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Acta Neurochirurgica

, Volume 155, Issue 12, pp 2263–2271 | Cite as

Meningioma surgery in the very old—validating prognostic scoring systems

  • Ane KonglundEmail author
  • Siril G. Rogne
  • Eirik Helseth
  • Torstein R. Meling
Clinical Article - Brain Tumors

Abstract

Background

Several studies acknowledge a higher risk of morbidity and mortality following intracranial meningioma surgery in the elderly, yet there is no consensus with regards to risk factors. Four prognostic scoring systems have been proposed. To evaluate their usefulness, we assess the very old meningioma patients in our neuro-oncological database according to the four methods, and correlate the findings with mortality and morbidity.

Methods

We retrospectively calculated scores according to the Clinical-Radiological Grading System (CRGS), the Sex, Karnofsky Performance Scale, American Society of Anesthesiology Class, Location of Tumor, and Peritumoral Edema grading system (SKALE), the Geriatric Scoring System (GSS) and the Charlson Comorbidity Index (CCI) from all patients aged 80–90 years who had primary surgery for intracranial meningiomas 2003–2013 (n = 51), and related our findings to morbidity and mortality.

Results

The mortality rates were 3.9 %, 5.9 % and 15.7 % at 30-days, 3-months and 1-year post-surgery. The rate of complications requiring surgery was 13.7 %, 5.9 % had evacuation of intracerebral hematomas and two patients (3.9 %) had surgery for intracranial infection/osteitis. 15.7 % of the patients were neurologically worsened on discharge. The patients with SKALE scores ≤ 8 had significantly increased mortality rates. The GSS, the CRGS and the CCI were not found to correlate with mortality.

Conclusions

Retrospectively evaluating four proposed scoring systems, we find that the SKALE score reflects the mortality at 1 month and 1 year following primary surgery for intracranial meningiomas in our very old patients. It may represent a helpful adjunct to their preoperative assessment.

Keywords

Brain tumor Elderly Meningioma Prognosis 

Introduction

One-third of the surgically treated tumors in the patients aged ≥ 80 years are considered histologically benign. The indications for such intracranial tumor surgery in the very old remain a topic of debate. We have previously found surgery of intracranial meningiomas in aging patients to carry twice the risk of mortality compared to brain tumor surgery in elderly patients in general, yet to be beneficial in the survivors [11, 19]. We were not able to statistically identify preoperative risk factors in the meningioma patients, with the exception of an increased risk of a serious complication if aged > 80 years [19].

Several studies acknowledge a higher risk of morbidity and mortality following intracranial meningioma surgery in the elderly, yet presenting conflicting findings with regards to prognostic risk factors [3, 8, 20, 22, 23].

Arienta et al. introduced a grading system in 1990 for standardizing the surgical decision making in elderly patients with intracranial meningiomas, the Clinical-Radiological Grading System (CRGS), based on a retrospective study of 46 patients aged 70–80 years (of which 34 had surgery) [1]. The CRGS incorporates six factors related to the preoperative status of the patient and radiological features of the tumor. The resulting score [6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18] was found to reflect mortality at 3 months, in that patients with a score of < 10 had a poor prognosis and a score of > 12 yielded a very good prognosis. The patients scoring 10–12 had a better prognosis with surgery than without. Caroli et al. prospectively validated the CRGS in 2005, acknowledging that patients with a score of more than 10 are the best candidates for surgery [6].

In 2007, Sacko et al. designed a scoring system (SKALE; Sex, Karnofsky Performance Scale, American Society of Anesthesiology Class, Location of Tumor, and Peritumoral Edema) to identify the patients aged 80–90 years who had an increased risk of mortality at 1 year following intracranial meningioma surgery [28]. Based on five preoperative factors, the patients were designated a score from 0 to 16. In a retrospective analysis of 74 patients, Sacko found increased mortality rates at 1 year with SKALE scores equal to or lower than 8.

