Journal of Neuro-Oncology (2018) 140:145–153

https://doi.org/10.1007/s11060-018-2944-z

CLINICAL STUDY

A missing piece? Neuropsychiatric functioning in untreated patients

with tumors within the cerebellopontine angle
Simone Goebel1 · Hubertus Maximilian Mehdorn2

Received: 27 May 2018 / Accepted: 27 June 2018 / Published online: 7 July 2018
© Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Purpose To date, little is known about neuropsychiatric symptoms in patients with tumors within the cerebellopontine angle
(CPA). These, however, might be of clinical relevance. Aim of this study was thus to assess possible impairment in cognition,
elevation in mood symptoms, and fatigue in this specific patient group.
Methods Forty-five patients with an untreated CPA tumor (27 vestibularis schwannoma, 18 meningioma) were tested within
a cross-sectional observational study in a single institution prior to neurosurgical treatment. Patients were administered a
multifaceted battery comprising of widely-used tests for assessment of neuropsychiatric functioning.
Results The majority of the included patients (69%) showed neurocognitive impairment, most frequently in the areas of
attention and visuo-motor speed (e.g., alertness) (62%) as well as visuo-construction (44%). Impaired structural integrity of
the brain stem was accompanied by more serious neurocognitive deficits. About one-third of the sample reported clinically
relevant depression and/or anxiety and an even higher proportion (48%) described high levels of fatigue. Cognitive and
affective symptoms as well as fatigue contributed significantly to patients’ Quality of Life, indicating the clinical relevance
of neuropsychiatric symptoms in patients with CPA tumors.
Conclusions Although patients with untreated CPA tumors often suffer from devastating and prominent physical symptoms,
neuropsychiatric problems are also frequent. Including these aspects in the routine clinical assessment and initiating treat-
ment accordingly might thus improve clinical management of the patients and improve Quality of Life.

Keywords Tumor · Cerebellopontine angle · Neuropsychology · Cognition · Affect · HRQoL

Introduction patients’ Health Related Quality of Life (HRQoL), psycho-

Tumors within the cerebellopontine angle (CPA) account
for 5–10% of intracranial tumors [1]. CPA tumors are often
accompanied by severe clinical symptoms due to their spe-
cific location close to vital anatomical structures, i.e., the
cranial nerves and/or the brainstem. These include, amongst
others, impaired facial nerve function, hearing loss, tinnitus,
vertigo, balance or visual problems, fatigue, and headache.
These symptoms are of high clinical relevance and impede
* Simone Goebel
goebel@psychologie.uni‑kiel.de
Hubertus Maximilian Mehdorn
prof@mehdorn‑consil.de
1
Department of Clinical Psychology and Psychotherapy,
Institute of Psychology, Christian-Albrechts University,
Olshausenstraße 62, 24118 Kiel, Germany
2 acoustic neuroma prior to treatment, giving an indication
Mehdorn Consilium, Prüner Gang 7, 24103 Kiel, Germany
social well-being, and participation [2–7]. Most CPA tumors
can be classified as chronic illness due to their benign nature
and early impact on functioning [6]. Treatment options
include watchful waiting, radiosurgery, and neurosurgical
treatment, each with possible detrimental effects [7–9].
It might be due to these prominent and dominant neuro-
logical symptoms and neurosurgical challenges that there
is only little research regarding possible neuropsychiat-
ric sequelae of CPA tumors. For the whole population of
patients with an intracranial neoplasm, it is known that about
90% of untreated patients suffer from cognitive deficits [10]
and prevalence of depression, anxiety, and psychosocial dis-
tress is high [11, 12]. Also, many neurooncological patients
suffer from fatigue [13]. These aspects have, however, to
date not been assessed in patients with a CPA tumor.
Hio et al. [14] reported rates of depression in 27% and
high anxiety in 20% in their sample of 30 patients with an

