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Occasion : Case Report

Title : Diagnosis and Management of Meningioma in Frontal Lobe

Purpose : Discuss about Diagnosis and Management of Meningioma in

Frontal Lobe

Day and Date : Thursday / November 29th

2012

Presentant : dr. Restu Susanti

Advisor : Prof. dr. Basjiruddin A, Sp.S (K)

Moderator : Prof. DR. dr. Darwin Amir, Sp.S(K)

Opponent : dr. Dherma Putra and dr. Ishlahuddin Ibnu Amin

ABSTRACT

Meningioma is a benign intracranial tumor that can cause focal neurologic and

neuropsychological deficits. Induced abnormalities depending on the location of

existing lesions. Treatment can be given in the form of operative and radiotherapy. This

disease has a good prognosis. Reported cases of women 48 years with progressive

headache, weakness of right limbs and neurobehavior function changes. Right

hemiparesis and papil edema obtained from physical examination and neurobehavior

function changes obtained from the value of mini mental state examination 4. The

results of a CT scan with contrast there was the frontal lobe meningioma. The patient

was treated with anti-edema and metabolic activators. Then proceed with the action

craniotomy and microsurgery as well as anatomical pathology examination of the

results of atypical meningioma. After the therapeutic action, no headache, there are

motor repair and better neurobehavior function.

INTRODUCTION

Meningiomas are tumors arising from the arachnoidal coverings of the brain. Found as

the second most common central nervous system tumor, accounting for approximately

20% of all primary adult intracranial tumors. The vast majority of meningiomas occur in

patients between 50 and 60 years of age, with a twofold higher incidence in women.

The biological behavior of meningiomas is one of continued growth, ultimately leading

to compression of neuronal structures. The treatment of choice is surgery, which is

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frequently successful in treating these tumors.1,2

Patient complain of increasingly severe

headache, right limb hemiparalysis and behavioral disorder.

CASE ILUSTRATION

A fourty eight-year-old female patient was admitted to neurology department of Dr.M

Djamil hospital Padang on June 26th

2012, with :

THE MAIN COMPLAINT:

Increasingly severe headache

HISTORY OF PRESENT ILLNESS

Patient complain of headache that become increasing intense since last 6 month.This headache very severe felt in all parts of the head and most of all day.

Initially her headache is not interfere her daily activities and than gradually her

activity be came discrupted as well.

Finally she could not work anymore.

Patients appear to have a defect in appearance daily in her behavior, she seemdepressed and often forgotten of time, place and other people of the former

familiar. She even forgot her name itself or something new that just happened.

Patient also difficult to do her daily job such as cooking, washing and unable toperform her job as a lecturer.

Patient had weakness of the right limb, but still able to walk on her own, but bythe way she found it difficult to wear slipper or buttoning her blouse.

She appeared with a face that is not symmetrical. Since 3 days ago patient contact worse, coldnot doing communication well.

Patient couldnot answer and doing everything people ask to her.

PAST ILLNESS HISTORY

Never been sick like this before

History of hypertension is not known

She had ovarian cyst surgery in 2008

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HISTORY OF FAMILY ILLNESS

No family members were sick like this.

SOCIAL ECONOMIC BACKGROUNDA lecturer in STIKES. The highest education S1, but since 2 years before is not

working anymore.

Married but has no children

PHYSICAL EXAMINATION

General Condition : Moderately ill

Awareness : Alert

Blood Pressure : 140/90 mmHg

Pulse : 82 x/minute, regularly

Temperature : 36,5o

c

Breathing frequency : 16 x/minute

Internal Examination

Eye : Conjunctiva was not anemic and sclera was not icteric

Lymph nodes : No enlargement

Neck : JVP 5-2 cm H2O. Bruit carotid (-)

Lungs :Symmetric static and dynamic, palpation is normal,

sonor, vesicular, ronchi (-/-), wheezing (-/-)

Heart : Ictus is not visible, palpable 1 finger medial LMCS ICS V,

Sinus rhytm, metallic sound, HR = 82X/minutes

Neurological Examination

GCS : E4M6V5

There are no signs of nuchael rigidity, neither brudzinski I and II. No kernig sign found.