Cohen-Inbar et al. proposed the Geriatric Scoring System (GSS) in 2010, for preoperative evaluation of meningioma patients aged ≥ 65 years [8]. A score of 8–24 was calculated from eight clinical and radiological parameters, and related to survival and functional outcome. A score of ≥ 15 was found to correlate with improved survival at 3 months and 5 years. The same group retrospectively validated the GSS in 2011, finding improved outcome if GSS ≥ 16.

In 2011, Grossman et al. retrospectively found the Charlson Comorbidity Index (CCI), age and operative elective status to reflect the mortality rate at 1 year following intracranial meningioma surgery in patients aged ≥ 65 years [16]. The CCI score is calculated from a range of weighted comorbidities [7] and is widely used in clinical oncology.

We appreciate the usefulness of a prognostic tool in our everyday practice, with particular regards to the very old patient group, yet it should be prospectively validated. Despite being the largest neurosurgical clinic in Norway, however, we have only seen half a hundred patients relevant to the scoring systems over the past decade. Awaiting a prospective validation, we assessed all our patients aged ≥ 80 years who had primary surgery for intracranial meningiomas between 2003 and 2013 according to the proposed scoring systems.

Methods

The relevant patients were identified in our neuro-oncological database, which incorporates all patients who have had surgery for tumors at the Department of Neurosurgery, Oslo University Hospital since 2003. From patient records, we retrospectively calculated a CRGS score (Table 1), a SKALE score (Table 2), a GSS score and the CCI, and analyzed their relation to morbidity and mortality.
Table 1

The clinical-radiological grading system (CRGS)

 

Score

1

2

3

Size of lesion (cm)

> 6

4–6

< 4

Neurological condition of the patient

Unrecoverable

Progressive

No deficits

KPS score

< 50

60–80

90–100

Critical location

Highly

Moderately

Not critical

Peritumoral edema

Severe

Moderate

Absent

Concomitant disease(s)

Decompensated

Compensated

Absent

cm centimeters, KPS Karnofsky Performance Scale

Table 2

The SKALE grading system

 

Score

0

2

4

Sex

M

F

KPS score

≤ 50

60–70

≥ 80

ASA class

IV

III

I or II

Location

Critical

Not critical

Edema

Severe

Moderate

No edema

ASA American Society of Anesthesiologists, KPS Karnofsky Performance Scale

The clinical-radiological grading system (CRGS)

The CRGS incorporates six factors related to the preoperative status of the patient and radiological features of the tumor, weighted with 1–3 points (Table 1):
  • Size of lesion

  • Neurological deficits: grouped as irrecoverable (complete and stabilized), progressive/recoverable or no deficits/seizures only.

  • Karnofsky Performance Scale (KPS)[18] score: grading of preoperative function from 0 to 100, where a score of ≥ 90 indicate minor or no signs and symptoms of disease, 60–80 includes the patients that requires occasional assistance and a score of < 50 is designated the poorer patients, who are not able to live at home.

  • Location of tumor: is considered critical if at the cranial base, in eloquent areas or near the large vessels, and subdivided into highly, moderately or not critical.

  • Peritumoral edema: severe edema is associated with contralateral shift, otherwise moderate or none.

  • Concomitant diseases: Grouped as decompensated, compensated (controlled by medical therapy) and none.

SKALE

Based on the influence of five preoperative factors, the patients were designated a score from 0 to 16 (Table 2):
  • Sex: Female sex is a positive prognostic factor.

  • KPS score: grading of preoperative function from 0 to 100, where a score of ≥80 indicates a normal level of activity, and 50–70 reflects that the patient is able to live at home with assistance.

  • American Society of Anesthesiology (ASA) class [29]: scoring system of 1–6 to assess fitness for surgery. ASA class I–II is a patient who is healthy or has mild systemic disease, while III reflects severe systemic disease, which in class IV is a threat to life.

  • Location of tumor: is considered critical if at the cranial base, in eloquent areas or near the large vessels.

  • Peritumoral edema: based on preoperative T2-imaging, severe edema is considered present when the ratio of the maximum ray of edema on the maximum diameter of tumor (in cm) exceeds 1.