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of the possible relevance of neuropsychiatric symptoms in
patients with a CPA tumor. Traditionally, neurocognitive
decline has been attributed to infratentorial lesions [15].
However, in recent years, it has been consistently reported
that supratentorial lesions are frequently accompanied by
neuropsychiatric symptoms as well. For example, patients
with cerebellar lesions are often impaired in cognitive and
affective functioning, suffering, amongst others, from defi-
cits in the areas of executive functioning, attention, spa-
tial cognition, and emotion regulation [16]. In addition,
impaired structural and functional integrity of the brain
stem has been linked to the decline in various cognitive
domains including attention and executive functioning [17,
18]. Moreover, Kim et al. [19] reported cognitive deficits
in patients with infratentorial stroke, which was associated
with white matter hyperintensities, and Meskal et al. [20]
included seven patients with an infratentorial meningioma
in their study who showed similar neurocognitive impair-
ment compared to patients with supratentorial lesions.
Thus, it is plausible to expect neuropsychiatric impairment
also in patients with CPA tumors.
Considering neurocognitive impairment and elevations
in moods symptoms is clinically recommended:
All these three aspects—cognitive deficits, elevated
mood symptoms and fatigue—relevantly impede HRQoL
in brain tumor patients [13]. Also, patients’ neuropsycho-
logical status gives important information with regard to
patients’ participation and might indicate necessary treat-
ment [21]. Neuropsychological impairment is robustly
associated with real-life change, including, amongst oth-
ers, the impairment in activities of daily living (ADL),
Employability, the ability to drive, or social integration.
This prediction of everyday functioning by neuropsy-
chological assessment data is referred to as ‘ecological
validity’ [21]. Moreover, neuropsychological change may
indicate tumor progression before visible change on CT
or MRI, stressing the relevance of an adequate baseline
assessment [22]. In addition, the patients’ cognitive abil-
ity is an important part of evaluation and quality control
regarding the success and the appropriateness of medical
treatments [23].
Despite this clinical relevance, no previous study has,
to the best of our knowledge, focused on cognitive and
affective symptoms as well as fatigue in patients with CPA
tumors to date. Thus, aim of this study was the assessment
of the cognitive and affective state as well as of fatigue in
untreated patients with a CPA tumor in order to analyse
whether including these aspects in the routine diagnosis
and treatment might help to improve clinical management
of the patients. More specifically, the following research
questions were addressed:
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Journal of Neuro-Oncology (2018) 140:145–153
1. What is the proportion of cognitive impairment, elevated
mood symptoms and fatigue in patients with a CPA
tumor?
2. Of which nature are possible deficits, i.e., which
aspects of cognition and affect are especially at risk in
this patient group? This helps to characterize patients’
impairments, better understand the patients’ clinical
situation, apply specific and focused test procedures
relevant to this specific patient group, and plan targeted
rehabilitative treatment.
3. Are there specific tumor attributes (e.g., tumor size or
histological features) associated with neuropsychiatric
symptoms? This can help to identify patients of special
risk to develop symptoms in the assessed areas.
4. What is the clinical relevance of these deficits? To test
this, we assessed the impact of cognition, affect, and
fatigue on Health Related Quality of Life (HRQoL).
Materials and methods
Study design
This cross-sectional observational study was conducted
between January 2009 and December 2010. We tested a
consecutive sample of patients scheduled for neurosurgical
tumor removal who fulfilled the following inclusion criteria:
diagnosis of an untreated CPA tumor, age 18 years or above,
approval of the ward physician, patients’ consent. The final
sample (Table 1), consisted of patients with either a menin-
gioma or a vestibularis schwannoma. Surgery was performed
1–4 days after the examination (Mx = 1.64, Sx = .88). The
study was approved by the appropriate ethics committee and
patients gave written, informed consent. This study was not
part of another study.
Variables
Patients participated in a comprehensive neuropsychological
examination consisting of standardised tests with published
normative data. Sociodemographic (age, gender, estimated
premorbid intelligence, employment status) and medical
information (Karnofsky Performance Status, tumor size,
lateralization, histological diagnosis and whether there was
visible brain stem suppression on MRI) was drawn from
patients’ charts (Table 1).
Neurocognitive variables
Following the recommendations from Taphoorn and Klein
[25], we included the following cognitive domains:
Journal of Neuro-Oncology (2018) 140:145–153 147

