Acta Neurochir (Wien) (2005) 147: 603–610

DOI 10.1007/s00701-005-0517-3

Clinical ArticleSurgical treatment of cerebellopontine angle meningiomasin elderly patients

M. Nakamura1, F. Roser2, M. Dormiani1, P. Vorkapic1, and M. Samii3

1 Department of Neurosurgery, Nordstadt Hospital, Teaching Hospital Hannover Medical School, Hannover, Germany2 Department of Neurosurgery, University of T€uubingen, T€uubingen, Germany3 International Neuroscience Institute, Hannover, Germany

Received August 23, 2004; accepted February 8, 2005; published online April 4, 2005

# Springer-Verlag 2005

Summary

Background. The aim of this study is to assess the morbidity and

mortality of meningioma surgery in patients over 70 years of age har-

bouring a tumour at the cerebellopontine angle as one representative

location of the posterior fossa in comparison with a matched group of

young patients.

Method. A retrospective analysis based on clinical charts, surgical

records, histological records, imaging studies and follow up records

was conducted to select patients over 70 years who underwent surgery

for cerebellopontine angle meningiomas. Tumours with comparable size

and location were matched with the younger group.

Findings. There were 421 meningiomas located in the cerebellopon-

tine angle, 21 patients were older than 70 years (range 70–84). Median

Karnofsky-Index at presentation was 80 (50–90), 16 patients had a

physical status grading ASA 2 and 5 patients ASA 3. The average

length of hospital stay was 22 days (7–99 days). The postoperative

median Karnofsky score at time of discharge was 80 (50–90). The most

common medical complication was postoperative pneumonia in 4

patients, among them 3 patients had lower cranial nerve disturbances

postoperatively. There were 56 younger patients (mean age 52.4 years;

range 24.5–69.75 years) with corresponding tumour size and location.

Pre-op Karnofsky score was 80 (70–90), 53 patients were graded as

ASA 2 and 3 patients as ASA 3. Length of hospital stay was 13.6 days

(8–32 days). Post-op Karnofsky score was 80 (50–90). Among 5 pa-

tients with postoperative lower cranial nerve disturbances no patient had

pneumonia postoperatively. There was no peri-operative mortality in

either group.

Conclusions. With modern neurosurgical techniques and neuro-

anesthesia elderly patients with CPA meningiomas can be operated

on with acceptable low morbidity and good neurological outcome

but recovery from surgery lasts longer compared to younger

patients. However, postoperative lower cranial nerve deficits in

elderly patients may not be well tolerated compared with younger

patients.

Keywords: Meningioma; cerebellopontine angle; elderly; geriatric.

Introduction

Meningiomas are common tumours accounting for

14–18% of intracranial neoplasms [6, 14]. Due to the

increasing life-expectancy and the general availability of

modern imaging techniques, neurosurgeons are now more

often faced with intracranial meningiomas diagnosed in

elderly patients. In the current literature, only few studies

have addressed the problem of treating elderly patients

harbouring intracranial meningiomas [1–5, 7, 10, 12, 13,

17, 18, 24]. Surgical mortality in elderly patients has been

reported to be as high as 55%. All reported surgical series

so far have investigated morbidity, mortality and prog-

nostic factors in intracranial meningiomas in various lo-

cations. Some authors have pointed out that outcome is

less favourable in elderly patients with meningiomas

located at the base of the skull, especially the posterior

fossa [1, 2, 4, 5, 20]. However, the numbers of elderly

patients harbouring skull base meningiomas, which were

analyzed in previous series were comparatively low. A

detailed comparison concerning the surgical outcome of

skull base meningiomas in different age groups was there-

fore not performed.

The aim of our study is to address the question,

whether the morbidity and mortality of surgery in elderly

patients harbouring a meningioma in the posterior fossa

differs from that observed in younger patients. As a large

number of cerebellopontine angle (CPA) meningiomas

were treated in our institution, these data, representing

one single comparable homogenous location in the pos-

terior fossa, allow us to statistically analyze the clinical

outcome in different age groups.

Patients and methods

A total of 1800 cases of meningiomas were operated on in the

Department of Neurosurgery, Nordstadt Hospital, Hannover between

1978–2002. Among them there were 421 meningiomas involving the

cerebellopontine angle.

