Treating Brain Meningiomas in Elderly Patients: What a Major Italian Study and Global Research Reveal

Table of Contents

• Key Points
• Background: Why This Research Matters
• How the Research Was Conducted
• Survey Results: How Italian Neurosurgical Centers Treat Elderly Patients
• How Caseload Size Affects Treatment Decisions
• Literature Review: What the Published Studies Show
• Meta-Analysis Findings: Risks in Elderly vs. Younger Patients
• Clinical Implications: What This Means for Patients
• Limitations: What the Study Could Not Prove
• Recommendations and Future Directions
• Frequently Asked Questions
• Source Information

Key Points

• A survey of 51 Italian neurosurgical centers found wide variation in how elderly meningioma patients are treated, largely because standardized guidelines do not exist.
• A meta-analysis of 18 studies covering 17,199 patients found that those aged 65 and older had significantly higher risks of permanent deficits, infections, hemorrhage, perioperative death, and medical complications.
• In the survey, 76.4% of centers said age alone did not influence the surgical decision; age mattered mainly when preoperative comorbidity risk was high.
• All responding centers (100%) chose a 'wait and scan' approach for elderly patients with asymptomatic incidental meningiomas without edema.
• The researchers conclude that prospective studies are needed to build stronger evidence for treating this growing patient group.

Background: Why This Research Matters

Meningiomas are tumors that grow from the membranes covering the brain and spinal cord. They account for 16% to 36% of all intracranial tumors in adults. These tumors are the most common type of primary brain tumor.

The incidence of meningioma is about 1 case per 12,500 individuals in the general population. However, this rate increases significantly with age. In people over 80 years old, the incidence reaches 1 case per 2,000 individuals.

Better diagnostic technology and longer life expectancy have led to more cases of both symptomatic and incidental meningiomas being discovered. This means more elderly patients are being diagnosed with these tumors. The growing demand for neurosurgical treatment in older patients raises important questions about the best balance between treatment benefits and risks.

Traditionally, surgical removal (resection) has been the gold standard of treatment for large, symptomatic lesions and for tumors that are growing rapidly under observation. The primary goal of surgery is to remove as much of the tumor as possible while minimizing complications and death.

However, existing literature on elderly meningioma patients (often abbreviated as MEP) has shown a very broad range of outcomes. Reported mortality rates range from 0% to 45%, and complication rates vary from 10% to 39%. Several studies comparing elderly and younger patients have indicated that surgery in elderly patients carries a higher risk of death and complications.

The shorter life expectancy of older patients and their higher rate of other medical conditions (comorbidities) have led some doctors to consider subtotal resection. Subtotal resection means removing most but not all of the tumor. Some doctors consider subtotal resection as an alternative to gross-total resection. Gross-total resection means removing the entire visible tumor. Subtotal resection is often combined with adjuvant radiotherapy (radiation treatment) or stereotactic radiosurgery (a precise, focused form of radiation), especially for meningiomas at the base of the skull.

A "wait and see" strategy may also be preferred for patients with other medical conditions and minimally symptomatic tumors. However, research has shown that elderly patients who chose conservative treatment had higher tumor-related mortality rates compared to those who underwent surgical removal. Additionally, elderly patients appear to develop atypical and anaplastic meningiomas (more aggressive, faster-growing tumor types) more frequently than younger patients. These aggressive tumors can complicate the clinical course.

No consensus has been reached on the best surgical approach for elderly meningioma patients. There are also limited established predictors of outcomes for this patient group. This leads to important questions: Is initial surgical intervention equally effective for older patients as it is for younger adults? Are postoperative outcomes, complications, surgical morbidity, and mortality comparable between these two age groups?

This investigation aimed to clarify the existing evidence and address the recognized challenges linked to treating meningiomas in elderly patients. The researchers also sought to describe the current clinical mindset of Italian neurosurgeons in light of recent literature data.

How the Research Was Conducted

This study had two main parts: a national survey of Italian neurosurgical centers and a systematic review with meta-analysis of the published medical literature.

Survey Design and Participants

The survey was designed by the Coordinators of the Neuro-oncology, Stereotactic Radiosurgery, and Neuroendoscopy Sections of the Italian Society of Neurosurgery (SINch). The survey was created using an online tool called Survey Monkey. The SINch members Board approved the survey before it was distributed.