Table 1  Sample description (n = 45) – Memory Verbal learning and memory Rey Auditory
Variable Mean SD Verbal Learning Test (RAVLT) [35]; Implicit visual-
spatial memory RCFT—delay [27]
Age in years (range 22–71) 53.91 13.01 – Language the four following subtests of the Aachener
Estimated premorbid intelligence (range 86–125) 111.66 7.872 Aphasie Test (AAT) [36], the Gold Standard for the
Karnofsky-Performance Status (range 50–100)a 84.1 12.1 assessment of aphasia in Germany, were used: Naming,
Tumor size in cm (maximal dimension) (range 2.41 1.54 Token Test (Language comprehension), Reading, and
0.4–5.3 cm)
Writing
Variable N %

Gender Assessment of patients’ emotional state, fatigue and HRQoL

Female 26 58
Male 19 42 The following questionnaires were applied:
Employment status
Currently employed 30 67 1. For assessment of patients’ emotional state, the Hospital
Retired 12 27 Anxiety and Depression Scale (HADS) [37], was applied.
Housekeeper/unemployed 3 7 The HADS is one of the most widely used instruments
Tumor lateralization for assessment of anxiety and depression via seven items
Right 19 42 each in patients with physical complaints. We used the
Left 26 58 cutoff scores of ≥ 10 as indicators for clinically relevant
Histological diagnosis depression/anxiety and the sumscore of both scales as
Vestibularis schwannoma 27 60 measure for patients’ overall emotional state.
Meningioma 18 40 2. For assessment of fatigue, the short form of the Profile
Visible brain stem suppression on MRI of Mood States (POMS) [38] was applied. We used the
No 36 80 tiredness/fatigue score consisting of 7 items for opera-
Yes 9 20 tionalization of patients’ fatigue.
3. For assessment of global HRQoL, question 29 (“How
a
Global measure of the patients’ physical status, ranging from 0 would you rate your overall health during the past
(death) to 100 (no complaints; no evidence of disease) [24]
week?”) and question 30 (“How would you rate your
overall quality of life during the past week?”) from the
– Premorbid intellectual functioning was estimated via “European Organisation for Research and Treatment of
the demographic formula provided by Barona [26]. Six Cancer core Quality of Life Questionnaire” (EORTC
cognitive domains represented by the following test pro- QLQ C-30) [39] were administered. Each question is
cedures were included in the assessment: answered on a Likert scale, ranging from 1 (“very poor”)
– Visuo-construction Rey–Osterrieth Complex Figure to 7 (“excellent”) recoded in 0–100%. We used the mean
Test (RCFT)—copy [27]; score of these two items as dependent variable.
– Visuo-perception Object recognition Object Decision
from the Visual Object and Space Perception Battery Study size
(VOSP) [28]; Space perception number location from
the VOSP; Visual field/neglect line bisection [29]; During the study period, 54 patients with a CPA tumor were
– Attention and visuo-motor speed Verbal short term eligible. Patients were excluded if they reported any previ-
memory digit Span Forward from the Wechsler Mem- ous brain impairment or if MRI scans showed supratento-
ory Scale—Revised (WMS-R) [30], Visuo-motor speed rial lesions (n = 2). Two patients could not be seen due to
Trail-Making-Test (TMT)-A [31]; Alertness subtest organizational reasons and five patients declined partici-
“Alertness” from the computerized test battery of the pation due to lack of physical well-being. Completing the
“Testbatterie zur Aufmerksamkeitsprüfung (TAP)”, the whole test-battery lasted for 90–120 min. Not all patients
German Gold Standard for assessment of attention [32]; were administered all tests due to patients’ exhaustion or
– Executive functions Verbal working memory Digit Span organizational reasons.
Backwards [30]; Flexibility/shifting TMT-B [31]; Verbal
Lexical Fluency German version of the Controlled Oral
Word Administration test COWAT, F-A-S) [33]; Figural Statistical analyses
Fluency (Five-point Test FPT) [34];
Patients were classified as impaired in any cognitive domain
if they scored below the 7th percentile (i.e., 1.5 standard