A retrospective analysis based on clinical charts, surgical records,

histological records, imaging studies and follow up records was con-

ducted to select patients older than 70 years who underwent surgery of

cerebellopontine angle meningiomas. Tumours were classified into 5

groups according to their location in relation to the internal auditory

meatus (IAC) (Group 1, anterior to IAC; Group 2, involving IAC; Group

3; superior to IAC; Group 4, inferior to IAC; Group 5, posterior to IAC)

and the maximal tumour diameter was measured.

Tumours with comparable size and location were matched with the

younger group of patients. Patients with recurrent, atypical or anaplastic

tumours or associated neurofibromatosis type 2 were excluded.

The pre- and postoperative facial nerve function was examined ac-

cording to the House and Brackmann grading system [9]. Pre- and

postoperative hearing function was graded according to the Hannover

Audiological Classification in steps of 20 dB hearing loss, calculated

as the mean of air conduction data at 1, 1.5, 2, and 3 kHz in the PTA

(Class H1, good, 0–20 dB; H2, useful, 21–40 dB; H3, moderate,

41–60 dB; H4, poor, 61–80 dB; H5, functional deafness, >81 dB) [11].

The best speech discrimination score for each patient was classified

as normal (100–95%), useful (90–70%), moderate (65–40%), poor

(35–5%), or nonexistent (<5%).

The pre- and postoperative clinical status was quantified retrospec-

tively according to the Karnofsky rating scale and patient’s general

health condition according to the criteria of the American Society of

Anesthesiology (ASA Classification).

The extent of tumour resection was classified according to the Simpson

Classification [22]: Grade I – total tumour resection with excision of

infiltrated dura; Grade II – total tumour resection and coagulation of

dural attachments; Grade III – gross total tumour resection without

excising dural attachments or extradural extensions (e.g. infiltrated sinus

or bone); Grade IV – subtotal tumour resection.

Data of both age groups were compared using the chi-square test with

one degree of freedom (for comparison of percentages) and unpaired

t-test for comparison of two mean values. A p-value was calculated for

each comparison using two-tailed analysis with significance assumed at

the 0.05 level.

Results

Clinical features

21 patients with CPA meningiomas, who underwent

microsurgical resection in our hostpital were older than

70 years (mean 73.8 years; range 70–84). 56 younger

patients under the age of 70 (mean age 52.4 years; range

24.5–69.75 years) with corresponding tumour size and

location were matched from our surgical series of CPA

meningiomas (Figs. 1þ 2).

The most common presenting symptoms were hearing

loss and dizziness in both the elderly and the young

group. Headache was more frequently complained of

in younger patients. Unsteadiness was a more common

complaint among elderly patients (Table 1).

As expected, concomitant medical diseases were more

often encountered in elderly patients. Only thyroid dis-

eases were more commonly seen among younger patients

(Table 2).

Concerning the ASA Classification most patients in

both groups had only a mild systemic disease with no

Fig. 1. The different location of CPA menin-

giomas in relation to the internal auditory

meatus (ventral=dorsal to the IAC or involving

the IAC). Distribution of the number of

patients in both, older and younger age group,

is illustrated. The tumour size in both groups

was matched

604 M. Nakamura et al.

functional limitation (ASA Class 2), 76.2% in the

elderly and 94.6% in the young group (Table 3).

The median preoperative Karnofsky scale was 80 in

both, the elderly (ranging 50–90) and the young (rang-

ing 70–90) age group.

Surgery

For microsurgical tumour removal, the lateral suboc-

cipital retrosigmoid approach in the semi-sitting position

was performed in all patients of both groups. The surgi-

cal technique has been previously described in detail

[21]. Intraoperative neuromonitoring of the facial and

the cochlear nerve was available since 1986 and standard-

ized protocols were routinely used since 1990 (Medelec

limited, Surrey, England). The intracranial part of the

surgery was carried out under the operating microscope.

Among 56 young patients, 27 patients had CPA me-

ningiomas with �4 cm diameter, 10 patients with large

CPA meningiomas (�4 cm diameter) revealed an obstruc-

tive hydrocephalus in preoperative imaging. Among 21

older patients, 14 patients had large CPA meningiomas

with �4 cm diameter, 6 patients had signs of obstructive

hydrocephalus in preoperative imaging studies. Indepen-

dent of age, we have operated on the tumours first as the

primary procedure in all cases. Only 1 patient in each age

group required a secondary ventricular drainage due to

persistent symptomatic hydrocephalus (Table 4).