The survey was sent by email to all Chiefs of Neurosurgical Departments in Italy. Each center was asked to provide a single representative to complete the survey. The survey remained open for responses from May 5, 2022, until November 21, 2022. All data were collected anonymously.

The survey included 31 questions organized into four domains:

1. Demographics and characteristics of the respondents
2. How "elderly" is defined and what risk assessment scales are used
3. Questions about treatment options
4. Questions about perioperative (around the time of surgery) and postoperative (after surgery) management

Completing the entire survey took approximately 8 to 10 minutes.

Literature Review Methods

The researchers conducted an extensive review of published studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. This is a standardized method for conducting thorough literature reviews.

The review question was formulated using the PICO scheme (Patients, Intervention, Comparison, Outcomes). The specific question was: In newly diagnosed meningioma patients, has surgery in patients over age 70 proven effective compared to surgery in younger patients? This question concerns morbidity (complications) and mortality (death).

The search strategy combined medical subject headings (MeSH) and free text terms. The search included terms such as "elderly," "meningioma," "surgery," "postoperative deficits," "postoperative mortality," "postoperative morbidity," "stereotactic radiosurgery," "radiosurgery," and "outcome."

The researchers included studies published from January 2000 to March 2023 that compared outcomes in elderly meningioma patients (65 years and older) versus younger meningioma patients (under 65 years). The outcomes compared were:

• Neurological complications
• Medical complications
• Mortality

The researchers excluded case reports, review articles, meta-analyses, abstracts, reports of aggregated data, and studies where surgery was not the primary treatment. They also excluded studies not published in English, non-comparative studies, and studies without quantitative data.

Two authors independently reviewed paper titles and abstracts, removing duplicates. In a second review phase, they assessed papers for inclusion based on specific criteria. They also checked the references of included papers to find any missed studies. Any disagreements were resolved through consensus. The level of agreement between the two reviewers was measured using Cohen's kappa coefficient.

Quality Assessment

The researchers used the ROBINS-I tool to evaluate the risk of bias in non-randomized controlled trials. The overall risk of bias was categorized as critical, serious, moderate, low, or with no available information. Two investigators performed this assessment independently. They evaluated seven main domains for potential systematic errors:

• Bias due to confounding factors
• Bias in participant selection
• Bias in how interventions were classified
• Bias from deviations in intended interventions
• Bias due to missing data
• Bias in outcome measurement
• Bias in result selection

Statistical Analysis

Categorical variables were reported as absolute numbers and percentages. Continuous variables were reported as median values with standard deviation. The survey results were analyzed using Chi-square or Fisher's exact tests to compare categorical variables.

The researchers specifically analyzed whether treatment strategies differed among centers with different caseloads. Centers were grouped into three categories:

• High caseload (more than 100 cases per year)
• Intermediate caseload (51 to 99 cases per year)
• Low caseload (fewer than 50 cases per year)

For the meta-analysis, the researchers collected raw data on patient demographics and outcomes. They calculated individual and pooled odds ratios (OR) for different outcomes using the Mantel-Haenszel fixed effect model. This model compared elderly versus young populations. For each outcome, they calculated 95% confidence intervals and two-sided p values. A p value less than 0.05 was considered statistically significant.

Heterogeneity (how much the studies differed from each other) was evaluated using the I-squared statistic. An I-squared value greater than 50% was considered indicative of significant heterogeneity. Publication bias was assessed through visual inspection of funnel plots. The statistical analysis was performed using Cochrane Review Manager software, version 5.4.

Survey Results: How Italian Neurosurgical Centers Treat Elderly Patients

The researchers contacted 120 Neurosurgical Centers electronically. Of these, 51 centers responded, giving a response rate of 42.5%.