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deviations below the respective mean). For comparability, all
data were transformed to the z-scale with a mean (Mx) of 0
and a standard deviation (SD) of 1. T-Tests were applied for
comparing the following groups: patients with/without visible
brain stem impairment; patients with meningioma/vestibularis
schwannoma; patients with left/right sided tumors. Pearson’s
correlations were used for calculation of associations between
variables. Correlations were calculated between our depend-
ent variables and medical characteristics. Moreover, associa-
tions between HRQoL, fatigue, patients’ emotional state (total
score of the HADS) and cognitive measures were calculated.
For examining which variables impact Quality of Life in
CPA-patients, we conducted linear regression analyses. As
our sample size did not allow for including cognition, affect,
and fatigue in one model, they were analyses separately. For
analysing the impact of cognition on HRQoL, we included
cognitive measures correlated with HRQoL (i.e., TMT-B
and alertness) in a multiple regression. Due to our explora-
tory approach, we chose a backward stepwise approach. Fur-
thermore, two linear regression analyses were carried out in
which the sum score of the HADS as indicator for patients’
psychological state, respectively the POMS fatigue score
were analysed as possible predictors for patients’ HRQoL.
Statistical analyses were performed with SPSS 21.0 with a
level of significance of alpha = .05. Due to the exploratory
nature of our study, we did not control for multiple testing.
Results
Sample description
Table 1 presents patient information. WHO tumor grading
was WHO° I for all patients. In one patient, the tumor was
found by incident. This patient displayed no neurological
symptoms. All other participants suffered from at least one of
the following problems: hearing impairment (71%), fatigue
(71%), balance (62%), tinnitus (43%), vertigo (43%), impaired
facial nerve function (38%), headache (38%), nausea and/or
Fig. 1  Original of the Rey–Osterrieth Complex Figure Test (RCFT) and results of the copy task of two impaired patients
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Journal of Neuro-Oncology (2018) 140:145–153
vomiting (24%), coordination (24%). During the structured
exploration, patients affirmed the following neuropsychiatric
changes: attention (43%), memory (38%), spatial navigation
(33%), and mood changes (58%).
Patients’ cognitive and affective state
Proportion and nature of cognitive impairment, elevated
mood symptoms and fatigue
Overall, 31 (69%) of the patients scored below the 7th per-
centile in at least one of the applied cognitive tests. The
most frequently impaired domains were visuo-construction
(Fig. 1), executive functioning as well as attention and visuo-
motor speed (Table 2). Regarding patients’ affective state, we
found high anxiety in 20% and clinically relevant depression
in 33% of the sample. Finally, about half of the patients (48%)
reported high fatigue.
Relationships between tumor attributes
and neuropsychiatric functioning
Patients with visible brain stem suppression on MRI (n = 9)
performed worse compared to the remaining sample in a vari-
ety of cognitive tasks (Table 2). All of these nine patients suf-
fered from cognitive impairment in at least one of the applied
measures. Neither tumor size nor the patients’ physical state
(Karnofsky Performance Status) was related to cognitive
performance (p > .2). No differences were found between
patients with vestibular schwannoma resp. meningioma as
well as between patients with left- resp. right-sided tumors
(p > .2). Neither affect nor fatigue were associated with any of
the included medical characteristics (p > .2). Also, we did not
find differences in affect or fatigue between groups of patients
with different tumor attributes (p > .2).
Journal of Neuro-Oncology (2018) 140:145–153 149