The geriatric scoring system (GSS)

The GSS includes the same parameters as found in the CRGS, with the exception of “concomitant diseases”; in the GSS, diabetes mellitus, hypertension and pulmonary disease are evaluated as separate factors, each designated three points if absent, two points if medically controlled/mild and one point if not controlled/severe. There are also differences in the classification of tumor size (> 5 cm, 3–5 cm and < 3 cm), and more detail with regards to tumor location [8].

The Charlson comorbidity index, age and operative elective status

The CCI score is a value between 0 and 15, calculated from a range of weighted comorbidities [7]. The score is calculated and adjusted for age using an on-line application [17]. In our data, 96.1 % had elective procedures.

Morbidity and mortality

We made note of serious post-operative complications, such as neurological deficits, intracerebral hemorrhage, pulmonary embolism, seizure/subdural hemorrhage, cerebrospinal fluid (CSF) leak, osteitis, respiratory and cardiac complications. The mortalities at 30 days (surgical mortality), 3 months and 1 year were recorded.

Statistical analysis

Data were analyzed using the IBM® SPSS® Statistics software, version 20.0 (IBM Corp., Armonk, NY, USA). Survival analysis was conducted using Kaplan-Meier curves and Cox proportional hazard analysis. A p value of < 0.05 was considered statistically significant.

Results

Of the 168 patients aged 80–90 years who had primary surgery for an intracranial tumor at our institution between 2003 and 2013, 24 males and 27 females (n = 51, mean age 83.4 years) had surgery for intracranial meningiomas (Table 3).
Table 3

Patient characteristics, total n = 51

 

n

%

Sex

 Male

24

47.1

 Female

27

52.9

Age at surgery (years)

 80–84.9

38

74.5

 85–90

13

25.5

KPS score at diagnosis

 ≤ 50

9

17.6

 60–70

21

41.2

 ≥ 80

21

41.2

Neurological deficits

 Absent (seizures only)

22

43.1

 Progressive

25

49.0

 Unrecoverable

4

7.8

Concomitant disease

 Absent

18

35.3

 Compensated

28

54.9

 Decompensated

5

9.8

ASA class

 I or II

17

33.3

 III

30

58.8

 IV

4

7.8

Critical tumor location

26

51.0

Peritumoral edema

 Absent

8

15.7

 Moderate

23

45.1

 Severe

20

39.2

SKALE score

 < 8

16

31.4

 8

14

27.5

 > 8

21

41.2

CRGS score

 ≥ 10

5

9.5

 < 10

46

90.2

Simpson grade

 1–2

41

80.4

 3–4

10

19.6

WHO grade

 1

45

88.2

 2

5

9.8

 3

1

2.0

KPS Karnofsky Performance Scale, ASA American Society of Anesthesiologists, CRGS Clinical-Radiological Grading System, WHO World Health Organization

They had a median calculated CRGS score of 12 (IQR 2), with 13.7 % scoring <10. Their median SKALE score was 8 (IQR 4), and 68.6 % had SKALE scores ≤8 (Table 3). The median GSS score was 17 (IQR 3), and the median CCI score was 7 (IQR 2).

Mortality

The surgical mortality was 3.9 % (two patients). One patient died of a myocardial infarction at day 15 following tumor surgery, having had decompressive surgery for cerebral edema at day 4. The other patient died of pneumonia day 29 postoperatively. One further patient died within 3 months of surgery, while the mortality rate at 1 year was 15.7 % (eight patients). The mortality rate in this age group in the general Norwegian population is 37.2 % [31]. The rate of follow-up at 1 year was 88.2 %, as six patients had surgery within less than 1 year of the registration date (100–303 days).