Total resection (Simpson Grade 1þ 2) was achieved in

18 patients (85.7%) in the elderly group and 50 patients

(89.3%) in the group of young patients. The difference

Fig. 2. The different location of CPA meningiomas in relation to the internal auditory meatus (superior or inferior to the IAC). Distribution of the

number of patients in both, older and younger age group, is illustrated. The tumour size in both groups was matched

Table 2. Concomitant diseases in elderly and young patients under-

going surgical resection of a CPA meningioma

Concomitant

diseases

Elderly (�70 years)

N¼ 21

Young (<70 years)

N¼ 56

Hypertension 8 (38%) 23 (41%)

Asthma=bronchitis 6 (28.6%) 7 (12.5%)

Cardiac arrhythmia 5 (23.8%) 1 (1.8%)

Cardiac insufficiency 4 (19%) 0

Gastrointestinal

disease

4 (19%) 2 (3.6%)

Coronary heart

disease

3 (14.3%) 3 (5.4%)

Diabetes mellitus 3 (14.3%) 1 (1.8%)

Thyroid disease 2 (9.5%) 10 (17.9%)

Table 3. ASA (American Society for Anesthesiology) classification in

elderly and young patients

ASA

classificaiton

Elderly (�70 years)

N¼ 21

Young (<70 years)

N¼ 56

I 0 0

II 16 (76.2%) 53 (94.6%)

III 5 (23.8%) 3 (5.4%)

IV 0 0

Table 1. Presenting symptoms in elderly and young patients harbouring

CPA meningiomas. Some patients had more than one symptom

Presenting

symptoms

and signs

Elderly (�70 years)

N¼ 21

Young (<70 years)

N¼ 56

Hearing loss 12 (57.1%) 23 (41%)

Unsteadiness 10 (47.6%) 8 (14.3%)

Dizziness 9 (42.9%) 31 (55.4%)

Tinnitus 5 (23.8%) 10 (17.9%)

Headache 5 (23.8%) 19 (33.9%)

Facial numbness 3 (14.3%) 8 (14.3%)

Dysphagia 2 (9.5%) 3 (5.4%)

Trigeminal

neuralgia

0 7 (12.5%)

Surgical treatment of cerebellopontine angle meningiomas in elderly patients 605

of resection grade between both groups was not statisti-

cally significant (p¼ 0.664).

Patients with residual tumour, regardless of age groups,

were observed with serial postoperative imaging studies.

No patient underwent postoperative radiotherapy. During

a mean follow up of 57.5 months (6–199 months), we did

not observe any recurrent tumour, which required a sec-

ond operation.

Facial and cochlear nerve function

In the elderly group (n¼ 21), 20 patients had pre-

operative normal facial nerve function and 1 patient a

mild paresis of House and Brackmann Grade 2 (H&B2).

Worsening of more than 1 H&B grade was observed in

1 patient (4.7%). In the young group (n¼ 56), 49 patients

had normal facial nerve function (H&B 1), 6 patients a

preoperative facial nerve paresis of H&B 2 and 1 patient a

paresis of H&B 3. In 4 patients, worsening of more than

1 H&B grade was observed (7.1%). Concerning auditory

function, 15 of 21 elderly patients presented with pre-

operative hearing of Class H1–4 (Hannover Audiological

Classification). Among them 14 patients had preservation

of hearing (Class H1–4) postoperatively (92.9%). In the

young group, 52 of 56 patients presented with preopera-

tive hearing of Class H1–4. Postoperative auditory func-

tion remained Class H1–4 in 49 patients (94.2%).

Morbidity and mortality

The most common surgical complication encountered

in both age groups was cerebrospinal fluid (CSF) fistula

with 9.5% in the elderly and 5.4% in the young group. All

patients with CSF fistula in the younger group required

a temporary lumbar drainage (5.4%) and 1 patient finally

underwent surgical revision (1.8%). Among the elderly

group only 1 patient needed a temporary lumbar drainage.

