Craniotomy For Resection of Meningioma An Age Stratified Analysis
Craniotomy For Resection of Meningioma An Age Stratified Analysis
Craniotomy For Resection of Meningioma An Age Stratified Analysis
- OBJECTIVE: We sought to describe complications after - CONCLUSIONS: In this study, we report complication
resection for meningioma with the use of longitudinal rates in patients undergoing resection for meningioma.
administrative data, which our group has shown recently to Because of the longitudinal nature of the MarketScan
be superior to nonlongitudinal administrative data. database, we were able to capture a wide array of specific
postoperative complications associated with meningioma
- METHODS: We identified patients who underwent
resection procedures. Care should be taken in the selec-
resection for meningioma between 2010 and 2012 in the
tion of candidates for meningioma resection.
Thomson Reuters MarketScan database. Current Proce-
dural Terminology coding at inpatient visit was used to
select for meningioma resection procedure. Comorbidities
and complications were obtained by use of the Interna-
tional Classification of Diseases, Ninth Revision or Current
Procedural Terminology coding. Associations between INTRODUCTION
complications and demographic and clinical factors were
evaluated with logistic regression.
- RESULTS: We identified a total of 2216 patients.
Approximately 41% developed 1 or more perioperative
M eningiomas are benign neoplasms that arise from the
dural layers covering the brain and spinal cord. They
account for up to 30% of all primary intracranial tumors
and typically are slow-growing.1 Many are asymptomatic and
frequently are discovered incidentally on magnetic resonance
complications. Approximately 15% were readmitted within imaging.2 Resection is indicated when the tumor becomes
30 days of their procedure. The most frequent complica- symptomatic or grows significantly in size over a limited time
tions that occurred in our cohort were new postoperative period. It is expected that the meningiomas will be diagnosed
seizures (11.8%), postoperative dysrhythmia (7.9%), intra- more frequently as the average human life expectancy continues
cranial hemorrhage (5.9%), and cerebral artery occlusion to increase and as diagnostic modalities continue to improve.
(5.4%). General neurosurgical complications and general This, coupled with the inherent risks associated with resection,
neurologic complications occurred in 4.4% and 16.1% of presents issues with regard to choice of operative therapy.
Several studies have reported widely varying results on operative
patients, respectively. Nearly 55% of elderly patients (‡70
outcomes.3-12
years) developed 1 or more perioperative complication (vs. We sought to undertake a national, longitudinal database study
39% of nonelderly patients). After we adjusted for comor- investigating operative outcomes of meningioma resection to
bidities, elderly status and male sex were found to be further describe the risks and benefits associated with this pro-
significantly associated with increased odds for a variety cedure. We used the Thomson Reuters MarketScan database to
of complications. investigate demographics, complications, and postoperative
Key words From the 1Department of Neurosurgery, Stanford University School of Medicine, Stanford,
- Adverse events California, USA; and 2Division of Epidemiology, Department of Health Research and Policy,
- Craniotomy Stanford University, Stanford, California, USA
- MarketScan To whom correspondence should be addressed: Gordon Li, M.D.
- Meningioma [E-mail: [email protected]]
Citation: World Neurosurg. (2015) 84, 6:1864-1870.
Abbreviations and Acronyms http://dx.doi.org/10.1016/j.wneu.2015.08.018
CPT: Current Procedural Terminology
Journal homepage: www.WORLDNEUROSURGERY.org
ICD-9: International Classification of Diseases, Ninth Revision
NIS: Nationwide Inpatient Sample Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.
