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Acta Neurochirurgica

, Volume 160, Issue 8, pp 1521–1529 | Cite as

Meningiomas in pregnancy: timing of surgery and clinical outcomes as observed in 104 cases and establishment of a best management strategy

  • Yosef Laviv
  • Ahmed Bayoumi
  • Anand Mahadevan
  • Brett Young
  • Myles Boone
  • Ekkehard M. Kasper
Review Article - Brain Tumors

Abstract

Background

There is a strong correlation between the level of circulating female sex hormones and the parturient growth of meningiomas. As a result, rapid changes in meningioma size occur during pregnancy, putting both the mother and fetus at risk. Large, symptomatic meningiomas require surgical resection, regardless of the status of pregnancy. However, the preferred timing of such complex intervention is a matter of debate. The rarity of this clinical scenario and the absence of prospective trials make it difficult to reach evidence-based conclusions. The aim of this study was to create evidence-based management guidelines for timing of surgery for pregnancy-related intracranial meningiomas.

Method

The English literature from 1990 to 2016 was systematically reviewed according to PRISMA guidelines for all surgical cases of pregnancy–related intracranial meningiomas. Cases were divided into two groups: patients who have had surgery during pregnancy and delivered thereafter (group A) and patients who delivered first (group B). Groups were compared for demographic, clinical and radiological features, as well as for neurosurgical, obstetrical and neonatological outcomes. Statistical analysis was performed to assess differences.

Results

A total of 104 surgical cases were identified and reviewed, of which 86 were suitable for comparison and statistical analysis. Thirty-five patients (40%) underwent craniotomy for resection during pregnancy or at delivery (group A) and 51 patients (60%) underwent surgery after delivery (group B). Groups showed no significant differences in characteristics such as age at diagnosis, number of gestations, presenting symptoms, tumor site and tumor size. Despite a comparable distribution over the gestational trimesters, group A had significantly more patients diagnosed prior to the 27th gestational week (46 vs 17.5%, p = 0.0075). Group A was also associated with a significantly higher rate of both emergent craniotomies (40 vs 19.6%, p = 0.0048) and emergent Caesarian deliveries (47 vs 17.8%, p = 0.00481). The time from diagnosis to surgery was significantly longer in group B (11 weeks vs 1 week in group A, p = 0.0013). The rate of premature delivery was high but similar in both groups (∼70%). Risks of maternal mortality or fetal mortality were associated with group A (odds ratio = 14.7), but did not reach statistical significance.

Conclusions

While surgical resection of meningioma during pregnancy may be associated with increased maternal and fetal mortalities, the overall neurosurgical, obstetrical and neonatological outcomes, as well as many clinical characteristics, are similar to patients undergoing resection postpartum. We believe that fetal survival chances have a significant impact on decision-making, as patients diagnosed at a later stage in pregnancy (≥27th week of gestation) were more likely to undergo delivery first. This complicated clinical scenario requires the close cooperation of multiple disciplines. While the mother’s health and well-being should always be paramount in guiding management, we hope that the overall good outcomes observed by this systematic review will encourage colleagues to aim for term pregnancies whenever possible in order to reduce prematurity-related problems.

Keywords

Meningioma Pregnancy Craniotomy Caesarian delivery 

Notes

Compliance with ethical standards

Funding

No funding was received for this research.

Conflict of interest

None.

Ethical approval

For this type of study formal consent is not required. This article does not contain any studies with human participants performed by any of the authors.