Respondent Characteristics

Among the respondents:

• 33.3% worked at academic hospitals, while 66.7% worked at public hospitals
• 41.2% were department chiefs, 15.6% were full-time professors, 5.8% were senior researchers, and 37.5% were hospital clinicians
• 66.7% had more than 15 years of experience in surgical management of cranial meningiomas, 13.7% had 10 to 15 years, and 19.6% had less than 10 years
• 37.3% were aged 35 to 45, 25.4% were aged 46 to 55, and 37.3% were over 55
• 88.2% were male and 11.8% were female
• 56.9% worked in northern Italy, 27.5% in central Italy, and 15.6% in southern Italy

Center Caseload and Available Treatments

Regarding the number of meningioma patients treated each year:

• 27.5% of centers treated fewer than 50 cases per year (low caseload)
• 49% treated 50 to 99 cases per year (intermediate caseload)
• 23.5% treated 100 or more cases per year (high caseload)

Available treatments varied across centers:

• 70.6% offered endoscopic surgery
• 55.9% offered stereotactic radiosurgery
• 74.5% offered fractionated stereotactic radiotherapy

For preoperative imaging, 88.2% of centers used an advanced imaging protocol, while 11.8% used standard MRI.

Intraoperative tools available at responding centers included:

• Neuronavigation: 100% of centers
• Electrophysiological monitoring/stimulation: 90.2%
• Intraoperative ultrasound: 60.8%
• 5-ALA (to evaluate bone infiltration): 27.5%
• Intraoperative CT: 19.6%
• Intraoperative laser: 11.8%

Defining "Elderly" and Assessing Risk

When asked how they define an elderly patient:

• 66.7% defined elderly as over 70 years
• 29.4% defined elderly as over 75 years
• 3.9% defined elderly as over 80 years

For preoperative risk assessment, all centers (100%) used the ASA (American Society of Anesthesiologists) grading system. Other tools were used less frequently:

• CCI (Charlson Comorbidity Index): 13.7%
• ECOG (Eastern Cooperative Oncology Group performance status): 19.6%
• Other tools such as CRGS and Clinical Frailty Scale: 3.9%

Only 17.6% of centers routinely used specific predictive scores for functional outcomes.

Multidisciplinary Discussion

When asked whether cases were discussed within a multidisciplinary group for risk stratification and treatment decisions:

• 37.3% always discussed cases in a multidisciplinary group
• 52.9% discussed cases only in selected situations
• 9.8% never discussed cases in a multidisciplinary group

Among those who discussed cases only in selected situations, the reasons included:

• Midline lesions less than 3 cm in maximum diameter: 51.8%
• High comorbidity risk: 18.6%
• Both reasons: 29.6%

Influence of Age on Treatment Decisions

In the majority of centers (76.4%), age by itself was not a factor influencing the surgical decision. Age influenced decisions only for cases with high preoperative comorbidity risk. For 21.5% of respondents, age always influenced the surgical indication, while 1.9% said age never influenced the decision.

When deciding between an endoscopic approach and classic microsurgery:

• 74.5% said age never played a role in this decision
• 19.6% said age played a role in selected cases
• 5.9% said age always played a role

For selecting the endoscopic approach as the first option, respondents chose it for:

• Midline lesions with maximum diameter less than 3 cm: 76.4%
• Cases with high preoperative comorbidity risk: 39.2%
• Residual tumor management: 66.7%

For median skull base meningiomas (tuberculum, planum, clivus), the endoscopic procedure was the first choice in:

• Fewer than 10% of cases: 54.8% of centers
• 11% to 30% of cases: 33.3% of centers
• More than 31% of cases: 11.8% of centers

When deciding between stereotactic radiosurgery (SRS) and open surgery:

• 62.8% said age influenced the choice in selected cases
• 29.4% said age never influenced the choice
• 7.8% said age always influenced the choice

For selecting the radiosurgical approach as the first option, respondents chose it for:

• Midline lesions with maximum diameter less than 3 cm: 76.4%
• Cases with high preoperative comorbidity risk: 39.2%
• Residual tumor management: 66.7%

Surgical Techniques and Materials

For convexity meningiomas associated with significant hyperostosis (bone thickening), 94% of centers performed cranioplasty (skull reconstruction) during the same surgical procedure. Only 6% did not.

