Epilepsy Research 38 (2000) 45 52

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Intracranial meningiomas and epilepsy: incidence, prognosis

and influencing factors
Ann-Shung Lieu, Shen-Long Howng *
Department of Neurosurgery, Kaohsiung Medical College Hospital, No. 100, Shih-Chuan 1st Road, Kaohsiung City 807, Taiwan,
ROC
Received 15 January 1999; received in revised form 15 June 1999; accepted 20 June 1999

Abstract

In a retrospective study of a consecutive series of 222 surgically treated meningiomas, it was found that 26.6% of
the patients presented epilepsy as their initial symptom. In this group, surgical excision of the intracranial
meningiomas stopped the epilepsy in about 62.7% of the patients. But approximately one-fifth of the patients with
intracranial meningiomas and no history of preoperative epilepsy developed new onset postoperative seizures. Of the
patients with early onset of postoperative epilepsy, epilepsy appeared in 66.7% within first 48 h after surgery. Of the
patients with postoperative epilepsy, 71.2% were seizure-free following 1 year of anticonvulsant therapy. Regarding
preoperative existing factors, intracranial meningiomas located at supratentorium, convexity, and with evidence of or
severe peritumoral edema significantly contributed to preoperative epilepsy. And in patients with preoperative
epilepsy, those tumors with evidence of or severe perifocal edema and cerebral edema at the operative site were
significantly more likely to suffer from postoperative epilepsy. 2000 Elsevier Science B.V. All rights reserved.

Keywords: Meningioma; Epilepsy; Incidence; Influencing factor

1. Introduction 1989; Yao, 1994; Chow et al., 1995). Surgical

Intracranial meningiomas are common in-
tracranial tumors, and epilepsy is one of the most
common symptoms of intracranial meningiomas
with an incidence of 20 50% as the first symptom
(Ramamurthi et al., 1980; Chan and Thompson,
1984; Giombini et al., 1984a,b; Rohringer et al.,
* Corresponding author. Tel.: + 886-7-3215049; fax: + 886-
7-3215039.
removal of the tumor is the first choice of treat-
ment. The incidence and causes of preoperative
and postoperative epilepsy have rarely been re-
ported in the literature (Chan and Thompson,
1984; Chow et al., 1995). In this study, a consecu-
tive series of 222 cases of surgically treated in-
tracranial meningiomas were retrospectively
reviewed. The incidence, prognosis, and influenc-
ing factors for preoperative and postoperative
epilepsy will be discussed.

0920-1211/00/$ - see front matter 2000 Elsevier Science B.V. All rights reserved.
PII: S 0 9 2 0 - 1 2 1 1 ( 9 9 ) 0 0 0 6 6 - 2
46 A.-S. Lieu, S.-L. Howng / Epilepsy Research 38 (2000) 4552

Table 1
Age and sex distribution

Age group Males Females Totala

Seizure no. Total Seizure no. Total

1019 1 2 1 1 3 (2)
2029 2 2 10 12 (2)
3039 3 10 5 22 32 (8)
4049 7 18 6 28 46 (12)
5059 7 21 12 37 58 (19)
6069 5 13 6 35 48 (11)
7079 1 7 3 16 23 (4)
Total 24 73 35 149 222 (59)

a
Numbers in parentheses represent total seizure cases in age group.

2. Materials and methods ings. The histologic classification was based on

This is a retrospective study of 222 consecutive
patients with intracranial meningiomas surgically
treated between April, 1982 and April, 1997. The
patients ranged in age from 12 to 79 years with a
mean age of 51.9 years. The female to male ratio
was 2.2:1. Early postoperative seizure was defined
as the onset of epilepsy within 1 week of surgery,
and late postoperative seizure was defined as on-
set of epilepsy beyond the first week of surgery.
The amount of associated brain edema was
classified according to the method used by Go et
al. (1988) who classify it as absent, marginal,
evident or severe depending on the extension of
the peritumoral hypodense area in the brain com-
puted tomographic (CT) scan. The location of
tumors was determined by brain CT scan, mag-
netic resonance image (MRI) or operative find-
the classification of Russell and Rubinstein
(1989).
Statistical analysis was performed using chi-
square test. A P-value of B 0.05 was considered
significant.
3. Results
In our series, 59 (26.6%) patients presented
epilepsy as their first clinical symptom. There
were 35 females and 24 males with a mean age of
50.2 years (range 1278 years old) (Table 1).
Statistically, our study demonstrates no difference
in occurrence between sexes (P= 0.140). A total
of 188 tumors were located at the supratentorium
with 57 (30.3%) of the patients presenting preop-
erative epilepsy. A total of 21 tumors were located