There was no statistically significant difference between

both age groups concerning the occurrence of CSF fistula

and its treatment. Also the complication rate concerning

postoperative hematoma, sinus thrombosis, ventricular

drainage or tracheotomy was not significantly different

among both groups (Table 4).

The most common medical complication after surgery

was pneumonia, which occurred in 4 patients (19%)

among elderly patients. No patient in the younger group

suffered from pneumonia. The difference was statistical-

ly significant (p¼ 0.0008). The incidence of other med-

ical complications was not significantly different among

both age groups (Table 5).

Among elderly patients who suffered from postop-

erative pneumonia (n¼ 4), 2 patients already noticed

dysphagia due to lower cranial nerve disturbance before

surgery. 1 patient additionally suffered from dysphagia

due to lower cranial nerve irritation after surgery. All 3

elderly patients with postoperative dysphagia developed

pneumonia. 1 patient developed postoperative pneumo-

nia without any concomitant lower cranial nerve deficit.

Although 6 patients (10.7%) among the younger group

had a postoperative dysphagia due to lower cranial nerve

disturbance, nobody suffered from pneumonia. 1 young

patient underwent tracheotomy due to severe symptoms

of postoperative lower cranial nerve deficit (Table 6).

Table 4. Surgical complications in elderly and young patients

Surgical complications Elderly

(�70 years)

N¼ 21

Young

(<70 years)

N¼ 56

CSF fistula (p¼ 0.509) 2 (9.5%) 3 (5.4%)

Lumbar drainage (p¼ 0.917) 1 (4.8%) 3 (5.4%)

Surgical revision due to CSF

fistula (p¼ 0.538)

0 1 (1.8%)

Postop hematoma (p¼ 0.465) 1 (4.8%) 1 (1.8%)

Ventricular drainage (p¼ 0.465) 1 (4.8%) 1 (1.8%)

Sinus thrombosis (p¼ 0.538) 0 1 (1.8%)

Tracheotomy (p¼ 0.538) 0 1 (1.8%)

Table 5. Medical complications in elderly and young patients

Medical complications Elderly (�70 years)

N¼ 21

Young (<70 years)

N¼ 56

Pneumonia

(p¼ 0.0008)

4 (19%) 0

Duodenal ulcer

(with surgery)

(p¼ 0.1002)

1 (4.8%) 0

Gastritis (p¼ 0.538) 0 1 (1.8%)

Urinary tract infection

(p¼ 0.1002)

1 (4.8%) 0

Table 6. Incidence of pre- and postoperative dysphagia and subsequent

pneumonia in elderly and young patients. Tracheotomy due to dyspha-

gia was performed in 1 patient of the younger group

Dysphagia

and pneumonia

Elderly (�70 years)

N¼ 21

Young (<70 years)

N¼ 56

Dysphagia (preop)

(p¼ 0.509)

2 (9.5%) 3 (5.35%)

Dysphagia (postop)

(p¼ 0.664)

3 (14.3%) 6 (10.7%)

Pneumonia (postop)

(p¼ 0.0008)

4 (19%) 0

Tracheotomy 0 1 (1.8%)

606 M. Nakamura et al.

The mean duration of hospital stay after surgery was

21.95 days (7–99 days) in elderly patients and 13.64

days (8–32 days) in younger patients. This difference

was not statistically significant (p¼ 0.124).

There was no peri-operative mortality in either group.

The median Karnofsky scale at time of discharge from

hospital was 80 (50–90) in elderly patients and 80

(50–90) in the younger. Median Karnofsky scale on long-

term follow up was 90 (70–100) in the elderly group

after a mean follow up time of 57.5 months (6–192

months). In the younger group, median Karnofsky scale

on long-term follow up was 85 (70–100) after a mean

follow up time of 53 months (6–199 months). This mini-

mal difference was not significant (p¼ 0.734).

Discussion

With increasing life expectancy in the industrial na-

tions and readily available modern imaging techniques,

an increasing number of elderly patients are diagnosed

with intracranial meningiomas. A rising number of el-

derly patients with intracranial meningiomas have been

operated on in recent years and few surgical series were

reported in the literature.

Reported mortality rates in previous series were quite

different. Papo [18] in 1983, was the first to present a

series of elderly patients with intracranial meningiomas.