The clinical-radiological grading system (CRGS)

Grouping according to Arienta’s findings, 13.7 % of our patients had CRGS score of < 10, 39.2 % had scores of 10–12 and 47.1 % had scores of ≥ 13. Their mean survival times were (in months) 29.9 (95 % CI 11.1–48.7), 60.7 (95 % CI 43.3–78.2) and 70.5 (95 % CI 51.1–88.8), respectively (log rank (Mantel-Cox) p = 0.339). The two patients who died within 30 days had CRGS scores of 11 and 14, respectively, and the patients who died within 1 year had a median CRGS score of 11 (range 9–14). Cox regression analysis of the CRGS as both a continuous and a grouped variable (di- and trichotomous) did not show statistic significance.

SKALE

The mean survival times were (in months) 38.1 (95 % CI 20.1–56.1), 48.0 (95 % CI 33.1–63.0) and 88.6 (72.0–105.1) with SKALE scores < 8, = 8 and > 8, respectively (log rank (Mantel-Cox) p = 0.012, Fig. 1).
Fig. 1

Kaplan-Meier survival estimate

Of the patients who died within 1 month, all had SKALE scores ≤ 8. The 1-year mortality rate observed in the patients with SKALE scores < 8 and = 8 was substantially increased at 56.3 % and 50 %, respectively. The patients who obtained scores of > 8 had a 1-year mortality rate of 14.3 %.

A Cox regression analysis confirmed that increasing SKALE scores had a significant impact on survival, (HR = 0.71 (95 % CI .57–.89), p = 0.002). Grouping the SKALE scores according to Sacko, we found a significant decrease in mortality if SKALE > 8 (HR = 0.17 (95 % CI .05–.63), p = 0.008). Assessing the patients with SKALE scores of ≥ 12 separately did not give any further information.

With regards to its component elements, univariate analysis confirmed the significance of sex, ASA and peritumoral edema. Including all elements in a multiple regression model (p = 0.002), we confirmed the significance of all items except ASA and location.

Tumor location

When substituting “tumor location” as per Sacko (critical versus non-critical) with the more detailed categorization of Arienta (highly, moderately or not critical) in the SKALE grading system (designated 0, 2 and 4 points, respectively), we found all component elements to be significant in a step-wise multiple regression model. We examined the consequences of such a substitution further, in what we termed the “modified SKALE score” (mSKALE). There appeared to be a shift of +2 points, from a median score of 8 (range 2–16, IQR 4) to median score 10 (range 4–18, IQR 4). Consequently, we attempted regrouping into SKALE < 10, 10 and > 10, but this grouping was not found to significantly correlate with survival (log rank (Mantel-Cox) p = 0.051). Maintaining the recommended cutoff at 8 as per Sacko, however, we found the mSKALE to predict increased mortality if the score was < or = 8 (log rank [Mantel-Cox] p = 0.002, mean survival times [in months] 27.0 [95 % CI 7.2–46.8], 60.5 [95 % CI 39.1–81.9] and 72.9 [8.1–56.9] with SKALE scores < 8, and > 8, respectively). The proposed mSKALE had a sensitivity of 0.75 when assessing mortality at 1 year in the group with scores ≤ 8 (positive predictive value [PPV] of 0.30), while we found the SKALE to have a sensitivity of 0.875 (PPV of 0.23). An ROC curve showed AUC of 0.20 (0.04–0.35) and 0.22 (0.04–0.39), respectively.

The geriatric scoring system (GSS)

Survival analysis did not show a significant relationship between the GSS score and mortality, either grouped or as a continuous variable. In our data, the majority (82.4 %) had scores of ≥ 16, while only 9.8 % had scores of ≤ 14.

The Charlson comorbidity index, age and operative elective status

Calculating the CCI adjusted for age, we found a median value of 7 (IQR 2), and 37.3 % had scores of ≥ 8. Survival analysis indicated improved survival if CCI ≤ 6, but this was not statistically significant (log rank (Mantel-Cox) p = 0.068).

