Skull Base Meningioma

What is a Skull Base Meningioma?          

A meningioma is a type of tumour that grows from the protective membrane (the meninges) which cover the brain and spinal cord.

A skull base meningioma is one that grows at the base of the skull. There are many areas within the skull base region where a tumour may occur.

Your surgeon or specialist nurse will give you more details about your specific tumour.

Meningiomas in general are slow growing tumours which do not spread elsewhere in the body. The vast majority have an average growth rate of 1-3mm per year and some do not grow at all. Because of this not all need to be treated immediately. However, if your meningioma is very large, causing a lot of pressure on adjacent brain or nerves, it may need to be treated sooner.

Meningiomas can be split into 3 grades based on their appearance under the microscope:

 

Grade 1 – The most common type of Meningioma. Very slow growing tumour which   is less likely to return following treatment

Grade 2 – Slow growing tumour, however more likely to recur following treatment

Grade 3 – Fast growing, aggressive in nature, likely to recur following treatment

What has caused my meningioma?

• For most people with a meningioma the cause is unclear. These tumours are most commonly found in middle-aged or older people, and in particular women.

• It is recognised that there may be a link between some female hormones and rate of growth, although further research is currently looking into this.

• A rare genetic condition called Neurofibromatosis type 2 is linked to a higher risk of developing a meningioma. If your consultant feels that you need any further investigations for this condition, they will discuss this with you during your outpatient clinic appointment.

• In a very small number of patients, a meningioma may develop where radiotherapy to the head or spine has previously been given. This is rare and happens many years after the radiotherapy treatment.

What are the symptoms?

The symptoms of a meningioma depend on the size and location of the tumour. They usually develop as a result of compression of surrounding structures such as the brain, vessels or cranial nerves.

Meningioma tumours commonly grow inward, indenting and causing pressure on the brain or spinal cord. Occasionally, cranial meningiomas can involve the adjacent skull, causing thickening of the adjacent bone (known as hyperostosis).

Patients may experience a variety of symptoms.

These can include:

• Gradual worsening of headaches over weeks or months
• Balance disturbance
• Blurred or double vision
• Visual loss in one or both eyes
• Reduction or loss of smell and taste
• Loss of hearing
• Swallowing difficulty
• Weakness in face, arm or legs, or even pin & needles and numbness in the limbs
• Bowel or bladder dysfunction
• Personality and behavioural changes, confusion, memory loss
• Seizures (fits)

Not everyone will have symptoms. On occasions, tumours may be found:

• During routine scanning for another complaint.
• During eye examination by an optician. This may reveal abnormalities, which then will lead on to further investigations.

This is called an incidental finding.

How is my meningioma diagnosed?

Meningiomas have certain characteristics that can be identified on a scan, so in the majority of cases this is how a consultant will identify if your tumour is a likely meningioma.

The scan can be either MRI (Magnetic Resonance Imaging) or CT scan (Computerized Tomography). Both scans usually require an injection of contrast medium (dye) into a vein. This allows clearer vision of the tumour.

Depending on your symptoms you may require other investigations, such as visual assessment, hearing tests or a small camera passed into your nostrils to look at your throat. (see FEES, page 7)

What type of specialist will I see?

If you have a meningioma of the floor of the skull underneath your brain, you will be seen by a Consultant Neurosurgeon who specialises in Skull Base Surgery.

 

Treatment

What are the treatment options?

Treatment will vary according to individual circumstances, such as tumour size, growth, location, symptoms and your overall general health. Ultimately it is your choice to proceed with treatment once we have ensured that you have fully understood the risks and benefits of each treatment option.

There are three treatment options which will be considered for any meningioma:

1. Interval Imaging
2. Surgery
3. Radiotherapy

Interval Imaging

If your tumour is small and not causing any symptoms we may suggest no active treatment until clear tumour growth is demonstrated. This means that we do not perform any intervention, and simply monitor the situation by repeating an MRI scan and assessing your clinical symptoms. This shows if the meningioma is growing. Therefore you will undergo a period of observation known as ‘watch, wait and rescan’.

An MRI scan is the best type of scan to use for monitoring these tumours. This scan takes around 45 minutes. It is painless but quite noisy.

Occasionally MRI is not possible, for instance if you have magnetic metal work inside your body. In this instance a CT scan will be performed instead.

Once the scan is done, the specialist will arrange an outpatient appointment in our Skull Base clinic to discuss the findings with you.

This close monitoring enables the team to reassess your options at any given time. However, it is important that between hospital visits you inform the specialist nurse of any new or worsening symptoms or concerns.

What happens if my meningioma grows during this time?

