Kliničke manifestacije i metode pretraga u dijagnozi kalcifikata

Notes
ganglia calciication. Mov Disord 2007; 22:1027-30.
19. Saito T, Nakamura M, Shimizu T, Oda K, Ishiwata
K, Ishii K, Isse K. Neuroradiologic evidence of presynaptic and post-synaptic nigrostriatal dopaminergic
dysfunction in idiopathic Basal Ganglia calciication:
a case report. J Neuroimaging 2010; 20:189-91.
20. Paschali A, Lakiotis V, Messinis L, Markaki E, Constantoyannis C, Ellul J, Vassilakos P. Dopamine transporter SPECT/CT and perfusion brain SPECT Imaging in idiopathic basal ganglia calcinosis. Clin Nucl
Med 2009; 37:421-23.
21. Le Ber I, Marie RM, Chabot B, Lalevee C, Defer GL.
Neuropsychological and 18FDG- PET studies in a
family with idiopathic basal ganglia calciications. J
Neurol Sci 2007; 258:115-22.
22. Paghera B, Caobelli F, Giubbini R. 123I- Iolupane SPŠECT in Fahr Disease. J Neuroimaging. Doi:
10.1111/j.1552-6569.2011.00581.x
Kliničke manifestacije i metode pretraga
u dijagnozi kalcifikata bazalnih ganglija
Ivanka Štenc Bradvica , Davor Jančuljak , Silva
Butković-Soldo1, Ivan Mihaljević2, Mirjana
Vladetić1, Mario Bradvica 3
1
1
Klinika za neurologiju, 2Zavod za nuklearnu medicinu i zaštitu
od zračenja, 3Odjel za očne bolesti; Klinički bolnički centar u
Osijeku, Osijek, Hrvatska
1
SAŽETAK
Cilj ovog rada je evaluirati kliničke simptome u
bolesnika s kalciikatima u bazalnim ganglijima i
usporediti različite dijagnostičke metode u potvrdi ovog stanja. Klinički smo pregledali i učinili
transkranijsku sonograiju svim bolesnicima kojima su kompjuteriziranom tomograijom dokazani kalciikati u bazalnim ganglijima. U jednog
od ovih bolesnika učinjen je i DaTSCAN. Utvrđen je širok raspon kliničkih znakova. Transkranijskom sonograijom bazalnih ganglija utvrđena
je hiperehogenost nucleus lenticularis u osam od
deset bolesnika. U jednog je bolesnika utvrđena
hiperehogenost substantia nigra, te je indiciran
DaTSCAN koji je bio uredan. Uz već postojeće
i ispitane dijagnostičke metode, kao što je kompjuterizirana tomograija mozga, transkranijska
sonograija je novija, korisna, neinvazivna i jednostavna metoda pretrage, koja može pridonijeti
detekciji kalciikata u području bazalnih ganglija
u bolesnika s različitim neurološkim simptomima. Kompjuterizirana tomograija mozga i nadalje ostaje najadekvatnija metoda pretrage u vizualizaciji kalciikata.
Ključne riječi: kalciikati bazalnih ganglija,
nucleus lenticularis, DaTSCAN, transkranijska
sonograija
NOTES
Intracranial meningeoma -ten-year
evaluation
Harun Brkić, Mirsad Hodžić, Mirza Moranjkić
Neurosurgical Department, University Clinical Center in Tuzla,
Bosnia and Herzegovina
Corresponding author: Brkić Harun; Neurosurgical Clinic,
University Clinical Center of Tuzla; Trnovac b.b. 75000 Tuzla,
Bosnia and Herzegovina; Phone +387 35 2303 245; +387 61
148 422; E-mail: harunbrkic@gmail.com
Original submission: 10 April 2012; Revised submission: 14
June 2012; Accepted: 17 September 2012.