No sign of increasing intracranial pressure.

Cranial Nerves

Nerve I : Normal Nerve II : Visual actuity and visual field could not be examine.

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Opthalmoscophy examination showed: papil side is not clear, hyperemis, cupping (+),

aa : vv = 1 : 3, av.crossing (-)

Impression: Oedema papil ocular dekstra and sinistra + Fundus hypertension KW Ist

grade

Nerve III,IV,VI : isocor pupil, 3mm/3mm, ligh reflex (+/+), Ortho position,movement of the eye balls were normal

N V : Corneal reflex +/+ N VII : facial assymmetry, lagoftalmus (-), right nasolabial fold flatter then

the left side

N VIII : Hearing function is normal N IX : vomiting reflex (+) N X : Symmetrical pharyngeal, uvula is in the middle N XI : normal N XII : Deviation of tongue (+),atrophy (-), fasciculation (-)Motoric function :

Right Left

Superior extremities Active Active

Muscle strength 4 +4 +4 + 555

Tone, trophy Eutonic, eutrophy Eutonic, eutrophy

Inferior extremities Active Active

Muscle strength 4 +4 +4 + 555

Tone, trophy Eutonic, eutrophy Eutonic, eutrophy

Sensoric function : normal exteroceptive and proprioceptive function

Autonomic function : normal

Physiological Reflex :

Right Left

Biceps ++ ++

Triceps ++ ++

KPR ++ ++

APR ++ ++

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Pathological reflex :

Hoffman tromner - -

Babinsky group - -

Laboratory Finding

Hb : 14.1 g/dL RBG : 104 mg/dL Sodium:139 mmol/L

WBCs: 10.200 /mm3

Ureum: 19 mg/dL Potassium: 3,7 mmol/L

Ht: 44 % Creatinin: 0,7 mg/dL

ECG: Sinus rhythm, HR: 82 x/min, ST elevation (-),ST depression (-), T inverted (-),

SV1 + RV5

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FURTHER INVESTIGATION :

1. Complete blood count: cell blood count, platelets, SGOT, SGPT, totalcholesterol, HDL, LDL, triglycerides, ureum, creatinine, uric acid, electrolytes

(Na, K, Cl), total protein, albumin, globuline

2. Tumor markers : CEA, AFP3. Skull x-ray sella tursika centration4. Chest x ray5. Brain CT scan with contrast6. Consult to neurobehavior specialist

FOLLOW UP

2th

day of hospitalization

Subjective : conscious, contacts have not been adequate, no headache or vomite

Objective : cm uncooperative, Bp: 140/90, Pulse rate: 72 x / minute, breath: 18 x / min,

temperature: 370C

Neurologic exam :

GCS E4M6V4, signs of increased ICP (-). Paresis of right seventh and twelveth nerves

central type. Motoric: tones and trophy was normal, upper and lower extremity strength

of right side 4+

4+

4+

Laboratory findings

Hb: 13,1 g/dL Uric Acid : 7,5 mg/dL SGOT: 26 mg/dL

Leucosyte: 11.800 /mm3

Ureum : 27,1 mg/dL SGPT: 16 mg/dL

Ht: 40,7 % Creatinin: 0,7 mg/dL AFP: 1,79 IU/ml

Thrombosyte: 222.000 /mm3

Total cholesterol: 212 mg/dl HDL: 47 mg/dl

LDL: 144 mg/dl Triglycerides: 101 mg/dlSodium:145mmol/L Potassium: 3,6 mmol/L Cloride:106 mmol/L

Total protein : 8 mg/dl Albumin: 4,4 mg/dl Globuline:3,6 mg/dl

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Skull X-ray (Sella Tursica Few) :

Visible destruction of the sphenoid of sella anterior and posterior and calcification of

the calvaria.