He reported a steep increase of postoperative complica-

tions and mortality in patients over the age of 65 with a

mortality rate of 55%. Reported 30 days mortality rates

were lower in later years with 1.8% in the series of

Black et al. [3], 2.2% in Maurice-Williams’ series [12],

3.6% in the report of McGrail and Ojemann [13], 5.4%

[24], 7.6% in the series of Buhl et al. [4], 8% in Awad’s

series [2], 12% in the report of Arienta et al. [1], 13% in

Nishizaki’s report [17], 14% in Gijtenbeek’s report, 16%

in Cornu’s series [5], 23% in Djindjian’s series [7] and

29% in Mastronardi’s series [10]. Elderly patients were

regarded as those with ages over 60 [8], 65 [3, 5, 12, 18],

70 [1, 2, 7, 13, 17] or 80 years [10]. Additionally, it has to

be mentioned that the patient population among previous

studies were sometimes not comparable, as for instance

21% of patients from Awad’s series was asymptomatic,

whereas nearly all patients in the series of Papo,

Djindjian and Cornu had some neurological symptoms.

This may partly explain the differences among previ-

ously reported mortality rates.

Papo [18] stated that surgery of intracranial menin-

giomas in geriatric patients over 65 still remains a tre-

mendous challenge despite all the advances in operative

technique, neuro-anesthesia and intensive care. Due to

the poor results, the author suggested that the surgical

indications in these patients be carefully evaluated and

that conservative management might be preferred.

Later studies have emphasized that good surgical out-

come is related rather to the preoperative neurological

and clinical condition of the patient, regardless of the

age [1, 2, 5, 7, 8, 10, 12, 17, 20, 24]. Djindjian et al. [7]

preferred surgery for meningioma in the elderly when

the Karnofsky rating scale is �50 and the physiological

condition for anaesthesia is good enough (ASA 1 or 2).

Arienta et al. [1] pointed out, that surgical indications

for treatment of meningiomas in elderly patients should

be restricted to patients in good general condition

proposing a Clinical-Radiological Grading System.

Umansky et al. [24] reported that those patients with a

low Karnofsky scale (<40) on admission present a more

complicated postoperative course than those who were

in good physical condition before surgery. Mastronardi

et al. [10] recommended to attempt total removal of

intracranial meningiomas even in very old patients

(more than 80 years) if the preoperative ASA Classifica-

tion is 1 or 2 and if the Karnofsky rating scale is �70.

Results concerning the prognostic relevance of ra-

diological factors like peritumoural edema and tumour

size were controversial. Some authors mentioned the

presence of peritumoural edema as a predictor of poor

outcome in elderly patients [1, 4, 7, 10], whereas others

did not find any relationship between edema and unfa-

vourable outcome [5, 18, 20]. Tumour size has been

considered as a predictive factor for postoperative out-

come by some authors [1, 4, 10]. Although in other

reports, tumour size did not have any significant influ-

ence on surgical morbidity [5, 8, 20].

It is generally assumed that elderly patients will not

tolerate a long surgical procedure as well as a younger

patient and few studies have emphasized the relevance of

duration of surgery on postoperative outcome [1, 4, 20]

but Umansky et al. did not reveal any correlation [24].

Some authors have pointed out that outcome is less

favourable in elderly patients with meningiomas located

at the base of the skull, especially the posterior fossa

[1, 2, 4, 5, 20]. Cornu et al. [5] reported that elderly pa-

tients with a tumour located on the base or posterior

fossa had a relative risk of poor outcome of 3.27 fold by

comparison with patients with tumours at other locations.

Arienta et al. [1] emphasized that location of the tumour

is one of the determining factors for the duration of

surgery and therefore indirectly affects mortality; since

skull base or posterior fossa meningiomas lead to longer

Surgical treatment of cerebellopontine angle meningiomas in elderly patients 607

surgery and higher mortality rates in elderly patients. We

have compared the surgical outcome of a meningioma in

the posterior fossa (namely CPA meningioma as one

homogenous entity of a posterior fossa meningioma)