For cranioplasty materials, among the 44 centers that responded:

• Custom-made implants: 29.5%
• Acrylic, alumina ceramics, or methyl-methacrylate: 61.4%
• Titanium: 9.1%

Managing Incidental Meningiomas

For elderly patients with asymptomatic incidental meningiomas without edema:

• 100% of centers chose a "wait and scan" approach
• 0% chose preventive radiosurgery
• 0% chose preventive surgery

For elderly patients with asymptomatic incidental meningiomas showing volumetric progression on MRI:

• 64.6% chose surgery
• 23.6% chose wait and see with regular MRI follow-up
• 11.8% chose stereotactic radiosurgery

Perioperative and Postoperative Management

For preoperative angiography and embolization (blocking blood vessels to the tumor):

• 84.5% used it in selected cases
• 15.6% never used it
• 1.9% always used it

Among those who used it in selected cases, the reasons included:

• Vascular encasement (tumor surrounding blood vessels): 35.7%
• Skull base lesions: 59.5%
• Giant supratentorial lesions: 16.7%

For postoperative treatment after incomplete removal based on WHO tumor grade:

For WHO grade I meningiomas with incomplete removal:

• Wait and scan with regular MRI follow-up: 82.4%
• Stereotactic radiosurgery: 17.6%

For WHO grade II meningiomas with incomplete removal:

• Fractionated radiotherapy or stereotactic radiosurgery: 64.8%
• Wait and scan with regular MRI follow-up: 33.3%
• Radiotherapy or proton therapy: 1.9%

For WHO grade III meningiomas with incomplete removal:

• Radiotherapy or proton therapy: 56.9%
• Fractionated radiotherapy or stereotactic radiosurgery: 43.1%

Venous Thromboembolism Prophylaxis

Among the 26 centers that responded to questions about blood clot prevention:

• 92.4% performed early (within 24 hours) deep vein thrombosis and thromboembolism prophylaxis
• 7.6% did not perform early prophylaxis

Methods used for prophylaxis included:

• Low molecular weight heparin (24 hours after surgery): 92.4%
• Early mobilization: 92.4%
• Preoperative compression stockings: 73.1%
• Intraoperative intermittent pneumatic compression: 30.8%
• Identifying patients at high risk for venous thromboembolism: 15.4%
• Continuous postoperative saturation monitoring for 48 hours after surgery: 7.7%

Before starting prophylaxis, 73.1% of centers performed an early brain CT scan, while 26.9% did not.

How Caseload Size Affects Treatment Decisions

The researchers explored whether treatment strategies differed based on the caseload of the responding centers. Significant differences were mainly observed in two areas: the influence of age on surgical indications and the frequency of multidisciplinary discussions.

Influence of Age on Surgical Indications

The factor of age had a significant impact on surgical indications in centers with high caseload. This difference was statistically significant compared to centers with intermediate and low caseload (p = 0.02). This means there is a 2% probability that this finding occurred by chance.

Multidisciplinary Discussion

Cases were more frequently discussed within multidisciplinary teams for risk stratification and defining the best treatment option in centers with high and intermediate caseload compared to low caseload centers (p = 0.01).

Choice Between Radiosurgery and Open Surgery

The factor of age played a significant role in the choice between a stereotactic radiosurgery approach and open surgery in centers with high and intermediate caseload compared to those with low caseload (p = 0.01).

Other comparisons did not show statistically significant differences, including:

• Whether age influenced the choice between endoscopic and microsurgical approaches (p = 0.16)
• Whether cranioplasty was performed during the same procedure for convexity meningiomas with hyperostosis (p = 0.11)
• Postsurgical treatment choices for incomplete removal of WHO grade I, II, or III meningiomas (p values ranged from 0.38 to 0.97)

Literature Review: What the Published Studies Show

The researchers identified 537 potentially relevant articles using their search strategy. After removing duplicates and papers published before 2000, 158 studies were excluded.

Overall, 379 studies were screened by title and then by abstract. This led to the exclusion of 201 more studies. The agreement between the two reviewers during this phase was very high (Cohen's k coefficient = 0.91).

Studies considered candidates for full-text reading numbered 178. Of these, 152 were removed according to exclusion criteria. The agreement between reviewers during this phase was also very high (Cohen's k coefficient = 0.97).

The remaining 26 studies underwent further selection by strict application of inclusion criteria. In the end, 18 retrospective comparative studies were selected for the meta-analysis.