Morbidity

The rate of serious complications requiring surgery was 13.7 %. Seven patients (13.7 %) experienced symptomatic intracerebral hemorrhage postoperatively, of whom three (5.9 %) required evacuation, and all within 24 h of primary surgery. One patient developed a subdural hematoma 2 weeks following tumor surgery, requiring evacuation. There were no cases of overt CSF leakage, yet one patient had a swelling indicative of subcutaneous CSF leakage that did not require treatment, and one patient developed shunt-dependent hydrocephalus 9-months post-surgery. Two patients had surgery for infection at day 16 and day 40, epidural and intracerebral, respectively. There were no cases of thromboembolic events in the immediate postoperative period. In the same period, five patients received treatment for pneumonia and nine patients for urinary tract infections (UVI) (25.5 % suffered from either a UVI or pneumonia or both). Eight patients (15.7 %) had new neurological deficits, four of whom had symptomatic postoperative intracranial hematomas. We could not find statistically significant correlations between morbidity and the calculated scores or their resident factors.

Discussion

We have retrospectively applied four proposed scoring systems to all patients aged 80–90 years who have had primary surgery for intracranial meningiomas in our practice over the last 10 years. We found a surgical mortality rate of 3.9 % and a mortality rate at 1 year of 15.7 %. Relating mortality to the SKALE score, we found significantly increased mortality in patients with SKALE scores of ≤8.

Mortality

There is limited data on intracranial meningioma surgery in the very old (Table 4). We find a surgical mortality rate of 29.4 % in the 1995 study by Mastronardi et al., and 0 % in the series of Riffaud et al. and Sacko et al., both published in 2007 [21, 27, 28]. This may reflect both improvements in general health care effecting healthier elders, and improvements in perioperative factors over 12 years. There might also be a stricter selection of patients for surgery, despite conflicting data on preoperative risk factors. Several large and recent studies suggest that increasing age is a risk factor in intracranial meningioma surgery [8, 16, 20, 23, 28], yet clinical and functional status [1, 5, 8, 10, 12, 13, 16, 21, 23, 24, 26, 28, 30] and radiological features [1, 5, 6, 8, 10, 13, 23, 25, 26, 28] are more frequently recognized as risk factors. Female sex has been shown to carry a better prognosis [6, 8, 28]. The length of time at surgery has not been found a significant risk factor in the series presented since 2000, and may be less relevant in modern day neurosurgery.
Table 4

Series on intracranial meningioma surgery in elderly patients

Authors

Year

Age group

N

Surgical mortality

Mortality at 3 months

Mortality at 1 year

Konglund et al.

2013

60+

54

5,6

7,4

NG

Schul et al.

2012

65+

164

3,7

6,7

6,7

Cohen-Inbar et al.

2011

65+

120

NG

5,8

8,3

Grossman et al.

2011

65+

5512

4,4

NG

NG

Cohen-Inbar et al.

2010

65+

250

NG

8,4

NG

Patil et al.

2010

70+

258

12,0

NG

NG

Boviatsis et al.

2007

65+

108

6,5

NG

NG

Sacko et al.

2007

80+

74

1,4

NG

9,4

Riffaud et al.

2007

80+

11

0

NG

9,1

D'Andrea et al.

2005

80+

37

13,5

13,5

13,5

Caroli et al.

2005

70+

90

6,7

7,8

15,6

Buhl et al.

2000

70+

66

7,6

12,1

16,7

Black et al.

1998

65+

57

1,8

NG

NG

Lieu et al.

1998

65+

36

11,1

16,7

NG

Proust et al.

1997

70+

39

7,6

NG

NG

Pompili et al.

1997

65+

43

9,0

NG

NG

Mastronardi et al.

1995

80+

17

29,0

29

NG

Nishizaki et al.

1994

70+

78

13,0

NG

NG

McGrail, Ojemann

1994

70+

56

3,6

NG

NG

Gijtenbeek et al.

1993

60+

93

14,0

NG

NG

Arienta et al.

1990

70+

34

12,0

20

NG

Cornu et al.

1990

65+

96

16,0

NG

NG

Awad et al.

1989

70+

25

8,0

NG

NG

61–70

50

6,0

NG

NG

Djindjian et al.