Table 2
Incidence of preoperative epilepsy relative to location

Localization Number of patients with epilepsy Total number of patients %

Cerebral convexity 33 81 40.7

Parasagittal/falx 14 51 27.5
Tuberculum sella 1 26 3.8
Sphenoid ridge 6 18 33.3
Olfactory groove 2 8 25.0
Tentorium 1 10 10.0
Posterior fossa 2 20 10.0
Multiple 3 0.0
Others 5 0.0
 A.-S. Lieu, S.-L. Howng / Epilepsy Research 38 (2000) 4552
Table 3
Patients with epilepsy associated with location

Tumor location Total number Preoperative epilepsy No preoperative epilepsy

of cases
ORa (95% CI)a No. of cases (%) No. with postoperative No. of cases (%) No. with postoperative epilepsy
epilepsy (%) (%)

Frontalb 63 1.00 21 (33.3) 8 (38.1) 42 (66.7) 9 (21 4)

Temporal 22 2.40 (0.896.45) 12 (54.5) 5 (22.7) 10 (45.5) 2 (20.0)
Parietalc 33 1.14 (0.472.76) 12 (36.4) 4 (33.3) 21 (63.6) 8 (38.1)
Occipital 15 0.31 (0.061.49) 2 (13.3) 1 (50.0) 13 (86.7) 2 (15.4)

a
95% CI, 95% confidence interval; OR, odds ratio.
b
Including convexity, parasagittal/falx and olfactory groove.
c
Including convexity and parasagittal/falx.

47
48 A.-S. Lieu, S.-L. Howng / Epilepsy Research 38 (2000) 4552
at the infratentorium with only two (9.5%) of the
patients presenting preoperative epilepsy. The
supratentorial tumors had significantly higher in-
cidence of preoperative epilepsy than infratento-
rial tumors (P = 0.03). The relative incidence of
preoperative epilepsy in different intracranial lo-
cation is showed in Table 2. Tumors located at
convexity, parasagittal/falx or sphenoid area had
significantly higher incidence of preoperative
epilepsy than others (P = 0.004). According to the
location of frontal, temporal, parietal and occipi-
tal lobe, our results demonstrate no significant
difference (P= 0.077) but the incidence of preop-
erative epilepsy in temporal lobe was eightfold
higher than occipital lobe and twofold higher than
frontal and parietal lobe (Table 3).
Of these 165 patients, 94 had predominantly
right-sided and 71 left-sided lesions; 29 (30.9%) of
the former and 25 (35.2%) of the latter had preop-
erative epilepsy. There is no significant difference
statistically (P=0.550) between right-sided and
left-sided intracranial meningiomas.
As regards peritumoral edema, of the 133 cases
with no or slight edema, 26 cases presented preop-
erative epilepsy. Among 78 cases with evident or
severe edema, 31 patients had preoperative
epilepsy, implying a correlation (P = 0.0009) be-
tween edema and epilepsy. Of the patients with
evidence of or severe peritumoral edema, 28 had
postoperative epilepsy. This figure is significantly
higher than those with no peritumoral edema
(P =0.0014). Among these 28 patients, cerebral
edema at operative site was noted in 11 patients
and it was significantly related to the peritumoral
edema (P=0.0462). The rate of preoperative
epilepsy in different histological types was as fol-
lows: meningotheliomatous (19.3%), transitional
(37.9%), psammomatous (20%), fibroblastic
(25%), angioblastic (50%), atypical (50%) and oth-
ers (40%). No correlation was observed (P =
0.199) between histological type and preoperative
epilepsy.
Various preoperative seizure types are shown in
Table 4. No patients had preoperative or postop-
erative status epilepticus. A total of 52 patients
had postoperative epilepsy. Among them, 22 pa-
tients (37.3%) had had preoperative epilepsy
which continued postoperatively. Of these 22 pa-
tients, the epileptic pattern changed in five pa-
tients. In three patients, the preoperative
generalized seizure changed to partial seizure. In
the other two, the partial seizure changed to
generalized seizure. A total of 30 patients with no
history of preoperative epilepsy developed new-
onset postoperative epilepsy. Among the 18 pa-
tients who developed early postoperative epilepsy,
cerebral edema was found at surgical site in 15
patients and hematoma at operative site in six
patients. There were 34 patients who had late
postoperative epilepsy. A recurrence of tumors
was noted in 13 of these patients. Regarding the
factors affecting postoperative epilepsy, patients
with preoperative epilepsy, evidence of peritu-
moral edema and cerebral edema at the operative
site had statistically significant associations with
the occurrence of postoperative epilepsy (Table 5).
The other factors have no significant effect.
Of the 52 patients with postoperative epilepsy,
the follow-up periods ranged from 1 to 12 years.
During the follow-up periods, 37 (71.2%) patients
were seizure-free after 1 year of anticonvulsant
(phenytoin or valproic acid) therapy. A total of
seven patients who all had late postoperative
epilepsy had intermittent seizure attacks and eight
patients had expired.
4. Discussion
Intracranial meningiomas account for approxi-
mately 20% of all intracranial tumors (Rachlin
and Rosenblum, 1991). The incidence of epilepsy
as the first symptom in intracranial meningiomas
Table 4
Preoperation type of epilepsy
Type Number of cases
Generalized seizure 40
Partial seizure 16
Partial seizure with secondary 2
generalization
Complex partial seizure 1
Total 59
 A.-S. Lieu, S.-L. Howng / Epilepsy Research 38 (2000) 4552 49