These 18 studies included a total of 17,199 patients who underwent surgery for intracranial meningiomas. Of these:

• 4,164 patients were in the Elderly-Meningioma group (MEP, the experimental group)
• 13,035 patients were in the Young-Meningioma group (YMG, the control group)

Meta-Analysis Findings: Risks in Elderly vs. Younger Patients

The pooled meta-analysis demonstrated that elderly patients had significantly increased risks compared to younger patients for several serious outcomes. All of these differences were statistically significant.

Permanent Neurological Deficits

Elderly patients had a significantly increased risk of permanent deficits compared to younger patients (p < 0.00001). This means there is less than a 0.001% probability that this finding occurred by chance. The result is highly statistically significant.

Postoperative Infections

The risk of postoperative infections was significantly higher in elderly patients (p = 0.0004). This means there is a 0.04% probability that this finding occurred by chance.

Hemorrhage (Bleeding)

Elderly patients had a significantly increased risk of hemorrhage after surgery (p = 0.0001). This means there is a 0.01% probability that this finding occurred by chance.

Perioperative Mortality (Death Around the Time of Surgery)

The risk of dying around the time of surgery was significantly higher in elderly patients (p < 0.00001). This result is highly statistically significant.

Medical Complications

Elderly patients experienced significantly more medical complications compared to younger patients (p < 0.00001). Medical complications are health problems not directly related to the brain surgery itself, such as heart problems, lung infections, or blood clots. This result is also highly statistically significant.

The researchers used the I-squared statistic to evaluate heterogeneity (how much the studies differed from each other). An I-squared value greater than 50% was considered indicative of significant heterogeneity. Publication bias was assessed through visual inspection of funnel plots for each outcome.

Clinical Implications: What This Means for Patients

This study provides the first comprehensive analysis of existing trends in the surgical management of meningiomas in elderly patients in Italy. The findings have several important implications for patient care.

Lack of Standardized Guidelines Leads to Variation in Care

The significant variation in practices across Italian neurosurgical centers primarily stems from the absence of standardized guidelines. This means that where a patient receives treatment may influence what treatment they receive. The survey revealed substantial differences in how centers approach elderly meningioma patients.

Multidisciplinary Care Is Not Yet Universal

While most centers have adopted some form of integrated approach, only 37.3% always discuss cases within a multidisciplinary group. More than half (52.9%) discuss cases only in selected situations, and nearly 10% never discuss cases in a multidisciplinary group. The researchers emphasize the need to promote a multidisciplinary care model as the standard approach.

Elderly Patients Face Higher Risks

The meta-analysis clearly demonstrates that elderly patients face significantly higher risks of serious complications after meningioma surgery compared to younger patients. These risks include:

• Permanent neurological deficits
• Postoperative infections
• Hemorrhage (bleeding)
• Perioperative death
• Medical complications

These findings underscore the importance of careful patient selection and thorough preoperative risk assessment when considering surgery for elderly patients.

Age Alone Should Not Determine Treatment

In the majority of Italian centers (76.4%), age by itself was not a factor influencing the surgical decision. Age influenced decisions only for cases with high preoperative comorbidity risk. This aligns with the understanding that biological age and overall health status matter more than chronological age.

Treatment Options Are Expanding

The endoscopic and stereotactic radiosurgery approaches are emerging as important options in the management of elderly meningioma patients. These less invasive approaches may offer alternatives for patients who are not good candidates for traditional open surgery.

Wait and Scan Is Standard for Incidental Tumors

All responding centers (100%) agreed on a "wait and scan" approach for elderly patients with asymptomatic incidental meningiomas without edema. This conservative approach avoids unnecessary intervention for tumors that may never cause problems.

Postoperative Management Is Generally Consistent

Overall, postoperative management options related to venous thromboembolism prophylaxis and adjuvant treatments were consistent with current literature data. However, the selection of adjuvant postoperative treatment was heterogeneous, especially for WHO grade II meningiomas with subtotal resection.

Limitations: What the Study Could Not Prove

This study has several limitations that patients and clinicians should consider when interpreting the findings.

Survey Limitations

The survey had a response rate of 42.5%, meaning that 51 of 120 contacted centers participated. The practices at non-responding centers may differ from those that responded. Additionally, the survey collected data anonymously, so the researchers could not verify the accuracy of individual responses.