Med Glas Ljek komore Zenicko-doboj kantona 2013; 10(1):157-160
ABSTRACT
The aim of the study was to analyze the prevalence, occurrence by gender, age, place of residence,
location and pathohistological type, focusing on
peculiarities of the surgically removed meningiomas in the irst post-war decade in Bosnia and
Herzegovina. The study was conducted in the region comprising more than 600.000 inhabitants.
During the post-war decade 162 patients were
surgically treated. Females accounted for 65.4%,
convexity meningioma accounted for 43.8%.
WHO grade I meningiomas occurred in majority
of patients, 60.5%, grade II in 23.5%, and grade III in 16.0% patients. The prevalence of malignant menigeomas was signiicantly higher in
males, 26.8%. Meningiomas were more common
during the sixth (33.9%) and seventh (35.2%) decade of life. The somewhat higher prevalence of
atypical and malignant meningiomas especially
in males requires further analysis that would clarify this phenomenon.
Key words: peculiarities, atypical, malignant
INTRODUCTION
Meningiomas are a diverse set of tumors arising
from the arachnoid layers surrounding the central nervous system. A comprehensive analysis
of meningiomas in a single paper is utterly impossible. The distribution of primary meningiomas and incidence of occurrence were previously
analyzed by gender, age, geographic, national
and other epidemiological characteristics (1-3).
The incidence of clinically signiicant meningiomas is approximately 2.3/100,000 population,
157
Medicinski Glasnik, Volume 10, Number 1, February 2013
and about 5.5/100,000 population when autopsy data are included . They occur most often in
women between 30 and 50 years of age (2,3).
Meningiomas occur in children, yet they are
exceedingly rare, accounting for only 1–4% of
all brain tumors in patients less than18 years old
(4). Furthermore, pediatric meningiomas account
for only 1.5–1.8% of all intracranial meningiomas (1,5,6,7). It should be noted that these incidence data encompass only those patients with
meningiomas that cause neurological symptoms
leading to clinical diagnosis and treatment (6).
Studies relating to characteristics and incidence
of intracranial meningeoma have not been published in Bosnia and Herzegovina yet.
The aim of this study was to analyze the incidence
of meningioma occurrence by gender, age, place
of residence, meningeoma location and pathohistological type, focusing on peculiarities possibly
as a result of war activities.
PATIENTS AND METHODS
The study was conducted in a tertiary neurosurgical service located in a densely populated region in Bosnia and Herzegovina with more than
600.000 inhabitants. Medical records of all patients surgically treated for intracranial meningeoma at the Department of Neurosurgery, University Clinical Center of Tuzla during the irst
post-war decade (1997-2007) were reviewed.
This retrospective study was performed on 162
patients. It analyzed the incidence of meningioma occurrence by gender, age, place of residence,
meningeoma location and pathohistological type,
focusing on peculiarities possibly as a result war
activities.
The results are presented depending on the localization of meningiomas on the convexity, lax,
supratentorial skull base, middle structures and
posterior fossae. Pathohistologocal analysis has
been presented according to the WHO classiication, grade I, II and III in both sexes (8).
Menigioma were classiied as atypical when
presented with two or more of the following
features: the presence of large cells, the growth
tendency in the “sheet”, highlighted nucleoli, mitotic igures, presence of small cells and the loss
of a typical layout. Malignant meningioma additionally included focal necrosis, polymorphism,
and invasion of brain. Mann-Whitney and T tests
158
were used to determine a statistically signiicant
difference between the groups (P<0.05).
RESULTS
In the period 1997-2007 162 patients with intracranial meningeoma were surgically treated at the
Department of Neurosurgery, University Clinical
Center of Tuzla. There were 106 (65.4%) females
and 56 (34.6%) males. The female to male ratio
was 1-1.8.
Mean age at the irst presentation of meningeoma
for females was 56.6 years (ranging from 14 to
74) and for males 52.7 years (ranging from 24 to
73) (p = 0.44). Six patients (3.7%) were younger
than 30 (Table 1).