References

  1. 1.
    Bakar B, Sav A, Tekkok IH (2010) Giant chordoid meningioma symptomatic immediately after pregnancy: report of a rare case. Clin Neuropathol 29:163–168CrossRefPubMedGoogle Scholar
  2. 2.
    Balki M, Manninen PH (2004) Craniotomy for suprasellar meningioma in a 28-week pregnant woman without fetal heart rate monitoring. Can J Anaesth 51:573–576. doi: 10.1007/bf03018400 CrossRefPubMedGoogle Scholar
  3. 3.
    Baxter DS, Smith P, Stewart K, Murphy M (2009) Clear cell meningioma presenting as rapidly deteriorating visual field and acuity during pregnancy. J Clin Neurosci 16:1502–1504. doi: 10.1016/j.jocn.2009.1502.1008 CrossRefPubMedGoogle Scholar
  4. 4.
    Bickerstaff ER, Small JM, Guest IA (1958) The relapsing course of certain meningiomas in relation to pregnancy and menstruation. J Neurol Neurosurg Psychiatry 21:89–91CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Cahill DW, Bashirelahi N, Solomon LW, Dalton T, Salcman M, Ducker TB (1984) Estrogen and progesterone receptors in meningiomas. J Neurosurg 60:985–993. doi: 10.3171/jns.1984.60.5.0985 CrossRefPubMedGoogle Scholar
  6. 6.
    Chacko JG, Miller JL, Angtuaco EJ (2010) Spontaneous postpartum resolution of vision loss caused by a progesterone receptor-positive tuberculum sellae meningioma. J Neuroophthalmol 30:132–134. doi: 10.1097/WNO.1090b1013e3181da1099d1059 CrossRefPubMedGoogle Scholar
  7. 7.
    Claus EB, Black PM, Bondy ML, Calvocoressi L, Schildkraut JM, Wiemels JL, Wrensch M (2007) Exogenous hormone use and meningioma risk: what do we tell our patients? Cancer 110:471–476. doi: 10.1002/cncr.22783 CrossRefPubMedGoogle Scholar
  8. 8.
    Cohen-Gadol AA, Friedman JA, Friedman JD, Tubbs RS, Munis JR, Meyer FB (2009) Neurosurgical management of intracranial lesions in the pregnant patient: a 36-year institutional experience and review of the literature. J Neurosurg 111:1150–1157. doi: 10.3171/2009.1153.JNS081160 CrossRefPubMedGoogle Scholar
  9. 9.
    Cohen-Kerem R, Railton C, Oren D, Lishner M, Koren G (2005) Pregnancy outcome following non-obstetric surgical intervention. Am J Surg 190:467–473CrossRefPubMedGoogle Scholar
  10. 10.
    Creanga AA, Bateman BT, Butwick AJ, Raleigh L, Maeda A, Kuklina E, Callaghan WM (2015) Morbidity associated with cesarean delivery in the United States: is placenta accreta an increasingly important contributor? Am J Obstet Gynecol 213:384.e1–384.e11. doi: 10.1016/j.ajog.2015.1005.1002 CrossRefGoogle Scholar
  11. 11.
    Ebner FH, Bornemann A, Wilhelm H, Ernemann U, Honegger J (2008) Tuberculum sellae meningioma symptomatic during pregnancy: pathophysiological considerations. Acta Neurochir (Wien) 150:189–193. doi: 10.1007/s00701-00007-01417-00705, discussion 193CrossRefGoogle Scholar
  12. 12.
    Elwatidy S, Jamjoom Z, Elgamal E, Abdelwahab A (2011) Management strategies for acute brain lesions presenting during pregnancy: a case series. Br J Neurosurg 25:478–487. doi: 10.3109/02688697.02682010.02550345 CrossRefPubMedGoogle Scholar
  13. 13.
    Felgenhauer K (1974) Protein size and cerebrospinal fluid composition. Klin Wochenschr 52:1158–1164CrossRefPubMedGoogle Scholar
  14. 14.
    Gazzeri R, Galarza M, Gazzeri G (2007) Growth of a meningioma in a transsexual patient after estrogen-progestin therapy. N Engl J Med 357:2411–2412. doi: 10.1056/NEJMc071938 CrossRefPubMedGoogle Scholar