Table 2  Results of the No of patients Min Max Mean SD Impaired

neurocognitive and affective N (%)
measures
Visuo-construction 16 of 38 (44%)
RCFT-copy*** 38 − 3.30 1.00 − 1.20 1.50 16 (44%)
Visuo-perception 7 of 45 (16%)
VOSP object decision 45 − 1.56 3.30 .19 1.54 3 (7%)
VOSP number location 45 − 3.30 3.30 .33 1.66 4 (9%)
Line bisection 45 – – – – 0
Attention and speed 28 of 45 (62%)
Digit span forward 43 − 2.05 2.05 − .46 1.07 9 (21%)
TMT-A** 38 − 3.30 .84 − 1.00 1.74 17 (45%)
Alertness—reaction time* 28 − 2.33 1.88 − .68 1.37 9 (32%)
Alertness—standard deviation of 28 − 2.33 2.33 − .036 1.54 5 (18%)
reaction times**
Phasic alertness 28 -2.33 2.33 .011 1.25 3 (11%)
Executive functioning 23 of 45 (51%)
Digit span backwards 43 -2.05 1.88 − .73 − 2.05 8 (19%)
“FAS”COWAT​ 42 -2.33 1.75 .40 1.21 6 (14%)
FPT—productivity* 45 -3.30 1.65 − 1.10 1.71 18 (40%)
FPT—perseveration 45 − 3.30 1.00 − .32 1.40 6 (13%)
TMT-B** 38 − 3.30 1.08 − 1.1 2.01 17 (45%)
Memory 15 of 42 (36%)
AVLT—learning 38 − 3.30 1.65 − .89 1.22 12 (32%)
AVLT—delayed free recall 38 -2.05 1.88 − .78 1.55 9 (24%)
AVLT—recognition 38 − 1.41 1.18 − .31 .91 0%
RCFT-delay** 36 − 3.30 1.80 − .70 1.37 10 (28%)
Language 0 of 45 (0%)
AAT—token test (0–120) 44 0 1 .04 .208 0
AAT—naming (0–120) 44 118 120 119.53 .757 0
AAT—reading (0–30) 44 30 30 30.00 .000 0
AAT—writing (0–30) 44 28 30 29.91 .358 0
All cognitive tests 31 of 45 (69%)
Affective measures 22 of 45 (49%)
HADS-anxiety (0–21) 45 0 14 5.78 4.11 9 (20%)
HADS-depression (0–21) 45 0 17 6.69 5.60 15 (33%)
Fatigue 22 of 45 (49%)
POMS-fatigue (0–42) 31 0 34 18.85 10.91 15 (48%)
Global HRQoL (0–100)
EORTC-QLQ question 29 + 30/2 45 16.67 100.00 67.59 25.55 –

Cognitive test results are presented in z-scores (Mx = 0, SD = 1). Patients were classified as impaired if
scoring below the 7th percentile (z < − 1.5) respectively below the suggested cutoff score according to pub-
lished norms. Tests with greater impairment of patients with brain stem lesions visible on CT/MRT are
marked by asterisks
Patients with brain stem impairment performed worse compared to the rest of the sample with *p < .1,
**p < .05, ***p < .01

Relationships between HRQoL, fatigue, cognition,
and emotional well‑being
Correlation analyses
Table 3 presents details regarding the associations between
variables. HRQoL and fatigue were highly intercorrelated.
For estimation of a patients’ overall neurocognitive state,
we calculated the mean z-score from all completed neu-
ropsychological tests. This score was not correlated with
patients’ global HRQoL. Regarding the individual cognitive
tests, both Alertness and TMT-B (but no other measures)
were correlated with HRQoL. The sumscore of the HADS
as indicator for patients’ emotional state and fatigue were
significantly correlated with HRQoL.