Suggested :Mass on the sella turcica

Suggesiton : brain CT scan with contras

Chest X-Ray PA position :

Heart and pulmonary within normal lmit

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Brain CT scan with contras:

Impression :

Hiperdens lesions, inhomogen large, well defined, irregular edges, accompanied by

calcification, edema, and midline shift perifokal to the right lateral ventricle with

obliteration and III in the left temporoparietal lesions appear fronto extends to sella

turcica (Chiasma). Widened sulci narrowed gyri. Ventricular system and sisterna not

widen. Pons, both CPA and cerebellum normally.

Impression: suggestive of astrositoma high grade DD/ meningioma

Assesment: frontal lobe meningioma

Management:

Diet low salt II, 1800 kcal Patient put on medication of :

Asetazolamide 250 mg qid (po)

KSR 500 mg bid (po)

Planning: consult to neurosurgery spesialist

3th

day of hospitalization


Objective : cm uncooperative, Bp: 120/70, Pulse rate: 78 x / minute, breath: 18 x / min,

temperature: 36,90C

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Neurologic exam :



of right side 4+ 4+ 4+

Consultation to neurosurgery specialist recommended that the diagnosis as a

meningioma and would be performed: tumor removal (after informed consent)

Plan: Tumor removal if the patient and family agree. If agreed preparation of operation:

Consult to Internal department and ICU, blood preparations: 4 PRC, 4 WB.

Assesment: left frontal meningioma

Management:

Diet MB RG II 1800 kcalMedication given :

Asetazolamide 4 x 250 mg (po) KSR 2 x 500 mg (po)

4th day of hospitalized


Objective : cm uncooperative, Bp: 130/80, Pulse rate: 82 x / minute, breath: 22x / min,

temperature: 36,80C

Neurologic exam :



of right side 4+

4+

4+

Assesment: left frontal meningioma

Management: Diet low salt II, 1800 kcal Patient put on medication of :

Asetazolamide 250 mg qid (po) KSR 500 mg bid (po)

Informed consent to families

Results: Family aggree for tumor removal

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Planning:

Consult to internal departement

Check the hemostatic physiology

Preparation of blood transfussion

Laboratory results:

PT: 11.3 seconds

APTT: 27.9 seconds

INR: 1

7th day of hospitalized

Internal specialist recommended :

operating tolerances : cardiovascular and pulmonary risk mild, metabolic and

coagulation either.

Suggestion: post-op stabilisation in ICU

Plan: waiting for neurosurgical operations scheduling

8th

day of hospitalized

Result of Neurobehavior spaecialist Consultation:

Symptoms of neuropsychological deficits were found: often forget this since 6 months

Attention: distracted Orientation: impaired Verbal sense: good

Language functions: spontaneous talk disturbed (not smooth)

Naming: impaired Repetition: impaired Read: impaired

Writing: impaired Memory function: impaired

Executive functions: impaired Visuospatial functions: impairedMMSE: 11

Orientation: 2 Registration: 3 Attention and calculation: 0

Recal: 0 Language: 6 Construction: 0

MoCA-Ina: can not be perform

Conclusion:

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Supposed that all modalities of neurobehavior examination in these patients showed that

the function function of attention, language, memory and executive functions and

visuospatial were impaired.

16th

day of hospitalized

at 13:50 am at afternoon:

Subjective : Patient complained of headache and vomite 3x.

Objective : impaired conciousness, BP: 120/80, pulse rate: 104 x / minute, respiratory

rate: 18 x / min, temperature: 36.90C

Laboratory revealed :

Hb: 13 g / dl; Leucosyte: 16 600/mm3; Ht: 41% Platelets: 212 000/mm3; Potassium: 3.5

mmol / L; Sodium: 141 mmol / L; Clorida: 107 mmol / L

Medication as follow:

IVFD RL 12 hours / kolf Diet low salt II, 1800 kcal Asetazolamide 250 mg qid (po) KSR 500 mg bid (po) Dexametason 10 mg (iv) qid (tappering off) Ranitidine 50 mg (iv) bid Ceftriaxon 1 gram (iv) bid

Operation had to be delayed because of waiting for theatre as a reason.