1988

70+

30

23,0

37

NG

N number of relevant patients (elderly patients with surgically treated intracranial meningiomas), NG not given

The value of prognostic scoring

A numerical representation of risk more readily justifies the choice of treatment, and is easier to communicate. Striving for a well-founded surgical indication, scoring systems incorporating several factors seem more robust than single factors. Contradictory results and a multitude of proposed scales contribute to confusion, however, and currently the surgeon makes the decision on treatment. Three prognostic grading systems relevant to older patients have been derived from retrospective analysis: the CRGS, the SKALE, and the GSS.

The clinical-radiological grading system (CRGS)

Introducing the CRGS in 1990 [1], Arienta et al. found 100 % mortality at 3 months in the surgical patients aged 70–80 years with a CRGS score of less than 9. The mortality was reduced with increasing scores, to 37 % and 0 % in the patients scoring 10–12 and > 12 respectively. They also included nonsurgical cases, who overall had higher scores. All of the nonsurgical patients who had died within 2 years had CRGS scores of ≤ 12. They concluded that the patients scoring < 10 had a poor prognosis, while the patients with scores of > 12 had a very good prognosis, irrespective of surgery. In the remaining patients, surgery carried a better prognosis. In 2005, Caroli et al. prospectively validated the CRGS grading system in surgical patients, finding a higher probability of survival at 3 months (p = 0.02) and 1 year (p = 0.06) if there was a higher total CRGS score [6]. They suggested avoiding surgery if CRGS score < 10.

In our data, we found a trend towards improved survival if CRGS > 10, but this did not carry statistical significance. Our patients are 10 years older, however, and are all, unlike his, preselected as surgical candidates.

SKALE

In 2007, Sacko et al. designed a scoring system (SKALE) to identify the patients aged 80–90 years who carried an increased risk of mortality at 1 year following intracranial meningioma surgery [28]. Based on five preoperative factors, the patients were designated a score from 0 to 16. In a retrospective analysis of 74 surgical patients, Sacko found increased mortality rates at 1 year with SKALE scores equal to or lower than 8.

In our data, we reproduce the findings of Sacko et al. with regards to the total score. When assessing its component elements in a multivariate analysis, ASA and tumor location do not gain significance. The ASA score is valid in univariate survival analysis, however. Substituting Sacko’s definition of location (critical or not) with a more detailed set of location as per Arienta’s definition (highly, moderately or not critical) in a multivariate analysis of the SKALE subset, we find all component elements to be statistically significant. The resulting modified SKALE score (mSKALE) is skewed + 2 points, but we find that it still predicts increased mortality at 1 year if the score is ≤ 8. According to our calculations, both the SKALE and the mSKALE score can be used to identify surgical patients at risk of increased mortality at 1 year.

The geriatric scoring system (GSS)

This system was based on the prognostic findings in a retrospective series of 250 surgical patients aged 65–90 years [8], and validated retrospectively [9] (same age group) in 2010. Its design is similar to the CRGS, assigning a total score of 8–24, which is related to functional outcome and mortality. In their data, Cohen-Inbar et al. find significantly higher GSS scores in the survivors at 3 months (median = 15) and 5 years (median = 16). The patients who did not survive had median GSS 13–14. With regards to mortality, we are not able to find a correlation with the GSS in our data. Unfortunately, we do not have sufficient data to evaluate functional outcome.

The Charlson comorbidity index, age and operative elective status

Grossman et al. has retrospectively validated the CCI in surgical candidates to reflect the mortality rate at 1 year following intracranial meningioma surgery in patients aged ≥ 65 years, adjusted for age, sex, ethnicity and operative elective status [16]. The CCI is a scale of risk due to comorbidities, and a well-validated prognostic tool. A number of disease conditions is graded according to severity, and the total score (0–15) reflects the mortality rate at 1 year [7]. The authors do not identify a transition point, i.e. a score beyond which the risk of mortality is significantly increased. In our data, analysis indicated improved survival if CCI ≤ 6, but this was not statistically valid.