Table 5
Factors affecting preoperative and postoperative epilepsy

Preoperation Postoperation

No. of patients No. of patients P-value No. of patients No. of patients P-value
with Ea with NEa with Ea with NEa

Sex
Female 35 114 0.140 33 116 0.52
Male 24 49 19 54
Age group (years)
1039 12 35 0.385 13 34 0.596
4059 24 80 25 79
6079 23 48 14 57
Location
Supratentorium 57 131 0.030 50 138 0.07
Infratentorium 2 19 2 19
Right 29 65 0.550 25 69 0.70
Left 25 46 17 54
Frontalb 21 42 0.077 17 54 0.499
Temporal 12 10 7 15
Parietalc 12 21 12 21
Occipital 2 13 3 12
Convexity 33 48 0.004 20 61 0.443
Parasagittal (or 14 37 16 45
falx)
Sphenoid ridge 6 12 6 12
Olfactory 2 6 3 5
Suprasellar 1 25 3 23
Cerebellopontine 1 13 2 12
Others 2 24 2 24
Peritumoral edema
Absent or mar- 26 108 0.0009 23 111 0.0014
ginal
Evident or severe 33 47 29 50
Pathology
Meningothelioma- 23 96 0.199 23 96 0.301
tous
Transitional 11 18 9 20
Psammomatous 5 20 2 23
Fibroblastic 2 6 1 7
Angioblastic 4 5 2 7
Atypical 4 8 4 8
Others 10 10 11 9
Preoperati6e E
Yes 59 22 0.025
No 163 30
Operation
Gross total re- 42 145 0.414
moval
Subtotal removal 10 25
Postoperati6e re-
currence
Yes 13 34 0.440
No 39 136