17th

day of hospitalized

at 7:30 pm:

Subjective : conscious, contacts have not been adequate, no headache or vomiteObjective : cm uncooperative, Bp: 110/80, Pulse rate: 82 x / minute, breath: 22 x / min,

temperature: 36,80C

Neurologic exam :



of right side 4+

4+

4+

Assesment: tumor removal ec left frontal lobe meningioma

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Medication as follow:

IVFD RL 12 hours / kolf Diet low salt II, 1800 kcal Asetazolamide 250 mg qid (po) KSR 500 mg bid (po) Dexametason 10 mg (iv) qid (tappering off) Ranitidine 50 mg (iv) bid Ceftriaxon 1 gram (iv) bid

At 09.00 am13.30 am : was performed craniotomy and micro surgery

Post craniotomy:

Treat A-B-C-D in the ICU

Medication : antibiotic, anticonvulsant and analgesic

Open the drain > 48 hours

Open sewing on 8th

post operation

Pathological anatomi laboratory

Wound and after wound dressing

July 20th

2012

Pathological diagnosis is transitional meningioma

August 8th

2012 (one month after craniectomy)

Patient complain that her right eye did not function.

Result of neurobehavior examination:

MMSE: 26



MoCA-Ina: 13

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September 3rd

2012 (two month after craniectomy)

Result of Neurobehavior spaecialist Consultation:

Attention: good Orientation: good Verbal sense: good

Language functions: good Naming: good Repetition: good

Read: good Writing: good Memory function: good

Executive functions: impaired Visuospatial functions: good

MMSE: 28



MoCA-Ina: 26

Conclution : neurobehavior function is more better than before doing craniectomy.

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DISCUSSION

Meningiomas usually benign, slow growing and not cancerous. Symptoms appear

gradually and vary depending on the location. Reported a 48 years old female patientwith a chief complaint of severe headache were more increasingly accompanied by a

weakness of the left limb and deterioration in behavior. From the physical examination

found paresis seventh cranial nerves dextra central type and MMSE score was 4. Based

on anamnesis and physical examination patients diagnosed with space occupying

lession suspected intracranial tumor.1,3

Traction headache is a increasingly severe headache that be happened in patient

in space occupying lesion like tumor. Patient complained that the headache couldnot

therapy by the analgetic, because this symptom they couldnot done their daily activity.

Intracranial tumor could gave more symptom and sign like hemiparalysis, deterioration

of neurobehavior and sometime uncioussness.4

After doing Brain CT scan with contrast the results is suggestive of high grade

astrositoma (radiology results) that differential diagnose with left frontal lobe

meningioma. Here means the etiology of focal neurology deficit that have was

meningioma.

Meningiomas occur primarily at the base of the skull, in the parasellar regions,

and over the cerebral convexities. Meningiomas are not strictly brain tumors, since they

arise from meningothelial cells that form the external membranous covering of the

brain. Thus, symptoms and signs directly reflect the location of the tumor. Most

meningiomas are slow growing and are not associated with substantial underlying brain

edema; they cause symptoms by the compression of adjacent neural structures. Patients

with tumors of the hemispheric convexities often present with a seizure or progressive

hemiparesis. Patients with skull-based lesions typically present with cranial neuropathy,

whereas meningiomas in any location may cause headache.4,5,6,7

. Meningiomas occur more frequently in women, with a female-to-male ratio of

3:2 or even 2:1 in some series. Incidence of meningioma is 18% from all brain tumor.