Age, mean (SD) 54.61 (12.74) 77.3 (4.7) 51.9 (10.5) < 0.0001
Follow-up, mean, (SD) 337 (222) 316 (212) 340 (223) 0.1110
Length of stay (nights), mean (SD) 4.87 (6.17) 7.1 (7) 4.6 (6) < 0.0001
Medicare, n (%) 405 (18.28) 239 (100) 166 (8.40) < 0.0001
Male, n (%) 639 (28.84) 94 (39.33) 545 (27.57) 0.20 (0.15e0.27) < 0.0001
Supratentorial (%) 1954 (88.18) 224 (93.72) 1730 (87.51) 2.13 (1.24e3.66) 0.0039
Discharge home, n (%) 1812 (81.77) 128 (53.55) 1684 (85.18) 0.20 (0.15e0.27) < 0.0001
Comorbidities, n (%)
Tobacco use 120 (5.49) 8 (3.4) 112 (5.7) 0.57 (0.27e1.18) 0.1313
Osteoporosis 353 (16.14) 65 (27.3) 288 (14.8) 2.17 (1.59e2.96) < 0.0001
Hypertension (Elixhauser) 1026 (46.91) 179 (75.2) 847 (43.5) 3.95 (2.9e5.37) < 0.0001
CHF (Charlson) 79 (3.61) 24 (10.1) 55 (2.8) 3.86 (2.34e6.37) < 0.0001
MI (Charlson) 41 (1.87) 17 (7.1) 24 (1.2) 6.17 (3.26 e11.66) < 0.0001
COPD (Charlson) 285 (13.03) 46 (19.3) 239 (12.3) 1.71 (1.21e2.43) 0.0041
COPD (Elixhauser) 280 (12.8) 45 (18.9) 235 (12.1) 1.70 (1.2e2.42) 0.004
Diabetes (Elixhauser) 352 (16.1) 76 (31.9) 276 (14.2) 2.84 (2.11e3.84) < 0.0001
Obesity (Elixhauser) 177 (8.09) 15 (6.3) 162 (8.3) 0.74 (0.43 e1.28) 0.3158
Region 0.0227
Northeast 445 (20.08) 46 (19.20) 399 (20.20)
North Central 553 (24.95) 71 (29.70) 482 (24.40)
South 757 (34.16) 69 (28.90) 688 (34.80)
West 404 (18.23) 52 (21.80) 352 (17.80)
Unknown 57 (2.57) 1 (0.40) 56 (2.80)
CHF, congestive heart failure; MI, myocardial infarction; COPD, chronic obstructive pulmonary disease.
(89.2%). In total, the average patient age was 54.6 years (SD, 12.7). (IQR, $28,390e$57,904), whereas the median 90-day total post-
Patients had a mean duration of follow-up of 11.2 months and a discharge payment was $3506 (IQR, $1128e$16,207) (Table 3). The
mean duration of stay of 4.87 days. The mean duration of stay was majority of patients in the cohort were discharged home (81.8%).
significantly greater in elderly patients compared with nonelderly The most frequent comorbid conditions were hypertension
patients (7.1 vs. 4.6, P < 0.0001). All elderly patients were enrolled (Elixhauser) (46.9%), osteoporosis (16.1%), diabetes (Elixhauser)
under Medicare (vs. 8.4% of nonelderly patients). The median (16.1%), and chronic obstructive pulmonary disease (Charlson)
total payment for the initial admission for resection was $39,297 (13.0%).
Hospital payments, median (IQR) 30,770 (20,398e45,672) 26,170 (15,036e40,584) 31,157 (21,220e46,528) 4987 (0.19) 0.0463
Physician payments, median (IQR) 4727 (3241e6723) 3047 (2550e3791) 5013 (3505e7087) 1967 (0.65) < 0.0001
Total payments, median (IQR) 39,297 (28,390e57,904) 33,145 (19,125e48,667) 40,405 (29,539e58,624) 7259 (0.22) 0.0014
90 day postdischarge payments, median (IQR) 3506 (1128e16207) 4498 (1460e20,005) 3402 (1091e15,852) 1096 (0.24) 0.9772
Any complication 898 (41.1) 130 (54.6) 768 (39.4) 1.85 (1.41e2.43) < 0.0001
All-cause readmission within 30 days 338 (15.45) 30 (12.6) 308 (15.8) 0.77 (0.51e1.15) 0.2174
Mortality, n (%) 19 (0.86) 4 (1.43) 15 (0.63) 2.29 (0.75e6.94) 0.158
Wound infection 48 (2.19) 3 (1.3) 45 (2.3) 0.54 (0.17e1.75) 0.4781
Wound dehiscence 14 (0.64) 2 (0.8) 12 (0.6) 1.37 (0.3e6.15) 0.6588
Wound hematoma 94 (4.3) 7 (2.9) 87 (4.5) 0.65 (0.3e1.42) 0.395
Other wound complication 23 (1.05) 2 (0.8) 21 (1.1) 0.78 (0.18e3.34) 1.00
General neurosurgical complication 97 (4.44) 20 (8.4) 77 (4) 2.23 (1.34e3.72) 0.0039
Iatrogenic stroke 63 (2.88) 14 (5.9) 49 (2.5) 2.42 (1.32e4.46) 0.0068