If the scan shows there is growth, we will discuss your treatment options with you. Options include: continuing to watch and wait and re-scan or intervention by way of radiotherapy or surgery. These forms of treatment will be fully discussed with you in clinic to ensure you are fully informed about which type of treatment is best for you.

 

Surgery

 

Surgical intervention aims to remove all, or as much of the tumour as is safely possible. It is a major operation performed under general anaesthetic. It is not always possible to remove the entire tumour, because meningioma can be adherent to surrounding nerves or brain tissue. If this is the case, it is safer to leave a tiny amount of tumour rather than risk permanent neurological damage.

The approach for surgery depends upon the tumour size and location. There are general risks of craniotomy and specific risks in relation to your individual case, your surgeon will explain these in depth with you to support you in making an informed decision about treatment.

If surgery is decided as a treatment option, you will need to attend a pre-operative assessment appointment at The Walton Centre. Here, the clinical nurse specialist will discuss the process and recovery period in more detail and you will have the opportunity to ask any questions you may have.

You will also have the opportunity to meet with the Anaesthetist (Doctor who specialises in general anaesthetic) to discuss any concerns and risks associated with the procedure.

Post-operatively you will be monitored on a neurosurgical ward. Staff on the wards are highly experienced with the complex needs of patients following removal of a meningioma.

Length of stay and follow-up

The average length of stay for this operation is five days. This is dependent on your recovery and any symptoms experienced after the surgery.

The clinical nurse specialist team will meet with you at discharge to offer advice prior to going home.

The nurse specialist will initially follow you up via the telephone. This takes place approximately 2 weeks after discharge following surgery. You will have an MRI scan around 8 -12 weeks after surgery and the consultant will see you in clinic after the scan to monitor your recovery and arrange follow-up.

You will be given the phone number for the specialist nurse in case you have any questions or concerns.

Who performs the surgery?

Surgery will take place in The Walton Centre NHS Foundation Trust. It is carried out by a team of Neurosurgeons: a Consultant, who specialises in skull base surgery; a senior Clinical Fellow with a specialist interest in skull base surgery, and a Specialist Registrar – who is undergoing formal neurosurgical training.

What are the risks of surgery?

General Risks of Craniotomy

Following any type of surgery there is a risk in the immediate post-operative period. Risks include:

Infection (wound infection)

Meningitis (infection of the meninges)

Bleeding

Hydrocephalus (build-up of fluid on the brain)

Leakage of cerebro-spinal fluid (CSF)

Seizures

Small risk of death

Location of meningioma	Associated risks
Anterior Region
Olfactory groove meningioma	Reduction in sense of smell (hyposmia) Complete loss of sense of smell (anosmia) Changes in personality and behaviour Visual loss or visual field defect Seizures
Sphenoid wing meningioma	Visual loss Visual field defects Double vision (diplopia) Loss of sensation in face. Pain in face. Loss or reduced pituitary function. Seizures
Central Region
Suprasellar meningioma	Unilateral or bilateral visual loss. Double vision. Loss of sensation in face and facial numbness. Loss or reduced pituitary function.
Posterior Region
CP angle meningioma	Temporary or permanent damage to facial nerve Walking and balance disturbance Reduced or complete loss of hearing. Loss of sensation in face. Pain in face. Speech and swallowing difficulties.
Post Fossa meningioma	Difficulty walking Loss of balance Vertigo and nausea Swallowing difficulties

 

Radiotherapy

 

Radiotherapy is increasingly used as a treatment for meningioma. It can be used as a first line treatment, or to treat residual tumour following surgery. It involves radiation which is targeted directly to the tumour. It works by stopping cells from dividing and therefore stops tumour growth.

There are two ways of carrying out radiotherapy:

Stereotactic radiosurgery

Fractionated radiotherapy

You will receive an outpatient appointment with a Consultant Clinical Oncologist to discuss your individual treatment plan.

Stereotactic radiosurgery (SRS)

Stereotactic radiosurgery treatment involves delivery of high dose focused radiation to the tumour in one single treatment.

There are different types of SRS – the most appropriate treatment for your individual case will be discussed with you.

Although the radiosurgery machine delivers a high dose of radiation to the tumour, very little radiation reaches the surrounding normal brain. The aim is to stop the tumour growing and achieve control.

There are risks and side effects associated with radiosurgery which will be discussed with you during your consultation with the consultant and neuro oncologist.

Fractionated radiotherapy

Fractionated radiotherapy is also a type of radiation treatment which aims to stop the meningioma from growing but it is delivered in multiple sessions (fractions) over a period of time (weeks).

There are risks and side effects associated with fractionated radiotherapy.

The consultant and neuro oncologist will discuss this with you during your consultation.