Focal deficits, which are applicable to the existing lesions. The cause of meningioma

was suspected as associated with hormonal based on the history that she did not has no

children a suffered from ovarian cyst.4,7,8

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We know more about the causes of meningiomas than about most brain tumors. There

are at least four factors that seem to be important in their development: genes, radiation

therapy, hormone receptors, and perhaps environmental factors.5,9

Radiation has a very important role in meningioma formation. Approximately

5% of all meningiomas are radiation induced. An intriguing aspect of meningiomas is

their relation to sex. They are known to occur more often in women than in men.

Increase in size during pregnancy; they have an increased incidence in patient with

carcinoma of breast; and their cells have progesterone and estrogen receptors, although

their role is not known. Women had more expression of the progesterone receptor than a

men. Meningiomas secrete parathormone-related peptide, which may be responsible for

their classification. Prolactin receptor is expressed in meningiomas. 5,7,9

The symptom from meningioma depend on the location of the tumor. 20%

meningioma located in frontal lobes, that gave the frontal lobe syndromes. Frontal lobe

tumor made deterioration of behavior and personality in 90% cases.7

Frontal lobe is the biggest lobe from our brain, comprising almost one-third of the total

cortical surface area and related to behavior aspect . Frontal lobe syndrome is behavioral

changes, emotion, and personality, caused by frontal lobe damage . Several caused

could make frontal lobe syndrome like a traumatic brain injury, tumours, fronto

temporal dementia, or post surgery aneurism.7,10,11,12

The frontal lobes control many of the brains activities including attention,

abstract thought, problem solving, reasoning, judgment, initiative, inhibition, memory,

parts of speech, moods, major body movements, and bowel and bladder control.7

The frontal lobes give many of the uniquely human characteristics of behavior,

and diseases of the frontal lobe are among the most dramatic in neuropsychiatry. Frontal

lobes are divided into the motor cortex adjacent to the Rolandic fissure, the premotorcortex anterior to the motor cortex, and the prefrontal cortex comprising the region

anterior to the premotor areas. Contralateral weakness, brisk reflexes, and Babinski

signs occur with lesions of the motor strip; Brocas aphasia and executive aprosodia

follow lesions of the left and right premotor areas, respectively; and alterations in

cognition, demeanor, and mood are associated with prefrontal dysfunction.10,11,12

Frontal lobe syndromes characterized by deterioration in behavior and personality

characteristic features are:10

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Table 1 : Frontal Lobe Symptoms and Their Assesment

Clinical manifestation have various type, but based on unable to manage behavioral. In

this patient characteristic of frontal lobe syndrome that the patient has are reduced

verbal fluency, non verbal fluency, poor judgemet, poor response inhibion, poor

memory organiation, reduced devided attention and contralateral hemiparesis.

Deterioration of behavior and motoric deficits that happened in this patient based on the

the location that contributed in this tumor, prefrontal and primary motoric cortexs.7,10

Therapy for this syndrome stress on its underlying desease, family councelling,

and surgery. Treatment of brain tumor depend on the location and type of the tumor.

Corticosteroid used for reduce the vasogenic oedema and controlled the intracranial

pressure. Treatment options for meningiomas include observation, surgery and

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radiation therapy. At the Brigham and Womens Hospital, make the statement was

deciding wheter to observe a tumor. The ultimate decision consist of symptoms,age and

imaging appearance, morbidity of surgery or radiation, patient preference and need for

definitive diagnosis.4,9,10

This patient then consulted for the diagnosis of neurological surgery and

enforced by the plan meningioma tumor removal. Meningioma operative therapy is the

first choice that followed by anatomical pathology examination. In these patients

performed a craniotomy with microsurgery is a major choice in the treatment of

meningioma with minimal recurrence. Microsurgical technique which can significantly

increase the radical surgical intervention for brain meningiomas, resulting in lower

frequency of recidives and reducing number of complications. Thus, the use of

microsurgical technique at the stages of resection of meningiomas with the consequent

coagulation of the matrix increases the radicality of surgical treatment, reduces the risk

of recidives and continued tumor growth.5,9,13,14

Pathologic exam of this meningioma who had surgery showed as transitional

meningiomas. These common tumours feature the coexistence of meningothelial andfibrous patterns as well as transitions between these patters. Based on World HealthClassification of Brain Tumors, transitional meningioma was Grade I, the benign group

(85-90%), have no prognostic significance but are merely descriptions of different

histology.5,9,13

After doing craniectomy and microsurgery the condition of patient is more

better, the symptom of the right hemiparalysis and improved the behavior function. Had

been doing the neurobehavioral examination follow up in this patient, that recognized

that the focal neurologic and neuropsychological deficit that happened in this patient

was the effect of the mass in frontal lobe, meningioma.