General neurological complication 353 (16.14) 48 (20.2) 305 (15.6) 1.36 (0.97e1.91) 0.0765
Intracranial hemorrhage NOS 128 (5.85) 32 (13.4) 96 (4.9) 3 (1.96e4.59) < 0.0001
Precerebral arterial occlusion 23 (1.05) 3 (1.3) 20 (1) 1.23 (0.36e4.17) 0.7324
Cerebral artery occlusion 118 (5.4) 24 (10.1) 94 (4.8) 2.21 (1.38e3.54) 0.002
Transient ischemia attack 25 (1.14) 2 (0.8) 23 (1.2) 0.71 (0.17e3.03) 1.00
Acute complication NOS 50 (2.29) 11 (4.6) 39 (2) 2.37 (1.2e4.7) 0.0188
Hemiplegia/hemiparalysis 39 (1.78) 11 (4.6) 28 (1.4) 3.32 (1.63e6.77) 0.0021
Subarachnoid hemorrhage 46 (2.1) 9 (3.8) 37 (1.9) 2.03 (0.97e4.26) 0.0871
Delirium 35 (1.6) 11 (4.6) 24 (1.2) 3.89 (1.88e8.04) 0.0008
Postoperative seizure 259 (11.84) 38 (16.0) 221 (11.3) 1.49 (1.02e2.16) 0.0431
Postoperative dysphagia 57 (2.61) 13 (5.5) 44 (2.3) 2.5 (1.33e4.72) 0.0078
Postoperative dysrhythmia 172 (7.86) 33 (13.9) 139 (7.1) 2.1 (1.4e3.15) 0.0008
Postoperative MI 64 (2.93) 15 (6.3) 49 (2.5) 2.61 (1.44e4.73) 0.0033
DVT 95 (4.34) 16 (6.7) 79 (4.1) 1.71 (0.98e2.97) 0.0635
Any thromboembolism 61 (2.79) 15 (6.3) 46 (2.4) 2.78 (1.53e5.07) 0.0024
Pulmonary complication 184 (8.41) 39 (16.4) 145 (7.4) 2.44 (1.66e3.57) < 0.0001
Pulmonary embolism 20 (0.91) 2 (0.8) 18 (0.9) 0.91 (0.21e3.94) 1.00
NOS, not otherwise specified; MI, myocardial infarction; DVT, deep-vein thrombosis.
Postoperative Outcomes hemorrhage (5.9%), cerebral artery occlusion (5.4%), and deep-
Postoperative outcomes are summarized in Table 4. Overall, the vein thrombosis (4.3%). Elderly patients generally displayed
30-day mortality rate was 0.86% (n ¼ 19). No significance differ- increased frequencies of complications compared with nonelderly
ence was detected in this rate for elderly versus nonelderly pa- patients. The risk of developing intracranial hemorrhage or
tients. Approximately 41.1% of all patients developed 1 or more hemiplegia/hemiparalysis was nearly 3 times as large in elderly
complications. Elderly patients had a complication rate of nearly patients. Likewise, the risk of developing postoperative delirium
55%, which was statistically significant compared with nonelderly was nearly 4 times as large.
patients (39%, P 0.0001). The overall rate of all cause 30-day
readmission was 15.5%, which did not differ significantly be- Multivariate Analysis
tween elderly and nonelderly patients. General neurosurgical, Using a stepwise logistic regression model, we examined age
neurologic, and pulmonary complications occurred in 4.4%, group, sex, and all previously identified comorbidities included in
16.1%, and 8.4% of patients, respectively. The most frequent in- Table 2 as predictor variables for the development of any
dividual complication measured was postoperative seizure, which complication, 30-day readmittance, general neurosurgical
occurred in 11.8% of patients. Other frequent complications complication, general neurologic complication, intracerebral
included postoperative dysrhythmia (7.9%), intracranial hemorrhage, cerebral artery occlusion, pulmonary complication,
5. Boviatsis EJ, Bouras TI, Kouyialis AT, Improvement Program. J Neurol Neurosurg Psy-
REFERENCES Themistocleous MS, Sakas DE. Impact of age on chiatr. 2010;81:502e505.
complications and outcome in meningioma sur-
1. Wiemels J, Wrensch M, Claus EB. Epidemiology
gery. Surg Neurol. 2007;68:407e411. 9. Poon MT, Fung LH, Pu JK, Leung GK. Outcome
and etiology of meningioma. J Neurooncol. 2010;9:
comparison between younger and older patients
307e314.