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Table 3  Associations between HRQoL, fatigue, cognition, and emo-
tional state
Fatigue Alertness TMT-B HADS
HRQoL − .607** .480** − .469** − .597**
Fatigue – − .330 .243 .602**
Alertness – – .336 − .587**
TMT-B – – – .233
**Significant with p < .01
Prediction of HRQoL via neuropsychiatric symptoms
We performed a linear regression analysis to analyse whether
cognitive functioning predicted HRQoL with alertness and
TMT-B as possible predictors. In the resulting model, only
alertness was a significant predictor of HRQoL ­(R2 = .37;
T = 3.01; p = .007). The sum score of the HADS as indica-
tor for the patients’ psychological state predicted 34.8% of
the variance of patients’ global HRQoL (­ R2; T = − 4.958;
p = .001). Also, fatigue significantly predicted HRQoL
­(R2 = .33; T = 3.233; p = .005).
Additional analyses
Visuo‑motor cognitive abilities
Five of the applied cognitive tests rely on visuo-motor pro-
cessing: Rey-copy, Rey-recall, TMT-A, TMT-B, and FPT pro-
ductivity. These five tests measure a variety of cognitive con-
structs and are assigned to four different cognitive domains
(see "Neurocognitive variables" section). However, patients
in our sample showed impairments in these tasks independ-
ent of the cognitive domain the tests were originally designed
to measure (Table 2). Thus, we searched for a pattern as we
hypothesized that this variety of deficits might be attributable
to a common course. In accordance with this assumption, we
conducted an exploratory factor analysis of these five tests.
This revealed that all five consisted single factor, explain-
ing 64% of the variance (factor loadings from .700 to .891).
All these five tests heavily rely on visuo-motor functioning.
Moreover, this is the only basic function linking these five
tasks. Thus, we hypothesize that generally, test procedures
demanding visuo-motor abilities were prone to be impaired.
Discussion
This was, to the best of our knowledge, the first comprehen-
sive assessment of cognitive and affective functioning in an
unselected sample of patients with an untreated tumor within
the CPA. We found that the majority of participating patients
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Journal of Neuro-Oncology (2018) 140:145–153
(69%) was impaired in at least one neuropsychological test
procedure, about one-third of our sample suffered from anxi-
ety and/or depression, and 48% described high fatigue.
Both language and visuo-perceptive abilities were spared
in the majority of our participants. Thus, patients did not
exhibit the typical profile of cognitive and affective symp-
toms after cerebellar lesions: the “cerebellar cognitive affec-
tive syndrome” (CCAS) is marked by deficits in the areas of
visual-spatial processing, linguistic function, executive func-
tions, and affective regulation [16, 40, 41]. Thus, our results
suggest that patients with CPA tumors suffer frequently from
neurocognitive deficits whilst exhibiting a distinct neuropsy-
chological profile. However, it should be noted that not all
aspects of language functioning which rely on cerebellar
processing were included in this study (e.g., agrammatism
or dysprosodia) [16, 40, 42].
In addition, the ability to encode and maintain informa-
tion was intact in all patients: Memory was only impaired
if it did require either free recall of information (which
demands executive and attentional resources) [43] or visuo-
constructive abilities.
Regarding executive functioning—one of the most fre-
quently impaired domains in patients with lesions to the cer-
ebellum [16, 40–42] or brain stem [18]—we found material-
specific results. Thus, only 13–19% of the patients exhibited
deficits in tasks independent of visuo-motor functioning
(e.g., verbal fluency) whereas 40–45% of the patients were
impaired in tasks requiring visuo-motor coordination (e.g.,
figural fluency). Generally, we observed a pattern of impair-
ment in our sample which reflected greater difficulties in test
procedures relying on visuo-motor abilities—independent
of the underlying cognitive construct the tests were in fact
designed to measure. A variety of reasons might attribute to
these visuo-motor difficulties: deficits in the areas of visual
[41, 44], motor [41, 45], or vestibular [46, 47] functioning,
impaired visuo-motor coordination [42, 48], as well as the
disruption of cerebro-cerebellar circuits as a form of “dia-
schisis” [49]. Future studies could include tasks for assess-
ment of basic visuo-motor functions, e.g., fine motor skills
or visual processing, to test for their influence on cognitive
tasks in patients with CPA tumors.
The second domain in which deficits were frequently (i.e.,
in about one-third of our sample) observed, was attention,
predominantly alertness and thus the general wakefulness
of an organism. Alertness is a fundamental function of the
brain stem [18, 50, 51]. In concordance with this, patients
with brain stem lesions were more severely impaired in the
area of alertness compared to the rest of the sample.
Completion of our whole test-battery took about
90–120 min. This was not manageable for a considerable
proportion of patients due to exhaustion. Thus, our test-
battery is not suited for the application in the routine neu-
ropsychiatric assessment in this patient group. Our results
Journal of Neuro-Oncology (2018) 140:145–153
can help to select and focus neuropsychological test proce-
dures, which likely is of special importance in more severely
impaired patients.
Patients with brain stem impairment were also more
severely impaired in the area of visuo-construction. In both
the study of Garrard et al. [18] and ours, all patients with
lesions of the brain stem showed neuropsychological impair-