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CONCLUSION

Meningioma is a primary brain tumor, more common in women. symptoms offocal neurological deficits caused depends on the location of the lesion.

Frontal lobe is the biggest lobe from our brain, comprising almost one-third ofthe total cortical surface area and related to behavior aspect.

Frontal lobes meningioma caused contralateral hemiparalisis and behaviordeterioration.

Frontal lobe syndrome is behavioral changes, emotion, and personality. Meningioma is a tumor that is operabel and radiosensitif. Focal neurologic and neuropsychological deficit that happened in this patient

was the effect of the mass in frontal lobe.

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REFERENCE

1. Kaye Andrew H, Edward R Laws. Brain Tumors an Encyclopedic Approach,Third Edition. Saunders Elsevier. China. 2012. Page 171

2. Pasztor Emil. Concise Neurosurgery for general practitioners and students.National Institute of Neurosurgery. Budapest, Hungary. Page 55

3. Sadewo Wismaji. Sinopsis Ilmu Bedah Saraf. Cetakan pertama. DepartemenBedah Saraf FKUI/RSCM. Jakarta. 2011. Hal 145

4. Lisa B Angelis. Brain Tumor. N Englaand J med, vol 344, No.2, Januari 2001.www.nejm.org

5. Louis N David, Hiroko Ohgaki, Otmar D Wiestler, et al. WHO Classification OfTumors Of Central Nervus System 4

thEd. International Agency for Research

and Cancer Lyon. 2007. 164-1726. Ahluwalia Manmeet et al. Brain Tumor in Outcomes Neuro 2010. Cleveland

Clinic 2010. www.ClevelandClinic.org

7. National Brain Tumor Foundation. Essential Guide of Brain tumor. Page 10-12,32. www.braintumor.org

8. American Brain Tumor Association. Focusing on Tumor Meningioma. Page 1-16. 2006. www.abta.org

9. Black et al. Meningioma : Science and Surgery. Clinical Neurosurgery. Volume54, 2007:91-99

10.Cumming L Jeffrey and Michael R Trimble. Concise Guide to Neuropsychiatryand Behavioral Neurology, 2nd Ed . American Psychiatric Publishing Inc.

Washington DC. 2005. Page 71-85

11.Rowe AD et al. Theory of Mind Impairments and Their Relationship toExecutive Functioning Following Frontal Lobe Exicisions. Brain. 2010;124:600-

616

12.Bor Daniel et al. Frontal lobe involvement in spatial span: Converging studies ofnormal and impaired function. Neuropsychologia 44 (2006) 229237

13.Minniti Giuseppe, Maurizio Amichetti and Riccardo Maurizi Enrici.Radiotherapy And Radiosurgery For Benign Skull Base Meningiomas.

Radiation Oncology 2009, 4:42, http://www.ro-journal.com/content/4/1/4214.Alimov Djamshidjon. Comparative Characteristics Of Surgical Treatment With

Subsequent Radiotherapy For Brain Typical And Atypical Meningiomas.

Medical And Health Science Journal, Volume 7, 2011, Pp. 44-48
http://www.nejm.org/http://www.clevelandclinic.org/http://www.braintumor.org/http://www.abta.org/http://www.ro-journal.com/content/4/1/42http://www.ro-journal.com/content/4/1/42http://www.abta.org/http://www.braintumor.org/http://www.clevelandclinic.org/http://www.nejm.org/

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