Literature ReviewIs Psychiatric Depression a Presenting Neurologic Sign of Meningioma? A Critical Review of the Literature with Causative Etiology
Introduction
Meningiomas are the most common type of central nervous system tumor, representing approximately 37% of all primary central nervous system tumors.1 Although the vast majority are benign solitary intracranial neoplasms typically located in the skull base or over the convexity of the brain, their position can result in significant morbidity and mortality.2, 3 The World Health Organization (WHO) classifies meningiomas into 3 categories by tumor differentiation and mitotic activity: benign (WHO grade I), atypical (WHO grade II), and anaplastic/malignant (WHO grade III).4 Population-based studies approximate that 80%–90% of meningiomas are WHO grade I.5, 6 Many meningiomas are extremely slow growing and are asymptomatic or minimally symptomatic. As such, diagnosis is often made via an incidental finding on neuroimaging or at an autopsy; a systematic review and meta-analysis of incidental findings on brain magnetic resonance imaging in approximately 20,000 patients found meningioma to be the most common incidental tumor, identified on 0.29% of magnetic resonance imaging.7, 8 For those that are symptomatic, the mass's location and the period of time over which the tumor grows primarily influence the symptoms at presentation.9 Early identification of meningioma before clinical progression is essential to maximize treatment options and efficacy, and it is often critical to avoid serious neurologic deficits and improve survival.10, 11
Early diagnosis of meningioma is challenging as so few tumors are initially symptomatic. Signs and symptoms that are typically viewed as consistent with meningioma presentation are seizures and focal deficits to include visual changes, loss of hearing or smell, mental status changes, and extremity weakness.11, 12, 13 It is well-documented that psychiatric signs are common complications of brain tumor progression and that depression is the most common in patients with meningioma, impacting more than 20% of patients.14, 15 It also has been found that larger tumor volumes, frontal location, and left/dominant hemisphere are predictors of possible neurocognitive deficits, with specific emphasis on depression and anxiety.16 However, in rarer cases, patients may present initially and primarily with psychiatric signs, notably depression. These presentations of depression are often treated with traditional antidepressant regimens to include selective serotonin reuptake inhibitors (SSRIs) and/or other classes of antidepressant medications, as well as psychotherapy, to which these patients are treatment-refractory.17 A subtle initial presentation of depression, preceding classic symptoms such as headache, visual disturbances, and focal deficits, could be an early sign of meningioma and may warrant a heightened sense of awareness on the part of the clinician. As opposed to a secondary depression due to receiving a brain tumor diagnosis or anticipating a neurosurgical procedure, initial depression on presentation may be a premature sign of meningioma. In this study, we explored a potential discernable link between treatment-refractory depression in patients with no previous history of psychiatric illness and identification of meningioma.
Section snippets
Methods
We conducted a comprehensive literature search through PubMed to identify prospective or retrospective studies, case reports, case series, and literature reviews that address depression and meningioma diagnosis. We selected the terms depression, psychiatric, meningioma, SSRI, and antidepressants. All applicable papers were evaluated for their relevance. Two reviewers independently examined the search results to screen for applicable papers. Exclusion criteria consisted of history of depression
Results
The flow chart depicted in Figure 1 outlines the selection of included studies and case reports. The literature search identified 156 records. There was agreement on 33 articles (14 clinical studies and 19 case reports) that met final inclusion criteria. Of the 14 clinical studies, 12 were prospective and 2 were retrospective. The included studies and reports represent an aggregate of 1401 patients with an intracranial meningioma. Summaries of the previous clinical studies and cases reports are
Discussion
The history of depression as a presenting sign of meningioma is complex and likely based on many independent variables. The earliest presentation of this potential relationship was first published as a case report in 1968.47 Current review of prospective studies have analyzed depression primarily via 4 approaches, comparing: the prevalence or severity of depression signs in meningioma patients versus other brain tumor types, the prevalence of depression as reflective of meningioma location,
Conclusions
There are likely subtle signs in neurologic presentation that often get missed in the initial diagnosis of patients with meningioma. Psychiatric depression may be one of these early signs preceding more traditional symptoms. There is evidence that depression is correlated with meningioma presentation, but that its prevalence as a sign is likely dependent on tumor location. An increased risk of clinical depression in patients with anterior-located tumors may be related to a disruption of the
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.