Table 1. Gender and age distribution of patients
No (%) of patients
Age (years)
0-20
21-30
31-40
41-50
51-60
61-70
71Total
Males
Females
Total
3 (5.4)
1 (1.8)
6 (10.7)
6 (10.7)
17 (30.4)
20 (35.6)
3 (5.4)
56 (34.6)
0
2 (1.9)
7 (6.6)
17 (16.1)
38 (35.8)
37 (34.9)
5 (4.7)
106 (65.4)
3 (1.9)
3 (1.9)
13 (8.2)
23 (14.0)
55 (33.9)
57 (35.2)
8 (4.9)
162
The most frequent meningioma location in both
sexes was convexity of the brain, in 71 (43.8%)
patients. Fourteen patients (8.7%) harbored meningioma in the posterior cranial fossa and only
four patients (2,5%) were with arising meningioma from midline structures (Table 2).
Table 2 . Meningeomas by location
Gender
Males
Females
Total
Falx
No (%) of patients
Cranial
Post.
Convexity
base
fossa
12 (21.4) 23 (41.1)
19 (17.8) 48 (45.4)
31 (19.1) 71 43.8)
14 (25)
28 (26.5)
42 (25.9)
4 (7.2)
10 (9.4)
14 (8.7)
Midline
structures
3 (5.3)
1 (0.9)
4 (2.5)
In our series there were 98 (60.5%) patients
with grade I meningiomas, 38 (23.5%) with
grade II, and 26 (16%) patients with grade III
meningioma. Furthermore, in the grade I group
tumors meningiothelial meningiomas accounted
for 49.0% (56), followed by ibrous, 16.3% (16),
psammomatous, 16.3% (16) and angiomatous,
11.2% (11) subtypes.
Atypical meningiomas were found in males
28.6.% (16), compared to 20.8% (22) in females
(P=0.044). The malignant menigioma occurred in
26.8% (15) of males and 10.3% (11) of females
Notes
(P=0.032) (Table 3). We found falx meningioma
in 19.1% (31) patients, of whom 35.8% (11) were
atypical (grade II) and 19.4% (6) were malignant
(P=0.033). Other localizations of meningioma
did not show statistically signiicant difference in
atypical as compared to malignant meningioma
(P>0.05) (Table 3).
Analysis of occurrence in relation to the region of
residence did not show signiicant differences in
incidence of meningiomas in relation to the region of residence.
Table 3. Tumor grade according to WHO classification
Gender/Grade
Males
Females
Localization/Grade
Falx
Convexity
Cranial base
Posterior fossa
Midline structures
Total
No (%) of patients
Grade I Gade II Grade III
Total
25 (44.6) 16 (28.6) 15 (26.8) 56 (34.6)
73 (68.9) 22 (20.8) 11 (10.3) 106 (65.4)
14 (36.8) 11 (35.8) 6 (19.4)
42 (59.2) 17 (23.9) 12 (16.9)
27 (64.3) 8 (19.1) 7 (16.6)
11 (78.7) 2 (14.2)
1 (7.1)
4 (100)
0
0
98 (60.5) 38 (23.5) 26 (16.0)
31 (19.1)
71 (43.8)
42 (25.9)
14 (8.7)
4 (2.5)
162
DISCUSSION
Our data indicate that meningiomas are most common in the sixth and seventh decades of life.
The fact remains that meningiomas can occur in
all age groups and that there is a tendency towards a more aggressive behavior in younger age
groups. Our study encompassed male patients
younger than 20 harboring two malignant and
one atypical meningioma. The youngest patient
was thirteen years old. Other reports suggest
that proliferative indices of meningiomas in young people tend to have higher values than proliferative indices in elderly (9,18). Atypical and
anaplastic meningiomas may show a signiicant
predominance in males (2,3,10,11).