6. Grossman R, Mukherjee D, Chang DC, et al. undergoing intracranial meningioma resections.
Preoperative Charlson comorbidity score pre- J Neurooncol. 2013;114:219e227.
2. Vernooij MW, Ikram MA, Tanghe HL, et al. dicts postoperative outcomes among older intra-
Incidental findings on brain MRI in the general cranial meningioma patients. World Neurosurg.
10. Rogne SG, Konglund A, Meling TR, et al. Intra-
population. N Engl J Med. 2007;357:1821e1828. 2011;75:279e285. cranial tumor surgery in patients >70 years of age:
is clinical practice worthwhile or futile? Acta Neurol
3. Bartek J, Sjåvik K, Förander P, et al. Predictors of Scand. 2009;120:288e294.
7. Konglund A, Rogne SG, Lund-Johansen M,
severe complications in intracranial meningioma Scheie D, Helseth E, Meling TR. Outcome 11. Roser F, Ebner FH, Ritz R, Samii M, Tatagiba MS,
surgery: a population-based multicenter study. following surgery for intracranial meningiomas in Nakamura M. Management of skull based me-
World Neurosurg. 2015;83:673e678. the aging. Acta Neurol Scand. 2013;127:161e169. ningiomas in the elderly patient. J Clin Neurosci.
2007;14:224e228.
4. Bateman BT, Pile-Spellman J, Gutin PH, 8. Patil CG, Veeravagu A, Lad SP, Boakye M.
Berman MF. Meningioma resection in the elderly: Craniotomy for resection of meningioma in 12. Schul DB, Wolf S, Krammer MJ, Landscheidt JF,
nationwide inpatient sample, 1998-2002. Neuro- the elderly: a multicentre, prospective analysis Tomasino A, Lumenta CB. Meningioma surgery in
surgery. 2005;57:866e871. from the National Surgical Quality the elderly: outcome and validation of two
proposed grading scores systems. Neurosurgery. 17. Mahaley MS, Dudka L. The role of anticonvulsant 21. Sayegh ET, Fakurnejad S, Oh T, Bloch O, Parsa AT.
2011;70:555e565. medications in the management of patients with Anticonvulsant prophylaxis for brain tumor sur-
anaplastic gliomas. Surg Neurol. 1981;16:399e401. gery: determining the current best available evi-
13. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical dence. J Neurosurg. 2014;121:1139e1147.
comorbidity index for use with ICD-9-CM adminis- 18. Ramamurthi B, Ravi B, Ramachandran V. Con-
trative databases. J Clin Epidemiol. 1992;45:613e619. vulsions with meningiomas: incidence and sig-
nificance. Surg Neurol. 1980;14:415e416.
14. Elixhauser A, Steiner C, Harris DR, Coffey RM.
Comorbidity measures for use with administrative 19. Siomin V, Angelov L, Li L, Vogelbaum MA. Re-
data. Med Care. 1998;36:8e27. sults of a survey of neurosurgical practice patterns
regarding the prophylactic use of anti-epilepsy Received 10 July 2015; accepted 19 August 2015
15. Veeravagu A, Cole TS, Azad TD, Ratliff JK. drugs in patients with brain tumors. J Neurooncol.
Citation: World Neurosurg. (2015) 84, 6:1864-1870.
Improved capture of adverse events after spinal 2005;74:211e215.
surgery procedures with a longitudinal adminis- http://dx.doi.org/10.1016/j.wneu.2015.08.018
trative database. J Neurosurg Spine. 2015;23:374e382. 20. Kong X, Guan J, Yang Y, Li Y, Ma W, Wang R. Journal homepage: www.WORLDNEUROSURGERY.org
A meta-analysis: do prophylactic antiepileptic
Available online: www.sciencedirect.com
16. Foy PM, Copeland GP, Shaw MD. The incidence drugs in patients with brain tumors decrease the
of postoperative seizures. Acta Neurochir (Wien). incidence of seizures? Clin Neurol Neurosurg. 2015; 1878-8750/$ - see front matter ª 2015 Elsevier Inc.
1981;55:253e264. 134:98e103. All rights reserved.