Radiotherapy side effects

There are some general side effects possible from radiotherapy for all meningiomas:

• Tiredness which can last for a few months after radiotherapy finishes. Very rarely lasts longer
• Headaches
• Mild nausea
• Hair loss. This can be localised and/or all around the back of the head. Nearly always grows back
• Slight redness or soreness of scalp
• Short term memory loss or poorer concentration long term
• Very small risk of second tumours about 20 - 30 years following radiotherapy

There are other side effects which are dependent on the location of your meningioma and/or the type of radiotherapy you receive, for example

• Temporary or permanent damage to cranial nerves
• Increased dizziness/ balance issues
• Permanent hearing damage
• Temporary or permanent visual damage or cataracts
• Loss or reduced pituitary function
• Radio-necrosis which is excessive swelling of the normal brain tissue and sometimes requires a period of steroids to settle

Your neuro oncologist will discuss the side effects which are relevant to you at your clinic consultation.

Radiotherapy monitoring and follow up

Fractionated radiotherapy

You will be monitored weekly during your radiotherapy treatment by the neuro oncology clinical nurse specialists. They will assess you clinically and ensure they manage any supportive needs that you may have during your treatment. They are also able to offer advice prior to starting treatment.

Following on from treatment you will have a telephone review with the clinical nurse specialist 2 weeks from completion of treatment, if you feel you would like a review prior to this appointment please let the clinical nurse specialist know and they will arrange this with you.

You will then have a follow up with your Consultant Clinical Oncologist or a member of the team 6 weeks following completion of treatment. At this point you will have the opportunity to ask questions and discuss any worries or concerns that you may have.

Stereotactic radiosurgery

You will be monitored during SRS treatment by the specialist radiographers. You will then be able to go home. The Neuro Oncology Clinical Nurse Specialist will contact you the following day via telephone to assess you clinically and ensure they manage any supportive needs that you may have following on from treatment. They are also able to offer advice prior to starting treatment.

You will then have a telephone review with the clinical nurse specialist 2 weeks from completion of treatment, if you feel you would like a review prior to this appointment please let the clinical nurse specialist know and they will arrange this with you.

You will then have a follow up with your Consultant Clinical Oncologist or a member of the team 4 - 6 weeks following completion of treatment. At this point you will have the opportunity to ask questions and discuss any worries or concerns that you may have.

 

Follow up

What happens after my treatment?

Aftercare of patients is individualised depending on different factors:

• What treatment you have had
• The grade of the meningioma
• Symptoms

Depending on your symptoms you may also need the input from other disciplines such as speech and language therapists, dieticians, vestibular (balance) physiotherapists, neuropsychologist, audiology, ophthalmology and neurology.

 

Nurse specialist led clinic

If your condition remains stable and your consultant feels it is appropriate then you will be offered follow up by our clinical nurse specialist team. This can take place at The Walton Centre in a face to face consultation or in a telephone clinic.

If your condition changes, you will be referred back to your consultant.

Hearing Tests

We may offer you hearing tests called PTA (pure tone audiogram) and Speech Audiometry at certain points in your pathway. This enables us to see how the tumour is affecting your hearing, and how you are able to communicate with other people.

Hearing Aids

If we feel you would benefit from a hearing aid, you will be referred to your local audiologists who will assess and discuss the options available to you.

You may also wish to discuss this with your GP who can also refer you to your local audiologist.

If your hearing has been affected by the meningioma and you are also hard of hearing on the side with no tumour, then it may be worth considering a lip reading class to gain additional skills and confidence with communication. Information on support groups and available resources are listed at the end of this document.

Tinnitus and Balance Problems

Tinnitus, a ringing, buzzing or whooshing noise can be quite troublesome and often becomes worse after any form of intervention.  There are a number of effective therapies and support groups, which can help with management of tinnitus.

For those patients with balance disturbance or dizziness we can arrange a vestibular assessment by a specialist physiotherapist, and teach you exercises to retrain the balance system and provide strategies for dealing with difficult environments.

Speech and Language Therapy

If you have any communication or swallowing difficulties you may be referred to the Speech and Language Therapists (SALT) for their specialist involvement.

If your consultant has any concerns about your swallow we may undertake a diagnostic procedure called a Fibre optic Endoscopic Evaluation of Swallowing (FEES) in clinic. This procedure involves passing a small camera into your nostrils to allow the consultant to assess your swallowing function.

The SALT team or medical team may feel it is necessary to investigate any swallowing problems you may have with a video fluoroscopy (VFSE). This is an x-ray undertaken in the radiology department that looks at the way your swallowing works.

Ophthalmology

If you have a meningioma that extends into or around the eye (orbital region) it may cause symptoms that affects how the eyes work or look. These symptoms may include visual loss, visual field loss, or double vision.  You may notice a bulging to one or both eyes or drooping of the eye lid. If this is the case it may be necessary to refer you to an ophthalmologist (eye doctor).