The female to male ratio in the present study
was similar to the previously published studies
by several other authors (12,13). Prevalence of
women among our patients with meningiomas
suggests the role of gender hormones in the
pathogenesis of these tumors. While the level
of estrogen receptors is low or undetectable in
most meningiomas, approximately two-thirds
of meningiomas express progesterone receptors
with particularly high values in women. It is
alleged that presence of progesterone receptors
in meningiomas presents a favorable prognostic
factor (14,16). Al Mefty and colleges classiied
meningiomas as either falx/parasagittal (25%),
convexity (19%), skull base (sphenoid ridge, suprasellar, olfactory groove) ( 34%) and posterior
fossa meningiomas (10%) (2). The location of
these lesions is quite important as it is one of
the factors that will determine prognosis, since
the recurrence is a major consideration in lesions which are incompletely excised, even if the
lesion has a benign histology. Our data reveal
signiicantly larger proportion of convexity meningiomas (43.8%).
There are several criteria that were set out by the
WHO in 1993 and revised in 1999 in Lyon, that
constitute a relatively accurate grading scheme
for meningiomas (17). According to the WHO
classiication even grade I meningiomas, which
show brain invasion histologically, will tend to
have a clinical course similar to an atypical (grade II) meningioma. It is therefore very unfortunate that no brain tissue was obtained from our
patients at the time of resection for pathological
assessment of brain invasion. Hystopataological
deinition of atypical meningioma includes an
analysis of mitosis, cellularity, ratio of nucleus/
cytoplasm and/or visible nucleoli, uninterrupted
appearance of squamous growth (U.S. sheet-like) and focuses of “spontaneous” or “geographical” necrosis (19). Malignant meningioma is
deined by histological features of frank malignancy, with the histological abnormalities present to a severely greater extent as compared to
the atypical meningioma (19). Previous reports
suggest that atypical and malignant variants are
present in only 6-10% of patients (9,17), whereas our data indicate a far greater proportion
of malignant and atypical meningiomas (23.5%
and 16.1% for atypical and malignant meningiomas, respectively). Furthermore, we found a
much higher prevalence of atypical and malignant meningiomas among male as compared to
female patients.
Potential factors contributing to this apparently
higher proportion of malignant and atypical meningioma variants could be related to the fact
that our study encompassed a post-war time period. We assume that males were readily exposed to various toxic compounds contained
in weapons of mass destruction. An analysis of
potential causal factors requires further studies.
Other potential contributing factors could be re-
159
Medicinski Glasnik, Volume 10, Number 1, February 2013
lated to NATO activities that were conducted at
the time, socioeconomic status or migration of
the population.
FUNDING
No speciic funding was received for this study.
TRANSPARENCY DECLARATIONS
Competing interests: none to declare.
REFERENCES
1. Wiemels J, Wrensch M, Claus EB. Epidemiology and
etiology of meningioma. J Neurooncol 2010; 99:307.
2. Haddad G, AL-Mefty O. Meningiomas: an overview.
In: Wilkins RH, Rengachary SS, editors. Neurosurgery. New York: McGraw-Hill, 1996: 833–41.
3. Buckner JC, Brown PD, O’Neill BP, Meyer FB, Wetmore CJ, Uhm JH. Central nervous system tumors.
Mayo Clin Proc 2007; 82:1271-86.
4. Alexiou GA, Mpairamidis E, Psarros A, Sfakianos G,
Prodromou N. Intracranial Meningiomas in Children.
Pediatr Neurosurg 2008; 44:373-5.
5. Ersahin A, Ozdamar N, Demirtas E, Karabiyikoglu
M. Meningioma of the cavernous sinus in a child.
Childs Nerv Syst 1999; 15:8–10.
6. Rubin G, Herscovici Z, Laviv Y, Jackson S, Rappaport ZH. Outcome of untreated meningiomas. Isr Med
Assoc J 2011; 13:157-60.
7. Giangaspero F, Guiducci A, Lenz FA, Mastronardi L,
Burger PC. Meningioma with meningoangiomatosis:
a condition mimicking invasive meningiomas in children and young adults: report of two cases and review
of the literature. Am J Surg Pathol 1999; 23:872–5.