  15. 15.
    Giannini A, Bricchi M (1999) Posterior fossa surgery in the sitting position in a pregnant patient with cerebellopontine angle meningioma. Br J Anaesth 82:941–944CrossRefPubMedGoogle Scholar
  16. 16.
    Haas JF, Janisch W, Staneczek W (1986) Newly diagnosed primary intracranial neoplasms in pregnant women: a population-based assessment. J Neurol Neurosurg Psychiatry 49:874–880CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Hatiboglu MA, Cosar M, Iplikcioglu AC, Ozcan D (2008) Sex steroid and epidermal growth factor profile of giant meningiomas associated with pregnancy. Surg Neurol 69:356–362. doi: 10.1016/j.surneu.2007.03.013, discussion 362–353CrossRefPubMedGoogle Scholar
  18. 18.
    Idowu OE, Shokunbi MT, Amanor-Boadu SD, Roberts OA, Eyo C (2004) Surgical management of tuberculum sellae meningioma in a patient with a twin pregnancy: case report. Surg Neurol 62:60–63. doi: 10.1016/j.surneu.2003.07.007 CrossRefPubMedGoogle Scholar
  19. 19.
    Isla A, Alvarez F, Gonzalez A, Garcia-Grande A, Perez-Alvarez M, Garcia-Blazquez M (1997) Brain tumor and pregnancy. Obstet Gynecol 89:19–23CrossRefPubMedGoogle Scholar
  20. 20.
    Ismail K, Coakham HB, Walters FJ (1998) Intracranial meningioma with progesterone positive receptors presenting in late pregnancy. Eur J Anaesthesiol 15:106–109CrossRefPubMedGoogle Scholar
  21. 21.
    Jhawar BS, Ranger A, Steven D, Del Maestro RF (2003) Risk factors for intracranial hemorrhage among full-term infants: a case–control study. Neurosurgery 52:581–590, discussion 588–590CrossRefPubMedGoogle Scholar
  22. 22.
    Johnson N, Sermer M, Lausman A, Maxwell C (2009) Obstetric outcomes of women with intracranial neoplasms. Int J Gynaecol Obstet 105:56–59. doi: 10.1016/j.ijgo.2008.1011.1037 CrossRefPubMedGoogle Scholar
  23. 23.
    Kanaan I, Jallu A, Kanaan H (2003) Management strategy for meningioma in pregnancy: a clinical study. Skull Base 13:197–203. doi: 10.1055/s-2004-817695 CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Kasper EM, Hess PE, Silasi M, Lim KH, Gray J, Reddy H, Gilmore L, Kasper B (2010) A pregnant female with a large intracranial mass: reviewing the evidence to obtain management guidelines for intracranial meningiomas during pregnancy. Surg Neurol Int 1:95. doi: 10.4103/2152-7806.74242 CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Kerschbaumer J, Freyschlag CF, Stockhammer G, Taucher S, Maier H, Thome C, Seiz-Rosenhagen M (2015) Hormone-dependent shrinkage of a sphenoid wing meningioma after pregnancy: case report. J Neurosurg 124:137-140. doi: 10.3171/2014.12.jns142112
  26. 26.
    Khong SY, Leach J, Greenwood C (2007) Meningioma mimicking puerperal psychosis. Obstet Gynecol 109:515–516CrossRefPubMedGoogle Scholar
  27. 27.
    Krovvidi H, Sharma S, Danks J (2008) Postpartum neurologic deficit: an intracranial cause. Int J Obstet Anesth 17:378–379. doi: 10.1016/j.ijoa.2008.1006.1002 CrossRefPubMedGoogle Scholar
  28. 28.
    Kumar S, Gupta V, Khandelwal N (2013) Hemorrhage in meningioma: an unwanted outcome of pregnancy. Neurol India 61:329–330. doi: 10.4103/0028-3886.115098 CrossRefPubMedGoogle Scholar
  29. 29.