a
E, epilepsy; NE, no epilepsy.
b
Including convexity, Parasagittal/falx and Olfactory groove.
c
Convexity and parasagittal/falx.
50 A.-S. Lieu, S.-L. Howng / Epilepsy Research 38 (2000) 4552
is reported to be from 20 to 50% (Ramamurthi et
al., 1980; Chan and Thompson, 1984; Giombini et
al., 1984a,b; Rohringer et al., 1989; Yao, 1994;
Chow et al., 1995). In the present study, epilepsy
is the most common clinical symptom and its
incidence is 26.6%. Although the ratio of female
to male patients with intracranial meningiomas is
2:1, our series and some reports (Chow et al.,
1995; Chozick et al., 1996) demonstrate no signifi-
cant difference of preoperative epilepsy according
to sex (P = 0.14). In spite of the fact that the
occurrence of epilepsy is not significantly different
(P= 0.385) in age group, it occurs more fre-
quently in the fifth and sixth decades.
The incidence of preoperative epilepsy in supra-
tentorium has been reported to be from 29 to 67%
(Ramamurthi et al., 1980; Chan and Thompson,
1984; Chozick et al., 1996); the incidence in our
series was 30.3%. The occurrence of preoperative
epilepsy in supratentorium is significantly higher
than infratentorium (P =0.03). To the best of our
knowledge, the difference in the occurrence of
preoperative epilepsy between left and right hemi-
spheric meningiomas has rarely been mentioned
(Scott, 1985). Although the study of Scott showed
that patients with predominantly left-sided menin-
gioma showed a statistically significant greater
chance of developing seizures after operation
(Scott, 1985), the occurrence of preoperative or
postoperative epilepsy is not significantly different
between right and left hemisphere lesions in our
series. The highest frequencies of preoperative
epilepsy are found in convexity, parasagittal/falx
and sphenoid ridge meningiomas. These findings
are similar to the report by Chow et al. (1995).
Hoefer et al. reported that meningioma in the
temporal lobe did not produce any form of preop-
erative epilepsy (Hoefer et al., 1947, cited in Chan
et al., 1979), but our study shows temporal lobe
meningiomas have a higher incidence of preopera-
tive epilepsy than frontal, parietal and occipital
lobe. Some authors (Flyger, 1956; Ramamurthi et
al., 1980; Chozick et al., 1996) have reported that
meningioma in parietal lobe has a significantly
higher incidence of postoperative epilepsy than
others, but it did not appear to be significantly
different in the present study.
Regarding the relationship between histological
types and preoperative epilepsy, while Chow et al.
stated that histologic types were not significantly
correlated with preoperative epilepsy (Chow et al.,
1995), Kawaguchi et al. believed that fibroblastic
meningiomas were (Kawaguchi et al., 1995).
While our study finds that angioblastic menin-
giomas have a high incidence of associated preop-
erative epilepsy, it does not demonstrate a
significant difference between histological type
and preoperative epilepsy.
In our study, preoperative epilepsy is found to
be significantly related (P= 0.0009) to peritu-
moral edema, similar to a report by Kawaguchi et
al. (1995). It should be noted that peritumoral
edema fluid consists of excessive concentration of
glutamate and aspartic acid (Chan et al., 1979;
Fishman and Chan, 1980) which may be involved
in denervation hypersensitivity and propagation
of excitatory influences (Kawaguchi et al., 1995).
According to the literature, surgical removal of
a meningioma eliminates epilepsy in 19.263.5%
of patients with preoperative epilepsy (Logue,
1974; Ramamurthi et al., 1980; Chan and Thomp-
son, 1984; Chozick et al., 1996), and postoperative
epilepsy develops in 5.142.9% of patients with
no history of preoperative epilepsy (Logue, 1974;
Foy et al., 1981; Chan and Thompson, 1984;
Giombini et al., 1984a,b; Chow et al., 1995; Choz-
ick et al., 1996). In our present study, 37 (62.7%)
patients enjoy complete cessation of epilepsy after
operation, and the incidence of patients with new-
onset epilepsy after surgery is 18.4%. In other
words, for patients with a meningioma and preop-
erative epilepsy, one can predict a postoperative
cessation of convulsions in approximately 62.7%
of the cases, and for those with no history of
preoperative convulsions almost 18.4% are likely
to develop postoperative seizures. In instances
of early onset, 66.7% of cases of postoperative
epilepsy appeared within the first 48 h, a find-