8. Louis DN, Ohgaki H, Wiestler OD, Cavenee WK,
Burger PC, Jouvet A, Scheithauer BW, Kleihues P.
The 2007 WHO Classiication of Tumours of the
Central Nervous System. Acta Neuropathol 2007;
114:97–109.
9. Kleihues P, Cavenee WK. Pathology and genetics of
tumours of the nervous system. Lyon: International
agency for research on cancer (IARC Press), 1997,
134-41.
10. Smith SJ, Boddu S, Macarthur DC: Atypical meningiomas: WHO moved the goalposts? Br J Neurosurg
2007; 21:588-92.
11. Younis GA, Sawaya R, De Monte F, Hess KR, Albrecht S, Bruner JM. Aggressive meningeal tumors:
review of a series. J Neurosurg 1995; 82:17-27.
12. Rogers L, Gilbert M, Vogelbaum MA. Intracranial
meningiomas of atypical (WHO grade II) histology.
J Neurooncol 2010; 99:393.
13. Staneczek W, Janisch W. Epidemiologic data on meningiomas in East Germany 1961-1986: incidence,
localization, age and sex distribution. Clin Neuropathol 1992; 11:135-41.
14. Caroll RS, Zhang MS, Dashner K. Progesterone and
glucocorticoid receptor activation in meningiomas.
Neurosurgery 1995; 37:92-7.
160
15. F Roser, M Nakamura, M Bellinzona, S K Rosahl,
H Ostertag, M Samii. The prognostic value of progesterone receptor status in meningiomas. J Clin Pathol
2004; 57:1033-7.
16. Nagashima G, Aoyagi M, Wakimoto H, Tamaki M,
Ohno K, Hirakawa K. Immunohistochemical detection of progesterone receptors and the correlation with
Ki-67 labeling indices in parain-embedded sections
of meningeomas. Neurosurgery 1995; 37:478-83.
17. Louis DN, Scheithauer BW, Budka H, von Deimling
A, Kepes JJ. Meningiomas. In: Pathology & Genetics: Tumors of the Nervous system. World Health
Organization Classiication of Tumors. Lyon, France:
IARC Press; 2000, 176-84.
18. Shah AB, Muzumadar GA, Chitale AR. Meningeomas: report of a hospital-based registry. Indian J Pathol Microbiol 2005; 48:468-71.
19. Riemenschneider MJ, Perry A, Reifenberger G. Histological classiication and molecular genetics of
meningiomas. Lancet Neurol 2006; 5:1045-54.
Intrakranijalni meningeomi –
desetogodišnja evaluacija
Harun Brkić, Mirsad Hodžić, Mirza Moranjkić
Klinika za neurohirurgiju, Univerzitetski klinički centar Tuzla,
Bosna i Hercegovina
SAŽETAK
Cilj istraživanja je analiza osobitosti slučajâ operativno liječenih pacijenata s intrakranijalnim meningeomima u prvom poslijeratnom desetljeću u
Bosni i Hercegovini, koje je provedeno u regiji
od 600.000 stanovnika. Analizirali smo incidencu
prema spolu, dobi, patohistološkom tipu, s eventualnom osobitošću slučajâ na posljedice ratnih
djelovanja. Ukupno su 162 bolesnika s intrakranijalnim meningeomom operativno liječena, od
toga 65,4% žena; lokalizacija na konveksitetu
mozga bila je zastupljena kod 43,8% pacijenata.
Prema klasiikaciji WHO-a gradus I bio je zastupljen kod 60,5% pacijenata, gradus II kod 23,5% i
gradus III kod 16% bolesnika. Incidencija zloćudnih meningeoma bila je značajno viša u muškaraca (26,8%). Najučestalija pojava bila je u šestoj
(33,9%) i sedmoj (35,2%) dekadi života. Nešto
veća učestalost atipičnih i malignih meningeoma,
pogotovo kod muškog spola, zahtijeva daljnju
analizu koja bi pojasnila ovaj fenomen.
Ključne riječi: speciičnost, atipični, zloćudni