    Kurdoglu Z, Cetin O, Gulsen I, Dirik D, Bulut MD (2014) Intracranial meningioma diagnosed during pregnancy caused maternal death. Case Rep Med 158326:10Google Scholar
  30. 30.
    Laviv Y, Ohla V, Kasper EM (2016) Unique features of pregnancy-related meningiomas: lessons learned from 148 reported cases and theoretical implications of a prolactin modulated pathogenesis. Neurosurg Rev 16:16Google Scholar
  31. 31.
    Lee E, Grutsch J, Persky V, Glick R, Mendes J, Davis F (2006) Association of meningioma with reproductive factors. Int J Cancer 119:1152–1157. doi: 10.1002/ijc.21950 CrossRefPubMedGoogle Scholar
  32. 32.
    Lee KH, Lall RR, Chandler JP, Bigio EH, Mao Q (2013) Pineal chordoid meningioma complicated by repetitive hemorrhage during pregnancy: case report and literature review. Neuropathology 33:192–198. doi: 10.1111/j.1440-1789.2012.01337.x CrossRefPubMedGoogle Scholar
  33. 33.
    Locatelli A, Consonni S, Ghidini A (2015) Preterm labor: approach to decreasing complications of prematurity. Obstet Gynecol Clin N Am 42:255–274. doi: 10.1016/j.ogc.2015.1001.1004 CrossRefGoogle Scholar
  34. 34.
    Lusis EA, Scheithauer BW, Yachnis AT, Fischer BR, Chicoine MR, Paulus W, Perry A (2012) Meningiomas in pregnancy: a clinicopathologic study of 17 cases. Neurosurgery 71:951–961. doi: 10.1227/NEU.0b013e31826adf65 CrossRefPubMedGoogle Scholar
  35. 35.
    Macarthur A (2004) Craniotomy for suprasellar meningioma during pregnancy: role of fetal monitoring. Can J Anaesth 51:535–538CrossRefPubMedGoogle Scholar
  36. 36.
    Mazze RI, Kallen B (1989) Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. Am J Obstet Gynecol 161:1178–1185CrossRefPubMedGoogle Scholar
  37. 37.
    Mealey J Jr, Carter JE (1968) Spinal cord tumor during pregnancy. Obstet Gynecol 32:204–209PubMedGoogle Scholar
  38. 38.
    Michelsen JJ, New PF (1969) Brain tumour and pregnancy. J Neurol Neurosurg Psychiatry 32:305–307CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Moscovici S, Fraifeld S, Cohen JE, Dotan S, Elchalal U, Shoshan Y, Spektor S (2014) Parasellar meningiomas in pregnancy: surgical results and visual outcomes. World Neurosurg 82:e503–e512. doi: 10.1016/j.wneu.2013.06.019 CrossRefPubMedGoogle Scholar
  40. 40.
    Nakamura M, Samii M (2003) Surgical management of a meningioma in the retrosellar region. Acta Neurochir (Wien) 145:215–219. doi: 10.1007/s00701-002-1053-z, discussion 219–220CrossRefGoogle Scholar
  41. 41.
    Narayansingh GV, Ramsewak S, Cross JN, Adam RU, Kissoon W (1992) Worsening neurological status in late pregnancy: consider meningioma. Postgrad Med J 68:486CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Nishio S, Morioka T, Suzuki S, Takeshita I, Ikezaki K, Fukui M, Nakano H (1996) Primary brain tumours manifesting during pregnancy: presentation of six cases and a review of the literature. J Clin Neurosci 3:334–337CrossRefPubMedGoogle Scholar
  43. 43.
    ACOG Committee on Obstetric Practice (2011) ACOG Committee Opinion No. 474: nonobstetric surgery during pregnancy. Obstet Gynecol 117:420–421. doi: 10.1097/AOG.1090b1013e31820eede31829 CrossRefGoogle Scholar
  44. 44.
    Nossek E, Ekstein M, Barkay G, Shahar T, Gonen L, Rimon E, Kesler A, Margalit N (2015) Visual deterioration during pregnancy due to skull base tumors compressing the optic apparatus. Neurosurg Rev 38:473–479. doi: 10.1007/s10143-10015-10608-10144, discussion 479CrossRefPubMedGoogle Scholar