ing similar to that of Pasquet et al. (1976). During
follow-up periods, 71.2% of patients became
seizure free after 1 year of anticonvulsant therapy.
There are seven patients (13%) who have late
postoperative epilepsy, who still have intermit-
tent seizure attacks. Patients with early post-
operative epilepsy have a better prognosis than
 A.-S. Lieu, S.-L. Howng / Epilepsy Research 38 (2000) 4552
late postoperative epilepsy. Although Chan et al.
and Olivecrona reported postoperative status
epileptus in patients with intracranial menin-
giomas in their reports (Olivecrona, 1947; Chan et
al., 1979), we have no instances of this. Factors
that have been associated with the development of
postoperative epilepsy after intracranial menin-
gioma operation include brain retraction, inter-
ruption of cortical veins, arterial damage,
preoperative epilepsy history, extent of tumor re-
moval, and postoperative hydrocephalus as well
as parietal location (Logue, 1974; Ramamurthi et
al., 1980; Foy et al., 1981; Chan and Thompson,
1984; Chow et al., 1995; Chozick et al., 1996). In
our study, a history of preoperative epilepsy, evi-
dence of peritumoral edema and cerebral edema
at operative site play significant roles in postoper-
ative epilepsy. About 37.3% of the patients with a
history of preoperative epilepsy suffered postoper-
ative epilepsy, making it a significant (P = 0.025)
contributing factor to postoperative epilepsy. In-
tracranial meningiomas with evidence of or severe
peritumoral edema was also a significant (P =
0.0014) influencing factor for postoperative
epilepsy. In the present series, tumors with evi-
dence of or severe perifocal edema associated
significantly with cerebral edema at the operative
site (P=0.0462), and thus also have an influence,
especially in the early onset of postoperative
epilepsy, which is an observation previously made
by others (Tsuji et al., 1993; Chow et al., 1995).
Surgical manipulation and slow resolution of per-
ifocal edema may be the cause of cerebral edema
at operative site. In 33% of our patients with early
onset of postoperative epilepsy, hematoma at op-
erative site was found, possibly indicating it may
have something to do with the early onset of
postoperative epilepsy. Chozick et al. (1996)
thought that subtotally resected tumor was a sig-
nificant predictor of postoperative epilepsy. Al-
though subtotally resected tumors may continue
to irritate the cortex or may invade brain tissue, in
the present series the extent of tumor removal did
not significantly influence the postoperative
epilepsy (P = 0.414). Tumor recurrence was not
significantly related to late onset of postoperative
epilepsy (P=0.440). Acute hydrocephalus may
cause cortical irritation leading to convulsions
51
(Chozick et al., 1996). In our series, one case with
a cerebellopontine meningioma developed acute
hydrocephalus and convulsion after operation.
Patients with parietal tumors appear to be more
susceptible to the development of new-onset post-
operative epilepsy (Ramamurthi et al., 1980;
Chozick et al., 1996). In our study, the preopera-
tive epilepsy in 66.7% of our patients with parietal
meningiomas was resolved whereas 38.1% of pa-
tients with a parietal meningioma and no history
of epilepsy developed postoperative epilepsy.
Overall, 26.7% of our patients with new-onset
postoperative epilepsy had parietal meningioma,
much less than the series reported by Chozick et
al.
5. Conclusions
From the present study, it is found that there is
a significant incidence of preoperative epilepsy in
patients with meningiomas located at supratento-
rium or evident/severe peritumoral edema. In
about 62.7% of patients with preoperative
epilepsy, the epilepsy could be eliminated by sur-
gical excision. Approximately one-fifth of patients
with a meningioma and no history of preoperative
convulsions were likely to develop postoperatively
new-onset seizures. Patients with parietal tumors
and no history of preoperative epilepsy had a high
incidence of new-onset of postoperative epilepsy.
Of our patients with postoperative epilepsy 70%
enjoyed good control of seizures with anticonvul-
sant therapy, which can be tapered off and then
discontinued entirely over a 1-year period. Preop-
erative epilepsy, evidence of peritumoral edema
and cerebral edema at operative site are important
predisposing factors for postoperative epilepsy.
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