ment. Thus, our data might be supportive of the postulation
of Garrad et al. [18] that neurocognitive impairment is not
always appropriately accounted for in this patient group.
Regarding the impact on HRQoL, we did not find an
influence of patients’ average cognitive test scores. However,
both deficits in alertness and TMT-B (demanding executive
and visuo-motor functioning) were associated with reduced
HRQoL. Moreover, alertness relevantly and significantly
predicted patients’ HRQoL. This effect might however have
been moderated by brain stem impairment and thus more
severe physical symptoms. Due to our sample size, our data
did not allow to control for possible moderators. Future stud-
ies could assess possible moderators as well as the influence
of specific cognitive impairment on HRQoL and participa-
tion in order to identify possible areas of neurocognitive
functioning with relevant influence on patients’ well-being.
Hereby, the most important targets for cognitive rehabilita-
tion could be identified.
About one-third of our sample described relevant anxiety
and/or depression. This is comparable to the proportion of
preoperative brain tumor patients in general [52]. Previous
studies demonstrated that depression is a major predictor
of HRQoL in patients with brain tumors [53]. Consistently,
elevated mood symptoms were a relevant and significant
predictor of patients’ HRQoL in our study. This stresses the
high clinical relevance of patients’ emotional state. On basis
of our data, we therefore recommend the routine screening
of patients for affective disorders and psychosocial distress.
About half of the patients described high fatigue. Both
emotional and physical symptoms might contribute to this.
In our study, fatigue was strongly associated with Quality of
Life and depression, but not with neurocognitive variables.
Fatigue also significantly predicted patients’ HRQoL.
The following shortcomings and specifics should be con-
sidered regarding our results: All patients were recruited
from a single centre and scheduled for a specific treatment,
i.e., neurosurgical intervention. Thus, patients were both
highly selected with regard to their tumor attributes and
in a highly specific situation: shortly before neurosurgical
tumor removal during inpatient hospital stay. This might
have influenced patients’ affect ratings and thus differ from
the emotional state patients usually experience in their all-
day life. An important shortcoming is that our patients were
solely compared to published norms. Thus, differences
between tests might in part be attributable to differences
in the underling norms, thereby impeding comparability.
151
Future studies might add a healthy control group to account
for this. Another factor that might have distorted our results
is that not all patients completed all test procedures. Patients
with more severe symptoms (e.g., high fatigue) possibly
were more likely to discontinue the assessment and thus,
our data might underestimate neurocognitive symptomatol-
ogy. As tumour localization, not histopathology or any other
clinical feature, was the tumor feature of main interest of this
study, we included patients with any CPA tumor resulting
in a sample composed of patients with either meningioma
or acoustic neuroma. We did not find any differences in
cognitive or affective measures between these two groups.
However, due to the small sample size, future research
might reveal that it could be more appropriate to distinguish
between these groups due to specific cognitive or affective
symptoms. Moreover, as this was the first study to assess
neuropsychiatric functioning in patients with CPA tumors,
we chose an exploratory approach, including a variety of
measures of potential interest and not accounting for multi-
ple testing. Thus, our results can only be seen as preliminary.
On basis of our results, future studies might address more
focused and specific aspects of cognition (e.g., attention,
visuo-motor functioning). Due to the small sample size and
hypothesis-generating approach, we refrained from carrying
out a multiple regression analysis for prediction of patients’
HRQoL as this would have been severely underpowered and
thus not been able to detect predictors of clinical relevance.
We presume that HRQoL in patients with a CPA tumor can
best be explained by complex relationships within a bio-
psycho-social model. Choosing multiple regression analysis
in future studies with larger sample sizes will help to deepen
the understanding of the patients’ clinical situation. Finally,
we solely included preoperative patients and thus, our data
do not allow accounting for the effect of surgery. Future
studies might use neurocognitive baseline assessments for
comparison of the effects of different treatment approaches
on cognition and affect [9] in order to be able to inform
patients about possible effects of different treatment modali-
ties [7].
Conclusion
In summary, this was the first extensive study of neuropsy-
chiatric symptoms in patients with tumors within the CPA.
Our results demonstrate that patients with an untreated CPA
tumor frequently suffer from cognitive disorders, fatigue,
and elevated mood symptoms. These symptoms affect
patients’ HRQoL and are thus of clinical relevance. Includ-
ing these aspects in the routine clinical assessment and initi-
ating treatment accordingly might improve clinical manage-
ment of the patients and improve Quality of Life.
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Acknowledgements The authors are grateful to Maren Hinck for valu-
able support during manuscript preparation.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
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