  45. 45.
    Nossek E, Ekstein M, Rimon E, Kupferminc MJ, Ram Z (2011) Neurosurgery and pregnancy. Acta Neurochir (Wien) 153:1727–1735. doi: 10.1007/s00701-00011-01061-y CrossRefGoogle Scholar
  46. 46.
    Otton GR, Giles W, Walters WA (1997) Large meningioma complicating pregnancy. Aust N Z J Obstet Gynaecol 37:466–469CrossRefPubMedGoogle Scholar
  47. 47.
    Patel S, Sharan V (2010) Meningioma in pregnancy. J Obstet Gynaecol 30:56–57. doi: 10.3109/01443610903267465 CrossRefPubMedGoogle Scholar
  48. 48.
    Perry A, Stafford SL, Scheithauer BW, Suman VJ, Lohse CM (1997) Meningioma grading: an analysis of histologic parameters. Am J Surg Pathol 21:1455–1465CrossRefPubMedGoogle Scholar
  49. 49.
    Pettorini BL, Park YS, Caldarelli M, Massimi L, Tamburrini G, Di Rocco C (2008) Radiation-induced brain tumours after central nervous system irradiation in childhood: a review. Childs Nerv Syst 24:793–805. doi: 10.1007/s00381-008-0631-7 CrossRefPubMedGoogle Scholar
  50. 50.
    Pimperl LC (2005) Radiation as a nervous system toxin. Neurol Clin 23:571–597CrossRefPubMedGoogle Scholar
  51. 51.
    Pliskow S, Herbst SJ, Saiontz HA, Cove H, Ackerman RT (1995) Intracranial meningioma with positive progesterone receptors. A case report. J Reprod Med 40:154–156PubMedGoogle Scholar
  52. 52.
    Rand CW, Andler M (1950) Tumors of the brain complicating pregnancy. Arch Neurol Psychiatr 63:1–41, illustCrossRefGoogle Scholar
  53. 53.
    Reedy MB, Kallen B, Kuehl TJ (1997) Laparoscopy during pregnancy: a study of five fetal outcome parameters with use of the Swedish Health Registry. Am J Obstet Gynecol 177:673–679CrossRefPubMedGoogle Scholar
  54. 54.
    Rodriguez-Porcel F, Hughes I, Anderson D, Lee J, Biller J (2013) Foster Kennedy Syndrome due to meningioma growth during pregnancy. Front Neurol 4:183Google Scholar
  55. 55.
    Roelvink NC, Kamphorst W, van Alphen HA, Rao BR (1987) Pregnancy-related primary brain and spinal tumors. Arch Neurol 44:209–215CrossRefPubMedGoogle Scholar
  56. 56.
    Rosen MA (1999) Management of anesthesia for the pregnant surgical patient. Anesthesiology 91:1159–1163CrossRefPubMedGoogle Scholar
  57. 57.
    Sadetzki S, Flint-Richter P, Ben-Tal T, Nass D (2002) Radiation-induced meningioma: a descriptive study of 253 cases. J Neurosurg 97:1078–1082. doi: 10.3171/jns.2002.97.5.1078 CrossRefPubMedGoogle Scholar
  58. 58.
    Sahu S, Lata I, Gupta D (2010) Management of pregnant female with meningioma for craniotomy. J Neurosci Rural Pract 1:35–37. doi: 10.4103/0976-3147.63101 CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Sayres WG Jr (2010) Preterm labor. Am Fam Physician 81:477–484PubMedGoogle Scholar
  60. 60.
    Schwartz AC, Afejuku A, Garlow SJ (2013) Bifrontal meningioma presenting as postpartum depression with psychotic features. Psychosomatics 54:187–191. doi: 10.1016/j.psym.2012.1001.1011 CrossRefPubMedGoogle Scholar
  61. 61.
    Scott A, Sharkawi E, Micallef C, Johns P, Grant L (2008) Chordoid meningioma presenting as painful orbital apex syndrome in pregnancy. Int Ophthalmol 28:355–357CrossRefPubMedGoogle Scholar
  62. 62.
    Shitara S, Nitta N, Fukami T, Nozaki K (2012) Tuberculum sellae meningioma causing progressive visual impairment during pregnancy. Case report. Neurol Med Chir (Tokyo) 52:607–611CrossRefGoogle Scholar
