 50 patients (4.1%) with newly diagnosed meningioma had a history of an extracranial malignant tumor at the time of their initial meningioma diagnosis. In general, most malignancies did not differ in prevalence from their expected frequency in the population in the present study. Notable exceptions were acute leukemia (p < 0.0001), and papillary thyroid carcinoma, which had a prevalence 2.5 times that expected in this population (p < 0.05).

Conclusions

The data support a growing body of evidence suggesting an epidemiological link between papillary carcinoma of the thyroid and meningioma. Although the link between these tumors is not immediately apparent, it is possible that further exploration will yield interesting insight into the pathogenesis of both diseases.

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Michael E. Sughrue, Martin J. Rutkowski, C. Jared Chen, Gopal Shangari, Ari J. Kane, Andrew T. Parsa, Mitchel S. Berger, and Michael W. McDermott

Object

Cushing and Eisenhardt were the first to describe sphenoid wing meningiomas in detail, categorizing globoid tumors into 3 groups: 1) medial; 2) middle; and 3) lateral. The authors review their experience with resection of sphenoid wing meningiomas at a single center, to examine whether this classification predicts clinical presentation and postsurgical outcome.

Methods

All patients undergoing resection of sphenoid wing meningioma at the authors' institution over a 9-year period were identified. Clinical data were compared from patients with tumors arising at different points along the sphenoid wing to determine if these tumors behaved differently in terms of symptoms, radiographic characteristics, and postsurgical outcome.

Results

A total of 56 patients underwent microsurgical resection for sphenoid wing meningioma during this period. The rates of optic canal invasion (medial 50% vs middle 5% vs lateral 0%; p < 0.0001, chi-square test), supraclinoid internal carotid artery encasement (medial 32% vs middle 5% vs lateral 0%; p < 0.01, chi-square test), and middle cerebral artery encasement (medial 45% vs middle 24% vs lateral 0%; p < 0.01, chi-square test) were all highest with medial-third tumors. New or worsened neurological deficits occurred in 10 (19%) of 56 patients. Of all the imaging characteristics studied, only location of the tumor along the medial third of the sphenoid wing significantly predicted an increased rate of new or worsened neurological deficit (OR 2.7, p < 0.05).

Conclusions

The authors report outcomes in a large series of sphenoid wing meningiomas that were treated using modern surgical techniques.

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Michael E. Sughrue, Martin J. Rutkowski, Edward F. Chang, Gopal Shangari, Ari J. Kane, Michael W. McDermott, Mitchel S. Berger, and Andrew T. Parsa

Object

Seizures in the perioperative period are a well-recognized clinical entity in the setting of brain tumor surgery. At present, the suitability of antiepileptic prophylaxis in patients following brain tumor surgery is unclear, especially in those without prior seizures. Given the paucity of tumor-type and site-specific data, the authors evaluated the incidence of postoperative seizures in patients with convexity meningiomas and no prior seizures.

Methods

The authors identified 180 patients with no preoperative history of seizures who underwent resection of a convexity meningioma. Some patients received antiepileptic prophylaxis for 7 days postoperatively while others did not, based on the practice patterns of different attendings. The rates of clinically evident seizures in the first 3–4 weeks after surgery were compared.

Results

Patients who received antiepilepsy drugs (129 patients) did not significantly differ from those who did not (51 patients) in terms of age, sex, WHO tumor grade, extent of resection, rate of previous cranial surgery or radiation therapies, or use of preoperative embolization. There was a single new postoperative seizure in the entire cohort, yielding a new seizure rate of 1.9% in patients not on antiepileptic prophylaxis compared with 0% in patients on antiepileptics (p = not significant).

Conclusions

While it is thought that the routine use of prophylactic antiepileptics may prevent new seizures in patients undergoing surgery for a convexity meningioma, the rate of new seizures in untreated patients is probably very low. Data in this study call into question whether the cost and side effects of these medications are worth the small benefit their administration may confer.

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Editorial

Simpson grade and treatment

Roberto C. Heros

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Oral Presentations

2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010