Peer-Review ReportPreoperative Charlson Comorbidity Score Predicts Postoperative Outcomes Among Older Intracranial Meningioma Patients
Introduction
Meningiomas account for nearly one-fourth of all primary brain tumors, with one-half of these lesions presenting in patients older than 65 years of age (11, 14, 16). There is an increasing incidence of these tumors, likely related to population demographics and the greater use of diagnostic imaging. Given the increasing numbers of patients in advanced age who will be diagnosed with meningioma in the coming decades, there is an increasing need to define reliable, preoperative predictors of safe neurosurgical intervention for these older patients (11, 18).
During the past 20 years, ambiguity has arisen regarding the decision of whether to resect meningiomas in older adults because of wide variability in reported mortality rates, which range from 1.8% to 45% (2, 3, 4, 5, 6, 15, 17, 19, 20, 21, 23, 25, 26). Some investigators have attempted to define preoperative indicators for safe neurosurgical intervention, with several demonstrating the predictive value of patient age, sex, tumor size, and general health indicators, such as American Society of Anesthesiologists (ASA) (6, 31) and Karnofsky Performance Status (KPS) (13, 15, 17) scores, whereas the authors of other series have negated the value of such measures (3, 4, 5, 6, 8, 12, 13, 14, 15, 17, 19, 21, 22, 23, 25, 26, 27, 29, 30, 32, 34).
In light of viable nonoperative management approaches, including conservative management or stereotactic radiosurgery, identification of reliable preoperative markers associated with successful tumor excision remains an important goal and allows for more informed operative decision-making and truly informed consent (7, 24). Through this multicenter, retrospective cohort study of the Nationwide Inpatient Sample, we demonstrate that the Charlson score is predictive of inpatient postoperative outcome among elderly patients with meningioma.
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Data Source
We obtained the National Inpatient Sample (NIS) in-hospital discharge database for the years 1998 through 2005. Compiled by the Agency for Healthcare Research and Quality (Rockville, Maryland, USA), the NIS contains discharge information from a stratified random sample of 20% of all hospitals in 37 participating states (1). This publicly available, deidentified dataset was exempt for review by the Johns Hopkins Institutional Review Board.
Inclusion and Exclusion Criteria
Inclusion criteria included patients 65 years of age and
Univariate Analysis
A total of 5717 patients were identified; among these, we found a slight female predominance (66.6%). Most patients (93.1%) had benign or low-grade (World Health Organization grade I), meningiomas. Mean age was 73.6 years (median, 73 years), and most patients were white (81.8%). Patients had a mean Charlson score of 0.99 (median, 0). Most (67.4%) patients underwent elective surgical procedures. Mean length of stay was 9.1 days (median, 6 days). Patients had mean total hospital charges of
Discussion
The authors of numerous past series have attempted to define preoperative markers of safe neurosurgical intervention in older patients with meningiomas. Most have often focused upon patient age, sex, tumor size, and general health indicators, such as ASA and KPS scores, as possible predictive markers, often with conflicting results (3, 4, 5, 6, 8, 12, 13, 14, 15, 17, 19, 21, 22, 23, 25, 26, 27, 29, 30, 32, 34). Our study used a multicenter database to determine the value of a widely validated
Conclusions
Our study provides unique and important information regarding the value of the Charlson comorbidity score in predicting inpatient postoperative death, as well as postoperative respiratory, neurological and cardiac complications, LOS, and hospital charges, among older patients with meningioma. Our data support the safe surgical resection of meningiomas within a select group of older patients with low Charlson scores up through the ninth decade of life. Incorporating the Charlson score into
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Rachel Grossman and Debraj Mukherjee are co-first authors of this manuscript.
Conflict of interest: This work was supported in part by funding from Johns Hopkins Center for Innovative Medicine (Mukherjee and Quinones-Hinojosa); American Physicians Fellowship for Medicine in Israel (Grossman); and the Departments of Neurosurgery (Brem, Olivi, Quiñones-Hinojosa), Surgery (Chang), and Medicine (Bennett) at Johns Hopkins University School of Medicine.