in both elderly and younger patients and did not find

any difference concerning surgical complications, mor-

bidity, resection rate of the tumour or postoperative clin-

ical status between both age groups. The length of

hospital stay was longer in elderly patients but the dif-

ference was not significant. There was no mortality in

either groups. Postoperative pneumonia was the only

medical complication, which was significantly more fre-

quent in elderly patients. Elderly patients with post-

operative dysphagia due to temporary disturbance of

lower cranial nerves had a higher risk of developing

pneumonia due to aspiration. Postoperative dysphagia

and lower cranial nerve deficit seem to be better toler-

ated in younger patients. It has to be remarked, that we

did not perform surgery on patients in poor preoperative

general health (ASA 4 or 5); therefore our results are

limited to patients with ASA Class 1–3 in both elderly

and younger patients. Previous studies [1, 2, 5, 7, 8, 10,

12, 17, 20, 24] have clearly shown that operative mor-

bidity and mortality in surgery of intracranial menin-

gioma is unacceptably high in patients with severe

systemic disease with constant threat to life or in mor-

ibund patients (ASA 4þ 5). We generally do not recom-

mend surgery in these patients, unless the tumour itself

is regarded to be the cause of the poor preoperative

clinical status.

Although our results show, that surgery of a menin-

gioma at the cerebellopontine angle in elderly patients is

not per se associated with higher morbidity and mor-

tality, results need to be considered in comparison with

other treatment options such as close observation or

radiosurgery.

One argument favouring meningioma surgery even in

elderly patients (presuming good general medical con-

dition) is based on the observation, that all intracranial

meningiomas show some tumour growth even in ad-

vanced age. We have recently analyzed the natural

history of intracranial incidental meningiomas with

volumetric measurements and noticed that all intra-

cranial meningiomas show tumour growth after serial

radiological follow up. The tumour growth rate in older

patients was lower when compared with younger pa-

tients but no tumour was stable in size even in elderly

patients [15]. To our knowledge, the natural history of

cerebellopontine angle meningiomas in particular has

not been investigated in the past but analysis of tumour

growth rates in petroclival meningiomas revealed even

rapid growth spurts more frequently among small and

medium-sized tumours [25]. We therefore recommend

surgery in elderly patients in good general medial con-

dition harbouring cerebellopontine angle meningiomas

of even small or medium size, when the tumour has be-

come symptomatic.

Radiosurgery has been increasingly proposed as a

primary therapeutic option where the patients’ medical

condition, age or difficult tumour location precludes him

being considered as a candidate for surgery. Subach et al.

[23] reported on a series of 62 patients with petroclival

meningiomas treated by stereotactic radiosurgery (23

cases as a primary treatment). During a follow up period

of 38 months tumour volumes decreased in 14 patients

(23%), remained stable in 42 patients (68%), but in-

creased in 5 patients (8%). Nicolato et al. [16] presented

a series of 62 patients with posterior fossa meningiomas

treated by gamma knife radiosurgery as a primary as

well as an adjuvant therapy. With a follow up period

of 29 months, tumour mass reduction or stable tumours

were observed in 95% of cases, there was tumour pro-

gression in 5% of cases. The death of 2 patients was

associated with tumour progression. Just recently,

Pollock et al. [19] presented a series of 16 patients har-

bouring meningiomas of the CPA extending into the

internal auditory meatus treated primarily by stereotactic

radiosurgery. The median follow-up was 36 months. Ten

meningiomas (63%) decreased in size, and 6 tumours

were unchanged. No patient developed facial weakness

but one patient (6%) had worsened facial sensation. The

1-, 2- and 5-year actuarial incidences of hearing preser-

vation were 93, 84 and 42%.

In summary, radiosurgical series treating posterior

fossa meningiomas showed tumour control (stable or

decrease in tumour size) in the majority but tumour

progression was also observed (5–8%). Concerning the

neurological status, results of posterior fossa meningio-

mas in general [16] or petroclival meningiomas [23]

treated by radiosurgery cannot be directly compared

with our presented microsurgical series of CPA menin-

giomas due to differing tumour location. Although, com-

parison with the radiosurgical series of Pollock et al.

[19] reveals a higher rate of hearing preservation in

patients treated with microsurgery, especially on long-

term follow up. Obviously, the objective of radiosurgery

differs essentially from that of microsurgery, as the goal

is prevention of tumour progression instead of cytore-

duction, which is achieved by microsurgery and there-

fore we still advocate microsurgical resection of CPA

608 M. Nakamura et al.

meningiomas even in elderly patients (presuming good

medical condition) as the risks of postoperative cranial

nerve deficits are comparable and complication rates are

within an acceptable range. In patients with a critical

general medical condition, who are considered as high

risk candidates for surgery, radiosurgery presents a good

treatment option.

