Meningiomas account for 15% of intracranial tumors and 90 percent of meningiomas are intracranial. They commonly occur in the fourth through sixth decades of life. They are more common in females and are rare in children. Meningiomas are brain tumors which do not arise from the cells of the brain (as against glioms which arise from glial cells and other tumors which arise from neural cells). As they do not arise from “brain” cells, they actually are extra-axial in location. By that I mean, they are located outside the brain but inside the skull. So meningiomas do not actually “invade” the brain, on the other hand as they grow in size they press on the brain from outside inwards. Meningiomas are slow growing tumors and as I stated earlier they usually do not invade the brain (though they may be locally invasive at times and these tumors are called atypical or malignant meningiomas).
Since these tumours are slow growing they can achieve enormous sizes before causing symptoms . there are areas in brain which are non eloquent ( areas which are non vital to daily functioning of brain ) such as frontal sub frontal areas , these tumours can achive huge sizes before causing any deficits . Such tumours are akin to large FOOTBALLS in brain . Removal of these tumours require patience and and long duration surgeries and some times tumour is removed sub totally in first attempt and to avoid complications of prolonged surgery in one go rest of tumour is removed next 1-2 days
SIGNS AND SYMPTOMS OF MENINGIOMAS DEPEND UPON THEIR LOCATION
Vision Changes
Meningioma that grows on the bгain mаy cauѕe vision problems, such аs blυrred οr double vision or vision loss.
Hearing Lοss
Hearing loss is а sүmptom οf meningioma near tһe аuditory nerνes oг the bones of the eаr
Headaches
Aсcording to the Mаyo Clіnic, meningioma cаn cause pressure аnd inflammation inside of the ѕkull and result іn headachөs.
Seizures
Mөningioma οf thө Ьrain maү cause sөizures іn people whο һave neνer beforө had а seizure oг seizure disorder.
Mental Dysfunction
Meningiomas at the base of the sĸull can cause mental dysfunction, such аs cοnfusion and memory loss, that may wοrsen over time as the tumor grows.
Weakness
Weakness of thө muscles in the аrms and legs may be а symрtom of meningioma of tһe spinаl cord, aсcording to thө Mayo Clinic.
CASE REPORT
A 22 year male presented in our emergency with complaints of Headache , Vomiting and Altered sensorium of two days duration. Patient s GCS on Examination was E2V2 M6 and had lower cranial nerve palsies. MRI of brain was done which reveled large extraaxial mass in right parieto-occipital region likely a meningioma measuring approx12-13 cms in size . Due to large size of tumour and deteriorating GCS of the patient he was operated in emergency by Dr Vineet Saggar and after 12 hours of marathon surgery complete tumour removal was achieved . Though patient remained on tracheostomy for few days due to lower cranial palsies which finally recovered and tracheostomy was removed , there was no other neurological deficit. Patient was discharged within 15 days of such a major surgery
Discussion
Surgery is indicated in patients with worsening neurological symptoms and in most patients under 70 who present with a seizure or with any neurological symptoms. If patients are over 70 and present with a seizure or have mild symptoms, they can be followed with scans and undergo surgery if there is evidence of definite growth. However, if there is significant edema or a history of worsening symptoms, age is not a contraindication to surgery. A number of patients are now seen in whom the tumor is found incidently and there is no edema. These patients can be followed with periodic scans, including those with large tumors.Since these tumours are slow growing and exra axial they may attain large sizes if they are located near non eloquent areas as brain continues to compensate due to slow groth rate of tumours . How ever these large sized tumours pose many technical challenges both intra operatively and post operatively.
Apart from increasing surgical and anaesthesia timing large tumours especially near skull base require some degree of brain retraction there by increasing risk of brain edema post operatively. Such tumours some times require extended skull base maneuvers such as extended frontal craniotomies, cranioorbitozygomatic approaches to increase exposure and decrease brain retraction.
M ost of the blood supply of the meningioms is from dura via external carotid system, however venous driange is generally towards venous sinuses and as they grow larger in size they start draining supply of surrounding brain via surrounding piamater .Due to prolonged com pression Autoregulation is also impaired in surrounding brain . So when these tumours are removed it suddeny increased blood supply to surrounding brain there by increasing brain edema or hyper perfusion syndrome.
Our patient had persistent tachycardia inspite of normal hydration and haematocrit following surgery and irritability which settled only few days after the surgery
CONCLUSION
In the end I would like to conclude that meningiomas are slow growing tumours of brain which are amenable to complete surgical removal however sometimes location and size of tumour precludes complete tumour removal,
Very large sized tumours measuring 10-15 cms in size or apprx 1/3 – ¼ volume of brain are rare and pose special challenges to surgeons both intra and post operatively. Such tumours appear like large FOOTBALLS in MR IMAGING require special setup and experienced medical team to counter challenges posed by altered haemodynamics in brain circulation and autoregulation.
Dr. Vineet Saggar (MCh)
Neuro Surgeon / Spinal Surgeon
Chandigarh, Mohali -
Ivy Hospital Sector 71
+91-9855990990
Neuro Surgeon / Spinal Surgeon
Chandigarh, Mohali -
Ivy Hospital Sector 71
+91-9855990990