The survey relied on self-reporting by a single representative from each center. This representative's views may not fully reflect the actual practices of the entire department.

Meta-Analysis Limitations

All 18 studies included in the meta-analysis were retrospective. This means they looked back at existing data rather than following patients forward in time. Retrospective studies are generally considered weaker evidence than prospective studies or randomized controlled trials.

The studies included in the meta-analysis may have varied in how they defined "elderly," what surgical techniques they used, and how they measured outcomes. This heterogeneity could affect the reliability of the pooled results.

The researchers used the ROBINS-I tool to assess risk of bias in the included studies. The overall risk of bias was categorized as critical, serious, moderate, low, or with no available information. The presence of bias in some studies could affect the validity of the meta-analysis findings.

Generalizability

The survey portion of this study was limited to Italian neurosurgical centers. The practices and outcomes observed in Italy may not be representative of practices in other countries with different healthcare systems and training approaches.

The meta-analysis included studies from multiple countries, which may improve generalizability. However, differences in healthcare systems, patient populations, and surgical techniques across countries could affect the applicability of the findings to any specific setting.

Recommendations and Future Directions

Based on their findings, the researchers make several recommendations for clinical practice and future research.

For Clinical Practice

1. Promote multidisciplinary care: The researchers emphasize the need to promote a multidisciplinary care model as the standard approach for managing elderly meningioma patients. This means bringing together neurosurgeons, radiation oncologists, medical oncologists, geriatricians, and other specialists to discuss each case.
2. Use standardized risk assessment: While all centers used the ASA grading system, other validated tools such as the Charlson Comorbidity Index and ECOG performance status were used less frequently. Broader adoption of these tools could improve risk stratification.
3. Consider less invasive options: Endoscopic surgery and stereotactic radiosurgery are emerging as important alternatives for elderly patients. These approaches may offer better risk-benefit profiles for selected patients.
4. Individualize treatment decisions: Age alone should not determine treatment. The decision should consider the patient's overall health status, comorbidities, tumor characteristics, and preferences.
5. Maintain vigilance for complications: Given the higher risks of complications in elderly patients, careful monitoring and preventive measures are essential.

For Future Research

The researchers state that prospective studies are needed to gather robust evidence in this clinical setting. Prospective studies follow patients forward in time and can provide stronger evidence than retrospective studies.

Specific research priorities include:

• Developing and validating predictive tools specifically for elderly meningioma patients
• Comparing different treatment approaches (surgery, radiosurgery, observation) in randomized controlled trials
• Identifying which elderly patients are most likely to benefit from surgery versus other approaches
• Studying quality of life outcomes in addition to survival and complication rates
• Evaluating the role of frailty assessments in treatment decision-making

Key Takeaways for Patients and Families

If you or a loved one is an elderly patient facing a meningioma diagnosis, this study suggests several important points to discuss with your medical team:

1. Ask whether your case will be discussed by a multidisciplinary team. This collaborative approach is recommended but not universally practiced.
2. Discuss all available treatment options, including observation, surgery, and radiosurgery. Each option has different risks and benefits.
3. Understand that age alone should not determine your treatment. Your overall health, other medical conditions, and the specific characteristics of your tumor are equally important.
4. Ask about the experience and caseload of the center where you are being treated. The survey found that caseload influences treatment decisions.
5. Be aware that elderly patients face higher risks of complications after surgery. Discuss these risks thoroughly with your surgeon.
6. For incidental tumors without symptoms, a "wait and scan" approach is the standard recommendation. Regular MRI follow-up can monitor the tumor without immediate intervention.

The researchers conclude that while most centers have adopted an integrated approach to treating elderly meningioma patients, there is a clear need to promote a multidisciplinary care model. The significant variation in practices across centers highlights the importance of developing standardized guidelines based on robust evidence. Until such evidence is available, treatment decisions should be individualized and made collaboratively between patients, families, and multidisciplinary medical teams.

Frequently Asked Questions

What is a meningioma?

A meningioma is a tumor that grows from the membranes covering the brain and spinal cord. These tumors are the most common type of primary brain tumor and account for 16% to 36% of all intracranial tumors in adults. Their incidence increases with age, reaching about 1 case per 2,000 people over 80 years old.