Conclusion

With modern neurosurgical techniques, neuromonitor-

ing and neuro-anesthesia, elderly patients with CPA

meningiomas (ASA Class 1–3) can be operated on with

low morbidity and good neurological outcome, which is

comparable to results in younger patients. However,

postoperative lower cranial nerve deficits in elderly pa-

tients may not be well tolerated compared to younger

patients. Aspiration pneumonia due to postoperative

temporary postoperative dysphagia was the single med-

ical complication more frequently observed in the el-

derly group. Careful monitoring of postoperative lower

cranial nerve deficits is essential to avoid aspiration and

in rare cases tracheotomy should be considered when

deficit persists to prevent further complications.

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Comments

The authors ought to be congratulated with the superior results

obtained in the surgery of both young and elderly patients with a

cerebellopontine angle meningioma. They have proven their point that

this type of surgery can be safe even in elderly patients convincingly.

The same has been shown for vestibulair schwannoma surgery [1, 2].

The elderly age group, however, is relatively small which, according to

my opinion, precludes any definite conclusions with regard to more

rarely occurring complications such as perioperative mortality and seri-

ous morbidity.

Unfortunately, in this series, hearing preservation is defined as the

preservation of hearing of any level including moderate and poor hear-

ing. No information is provided on whether the hearing was preserved

within the same hearing class. In my opinion, the term hearing preserva-

tion should be used for a postoperative hearing level which is con-

sidered to be useful for the patients and this is already subject of much

controversy.

Surgical treatment of cerebellopontine angle meningiomas in elderly patients 609

The tumour sizes in the elderly patients varied from 2–6 cms. In the

patients with the smaller tumours radiosurgery or stereotactic radiother-

apy would have been an alternative option provided that there were no

tumour symptoms other than cochleo=vestibular symptoms. The argu-

ment provided by the authors in favour of microsurgery is that cytore-

duction is to be preferred to tumour control. In my opinion, this

argument does not hold as the ultimate goal of treatment is to keep

the patient symptom free for the rest of their life. If microsurgery and

radiosurgery would be equally effective and the complication rates

comparable, then radiosurgery would be the better option, as it is more

patient friendly and less costly.

The authors do not provide detailed information on the follow-

up of their patients. The statement that no recurrent tumour which

required second surgery was observed is somewhat ambiguous. If

there was any recurrent tumour, it may require surgery in the

future. Skull base meningiomas carry a substantial risk of recur-

rence even after complete resection. In Mirimanoff’ series the prob-

ability of needing a second surgery following a subtotal excision

after five, ten and fifteen years was 25%, 44% and 84%, respec-

tively [3]. A clinical trial, co-ordinated by the EORTC, has been

recently started comparing observation versus conventional fractio-

nated radiotherapy or radiosurgery after non-radical surgery for

benign meningiomas.

References

1. House JW, Nissen RL, Hitselberger WE (1987) Acoustic tumour

management in senior citizens. Laryngoscope 97(2): 129–130

2. Pulec JL, Giannotta SL (1995) Acoustic neuroma surgery in patients

over 65 years of age. Ear Nose Throat J 74(1): 21–27

3. Mirimanoff RO, Dosoretz DE, Linggood RM, Ojemann RG, Martuza

RL (1985) Meningioma: analysis of recurrence and progression

following neurosurgical resection. J Neurosurg 62: 18–24

C. J. J. Avezaat

Rotterdam

We think that this is an impressive series of 421 meningiomas of the

cerebellopontine angle of which 21 were older than 70 years. Because of

the increasing number of elderly patients there is a major relevance of

publications concerning the results of surgery in those patients.

V. Seifert and M. Setzer

Frankfurt

Correspondence: Makoto Nakamura, Department of Neurosurgery,

Nordstadt Hospital, Teaching Hospital Hannover Medical School,

Haltenhoffstr. 41, 30167 Hannover, Germany. e-mail: mnakamura@web.de

610 M. Nakamura et al.: Surgical treatment of cerebellopontine angle meningiomas in elderly patients