The SKALE, the GSS and the CRGS have different qualities that might account for our findings. The CRGS and the GSS were designed from younger patient groups. People in their seventies presumably have fewer comorbidities and a lower ASA score as a group, than their seniors. It can also be hypothesized that the relatively younger patients as a group might be more diverse with regards to health status, reflected by greater variation in the ASA and the KPS. The CRGS/GSS and Grossman’s approach do not consider the sex of the patients, despite it being acknowledged as a prognostic factor in recent large series [8, 28]. SKALE, on the other hand, does not incorporate tumor size or preoperative neurological deficits. The CRGS, SKALE, GSS and the CCI all take comorbidities into account (reflected in ASA), but Grossman et al. do not comment on the radiological features of the tumor. None of the proposed methods reflect on changes over time, radiological or physical.

In 2012, Schul et al. confirmed the predictive value of the total score of the CRGS and the SKALE with regards to mortality at 1 year following intracranial meningioma surgery in patients aged ≥ 65 years [30], but could not reproduce statistical significance of all component elements. As neither system allows for adjusting to age, extending their use to younger age groups can be difficult.

Besides the convincing prediction of mortality when retrospectively applied to our data, the SKALE scoring system appears easy to incorporate in the daily clinical setting, and could henceforth ease the communication with and treatment of relevant patients. Our findings suggested more detail in the classification of tumor location. It must be emphasized that we consider the SKALE system a useful adjunct to the difficult evaluation of older meningioma patients, given that a numerical system that does not consider changes over time or the patient’s subjective tumor burden cannot fully replace experience.

Morbidity

Our rate of complication requiring surgery was 13.7 %. The literature on morbidity in our patient and age group is scarce, but Sacko et al. report 9.4 % in their patients in the ninth decade [28]. However, series on meningioma surgery in patients aged > 65 years report complication rates of 17.5–54.3 % [2, 4, 15, 16, 20, 30]. We found postoperative hematomas in 15.7 % (eight patients), encompassing all patients with symptomatic or radiologic evidence of intracranial bleeding as a consequence of surgery. Four patients (7.8 %) required evacuation of a hematoma, of which three (5.9 %) were intracerebral. This is higher than the reported figure of 2.7 % by Sacko et al., yet is comparable to the findings of series on younger patients (> 65 years), reporting 3–16 % [1, 4, 5, 8, 10, 30]. It has been shown that meningioma surgery in the elderly carries a higher risk of postoperative hematoma [14]. We were not able to statistically recognize significant risk factors for morbidity.

Limitations of the study

The retrospective nature of the study allows for bias in collecting data. The data are up to 10 years old, and might not reflect recent improvements in surgical techniques and equipment. Importantly, there is a preselection of patients for surgery, missing the patients that are not admitted or not referred to our department. This impedes a comparison with the data of Arienta et al. The construction of the SKALE and the GSS is based on a similarly preselected (surgical) material, however, as are the findings of Grossman et al. Furthermore, the finding of increased mortality and morbidity in a surgical subgroup could indicate a need for a second line of evaluation when considering referrals to the neurosurgical department, such as the application of the SKALE.

Conclusions

Retrospectively evaluating four proposed scoring systems, we find that the SKALE score reflects the mortality at 1 month and 1 year following primary surgery for intracranial meningiomas in our very old patients. It may represent a helpful adjunct to their preoperative assessment.

Notes

Acknowledgments

We thank Elisabeth Elgesem for her kind assistance, and for her work with organizing and maintaining our neuro-oncological database. We also thank Are Hugo Pripp at the Department of Biostatistics, Epidemiology and Health Economy, OUS, for his kind advice.

Conflicts of interest

None.

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Copyright information

© Springer-Verlag Wien 2013

Authors and Affiliations

  • Ane Konglund
    • 1
    Email author
  • Siril G. Rogne
    • 1
  • Eirik Helseth
    • 1
    • 2
  • Torstein R. Meling
    • 1
  1. 1.Department of Neurosurgery, RikshospitaletOslo University HospitalOsloNorway
  2. 2.Faculty of MedicineUniversity of OsloOsloNorway

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