How did this research examine meningioma treatment in elderly patients?

The research combined a national survey of 51 Italian neurosurgical centers with a systematic review and meta-analysis of 18 studies covering 17,199 patients. The survey asked how centers define elderly patients and make treatment decisions, while the meta-analysis compared surgical outcomes between patients aged 65 and older and younger patients.

What risks did the meta-analysis find for elderly patients after meningioma surgery?

The meta-analysis of 18 studies found that patients aged 65 and older had significantly higher risks than younger patients for permanent neurological deficits, postoperative infections, hemorrhage, perioperative death, and medical complications. All of these differences were statistically significant. These findings highlight the importance of careful patient selection and thorough preoperative risk assessment.

Does age alone determine whether an elderly patient receives surgery for a meningioma?

In the survey, 76.4% of Italian centers said age by itself did not influence the surgical decision; age mattered mainly when there was a high preoperative comorbidity risk. Only 21.5% said age always influenced the surgical indication. This aligns with the understanding that overall health status matters more than chronological age.

What is the recommended approach for an incidental meningioma without symptoms in an elderly patient?

All 51 responding Italian centers (100%) chose a 'wait and scan' approach for elderly patients with asymptomatic incidental meningiomas without edema. None chose preventive radiosurgery or preventive surgery. Regular MRI follow-up can monitor the tumor without immediate intervention. If the tumor shows volumetric progression on MRI, 64.6% of centers then chose surgery.

What does it mean that a result was statistically significant in this research?

A statistically significant result means the finding is unlikely to have occurred by chance. For example, the higher risk of permanent neurological deficits in elderly patients had a p value less than 0.00001, meaning less than a 0.001% probability the finding was due to chance. This indicates a highly reliable difference between the groups.

What are the limitations of this research on meningioma treatment in elderly patients?

The survey had a 42.5% response rate, and practices at non-responding centers may differ. All 18 studies in the meta-analysis were retrospective, which is generally weaker evidence than prospective studies. The studies also varied in how they defined 'elderly' and measured outcomes. The survey was limited to Italian centers, so findings may not apply everywhere.

Should an elderly patient with a meningioma get a second opinion before surgery?

A second opinion is reasonable when surgery is proposed for an elderly patient with a meningioma. Reported mortality ranges from 0% to 45% and complication rates from 10% to 39%, and elderly patients face significantly higher risks of permanent neurological deficits, postoperative infections, hemorrhage, perioperative death, and medical complications. Practice varies widely because standardized guidelines do not exist, and only 37.3% of centers always discuss cases in a multidisciplinary group. A second opinion can clarify whether observation, surgery, or radiosurgery fits your health status and tumor. Diagnostic Detectives Network provides independent expert second opinions.

Source Information

Original Article Title: From data to practice: brain meningioma treatment in elderly patients - a survey of the Italian Society of Neurosurgery (SINch®) and systematic review and meta-analysis.

Journal: Neurosurgical review

License: CC BY (open access)

Authors: Tamara Ius, Giovanni Raffa, Denis Aiudi, Pier Paolo Panciani, Giuseppe Maria Della Pepa, Federico Pessina, Domenico Solari, Teresa Somma, Filippo Flavio Angileri, Michele Nichelatti, Paolo Cappabianca, Vincenzo Esposito, Maurizio Fornari, Domenico Gerardo Iacopino, Alessandro Olivi, Francesco Sala, Luigi Maria Cavallo, Alessandro La Camera, and the SINch NeuroOncology Study Group

Publication: Neurosurgical Review (2024) 47:373

DOI: https://doi.org/10.1007/s10143-024-02524-8

Received: February 21, 2024

Revised: May 2, 2024

Accepted: June 17, 2024

Published online: July 31, 2024

Publisher: The Author(s) 2024

This patient-friendly article is based on peer-reviewed research. The original study was published in Neurosurgical Review, a peer-reviewed medical journal. The findings described here represent the results of a survey of Italian neurosurgical centers and a systematic review and meta-analysis of previously published studies. Individual patient circumstances may vary, and treatment decisions should always be made in consultation with qualified healthcare providers.