Can I drive if I have a meningioma?

You must inform the DVLA about your diagnosis of a meningioma.

Certain factors can restrict your right to drive including surgery, seizures, symptoms, vision, and radiotherapy/SRS.

Note: It is the DVLA (not your consultant) that makes the decision concerning you driving and the length of time you must refrain from driving.

It is your legal responsibility to contact the DVLA.

You can contact the DVLA by phone on 0300 7906806 or at www.dvla.gov.uk.

Clinical Trials

Sometimes it isn’t always clear what the best treatment option is.

In order to clarify and help plan care for patients in the future, we have clinical trials running, both locally and nationally.

If you are eligible to participate in a clinical trial, your consultant will discuss it with you during your consultation.

 

Contacts

Who to contact?

Many questions can arise after diagnosis of a meningioma. Your assigned ‘key worker’ can provide further advice, information and support.

The key worker is usually the clinical nurse specialist (CNS). We advise that if you have any questions, no matter how small, or if you have any changes in your symptoms to contact the CNS

You may wish to discuss your diagnosis with your GP.

 

Skull Base Team

The Skull Base Team consists of specialists from The Walton Centre NHS Foundation Trust, Aintree University NHS Foundation Trust and Clatterbridge Cancer Centre NHS Foundation Trust.

 

Consultant Neurosurgeons

Miss C Gilkes

Mr Jawad Yousaf

 

There is also a wider multidisciplinary team who may be involved in your treatment including radiologists, radiographers and therapists. Together they work with other disciplines and ward staff to ensure that the highest quality of care is delivered to you.

Consultant ENT surgeons

Miss N Munir

Mr A Youssef

 

Consultant ENT Surgeon and Rhinologist

Mr S. Leong

 

Consultant Oncologists (Radiation Specialists)

Dr Chloë May

Dr Aditya Shenoy

 

Neurosurgical Clinical Nurse Specialist

Emma Wilby

Chloe Clayton

Hannah Gordon

 

Neuro Oncology Clinical Nurse Specialist

Jill Sokratous

 

Clinical Support Coordinator

 

Lead Audiologist

Tony Kay

 

Balance Physiotherapy Team

 

Nova Mullin, Cathy Morrow

 

Contact details of Skull base team:

 

Consultant seen in clinic:               ___________________________          

 

Clinical Nurse Specialist:                ___________________________

 

Walton Clinical Nurse Specialist Team Telephone: 0151 556 3449

Bleep via the switchboard 0151 529 3611 bleep 5342

Clatterbridge Cancer Centre Clinical Nurse Specialist Team: 0151 556 5850

 

Secretaries

Miss Gilkes:                                      Pam Armitage 0151 529 5671

Mr Yousaf:                                        Tina Hughes   0151 556 3350

Mr Youssef and Miss Munir:          Carol Taylor    0151 529 3404

Dr May:                                              Jane Williams  0151 556 5187

Dr Shenoy:                                        Jane Richards 0151 556 5054

 

For Walton admission, appointments or scan enquiries please call:

Pam Armitage 0151 529 5671

Tina Hughes   0151 556 3350

 

Chaplaincy service

The hospital provides a chaplaincy service if you would like to see a chaplain, please leave a message on 0151 529 3195.

 

Did you know……?

 

Many Hospital Trust websites (including The Walton Centre) now have the facility for making documents more accessible. This includes the ability to make them easier to read by changing font size, text colour and background colour. Documents in many other languages can be accessed and printed.

Resources and Support

The Brain Charity

Provides support that complements medical provision to people with a neurological condition, their families and professionals who care for them throughout their journey.

Norton Street Liverpool L3 8LR Tel:  0151 298 2999

www.thebraincharity.org.uk

British Tinnitus Association

The British Tinnitus Association

Ground Floor, Unit 5 Acorn Business Park, Woodseats Close

Sheffield S8 0TB Tel: 0800 018 527

info@tinnitus.org.uk

 

Action on Hearing Loss

Information Line: Telephone 0808 808 0123/9000

Email: informationline@hearingloss.org.uk

 

Meningioma UK 01787 374084 www.meningioma.org.uk enquiries@meningiomauk.org	Macmillan Cancer Support General enquiries tel. 020 7840 7840 www.macmillan.org.uk
Brain and spine foundation tel. 0808 808 1000 www.brainandspine.org.uk	Brain Tumour Action tel. 0131 466 3116 www.braintumouraction.org.uk
The Brain Tumour Charity Tel. 0808 800 0004 www.thebraintumourcharity.org/	Epilepsy Action tel. 0808 800 5050 www.epilepsy.org.uk