  63. 63.
    Smith JS, Quinones-Hinojosa A, Harmon-Smith M, Bollen AW, McDermott MW (2005) Sex steroid and growth factor profile of a meningioma associated with pregnancy. Can J Neurol Sci 32:122–127CrossRefPubMedGoogle Scholar
  64. 64.
    Starke RM, Przybylowski CJ, Sugoto M, Fezeu F, Awad AJ, Ding D, Nguyen JH, Sheehan JP (2015) Gamma knife radiosurgery of large skull base meningiomas. J Neurosurg 122:363–372. doi: 10.3171/2014.3110.JNS14198 CrossRefPubMedGoogle Scholar
  65. 65.
    Stevenson CB, Thompson RC (2005) The clinical management of intracranial neoplasms in pregnancy. Clin Obstet Gynecol 48:24–37CrossRefPubMedGoogle Scholar
  66. 66.
    Terry AR, Barker FG II, Leffert L, Bateman BT, Souter I, Plotkin SR (2012) Outcomes of hospitalization in pregnant women with CNS neoplasms: a population-based study. Neuro-Oncology 14:768–776. doi: 10.1093/neuonc/nos1078 CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    Tyson JE, Parikh NA, Langer J, Green C, Higgins RD (2008) Intensive care for extreme prematurity—moving beyond gestational age. N Engl J Med 358:1672–1681. doi: 10.1056/NEJMoa073059. CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Verheecke M, Halaska MJ, Lok CA, Ottevanger PB, Fruscio R, Dahl-Steffensen K, Kolawa W, Gziri MM, Han SN, Van Calsteren K et al (2014) Primary brain tumours, meningiomas and brain metastases in pregnancy: report on 27 cases and review of literature. Eur J Cancer 50:1462–1471. doi: 10.1016/j.ejca.2014.1402.1018 CrossRefPubMedGoogle Scholar
  69. 69.
    Wahab M, Al-Azzawi F (2003) Meningioma and hormonal influences. Climacteric 6:285–292CrossRefPubMedGoogle Scholar
  70. 70.
    Wigertz A, Lonn S, Mathiesen T, Ahlbom A, Hall P, Feychting M, Swedish Interphone Study G (2006) Risk of brain tumors associated with exposure to exogenous female sex hormones. Am J Epidemiol 164:629–636. doi: 10.1093/aje/kwj254 CrossRefPubMedGoogle Scholar
  71. 71.
    Wrensch M, Minn Y, Chew T, Bondy M, Berger MS (2002) Epidemiology of primary brain tumors: current concepts and review of the literature. Neuro-Oncology 4:278–299CrossRefPubMedPubMedCentralGoogle Scholar
  72. 72.
    Zoli M, Faustini-Fustini M, Mazzatenta D, Pasquini E, Frank G (2012) Tuberculum sellae meningioma growing during pregnancy: a difficult decision-making process. J Clin Endocrinol Metab 97:1418–1419. doi: 10.1210/jc.2012-1155 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Wien 2017

Authors and Affiliations

  • Yosef Laviv
    • 1
  • Ahmed Bayoumi
    • 1
    • 2
  • Anand Mahadevan
    • 3
  • Brett Young
    • 4
  • Myles Boone
    • 5
  • Ekkehard M. Kasper
    • 1
  1. 1.Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
  2. 2.Department of Neurosurgery, Medical Park Goztepe HospitalBahcesehir University School of MedicineIstanbulTurkey
  3. 3.Department of Radiation Oncology, Department of Radiology/Division of Neuroradiology, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
  4. 4.Department of Obstetrics and Fetal Maternal Medicine, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
  5. 5.Department of Anesthesia, Pain and Critical Care Medicine, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA

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