What is the approach to taking a history and performing a physical examination (PE) for a suspected meningioma case?

History and Physical Examination Approach for Suspected Meningioma

The most effective approach to history taking and physical examination for a suspected meningioma case should focus on identifying neurological symptoms based on tumor location, assessing for signs of increased intracranial pressure, and documenting any seizure activity. 1

History Taking

Chief Complaint and Presenting Symptoms

• Document typical presenting symptoms including headache (present in 42% of cases), seizures (30%), and visual disturbances (28%) 2
• Note the duration of symptoms, as 70% of patients have symptoms for up to two years before diagnosis, while 25% have symptoms for less than six months 2
• Record any focal neurological symptoms that may correlate with tumor location 1

Specific Symptoms to Inquire About

• Headache characteristics: timing, severity, exacerbating factors, and response to analgesics 1
• Visual changes: diplopia, blurry vision, visual field defects 3
• Hearing loss or tinnitus (may indicate cranial nerve VIII involvement) 3
• Mental status changes: confusion, personality changes, memory issues 3
• Gait difficulties or balance problems 3
• Focal or radiating neck and back pain 3
• Seizure activity: type, frequency, duration, and precipitating factors 1

Important Associated Symptoms

• Nausea and vomiting (may indicate increased intracranial pressure) 3
• Bladder, sexual, and bowel dysfunction (often underreported) 3
• Sensory deficits in extremities 3

Physical Examination

General Neurological Examination

• Use a standardized neurological evaluation form to document findings systematically 3
• Assess mental status, including level of consciousness, orientation, and cognitive function 1
• Evaluate cranial nerve function, particularly II, III, IV, VI, and VIII, which are commonly affected 3

Focal Neurological Assessment

• Document any subtle weakness, sensory changes, or cranial nerve deficits based on suspected tumor location 1
• Assess for paresis, which is common in falx convexity region meningiomas 2
• Check for reflex differences (present in 30% of cases) and hemiparesis (13% of cases) 2

Signs of Increased Intracranial Pressure

• Evaluate for papilledema (present in 41% of patients with meningiomas) 2
• Assess for nausea, vomiting, and headache that worsens with position changes 1
• Check for bradycardia and hypertension (Cushing's triad) in severe cases 1

Special Examination Techniques

• Perform jolt accentuation test (positive when horizontal rotation of the head worsens headache) 4
• Assess for resistance to passive flexion of the neck (most commonly observed meningeal sign) 4
• Examine for any petechial rash, which may indicate meningeal involvement 4

Important Considerations

Location-Specific Assessment

• For suspected skull base meningiomas: perform detailed cranial nerve examination 1
• For posterior fossa lesions: assess for brainstem compression symptoms and cerebellar signs 1
• For intraventricular meningiomas: focus on signs of hydrocephalus 1

Age-Specific Considerations

• In pediatric patients: meningiomas are more likely to present with calcifications and cystic transformation 1
• In elderly patients: consider comorbidities that may affect symptom presentation 1

Diagnostic Pitfalls to Avoid

• Do not rule out meningioma based on absence of neurological findings, as some patients may be asymptomatic despite large tumors 2
• Remember that meningiomas can mimic other conditions, and not all enhancing dural-based lesions are meningiomas 1
• Be aware that even histologically typical meningiomas can have unusual or misleading radiologic features 5

Documentation and Next Steps

• Document all findings systematically using a standardized neurological assessment form 3
• Based on history and physical examination findings, determine the need for appropriate imaging studies 3
• MRI with and without contrast is the preferred imaging modality for suspected meningiomas 3
• Consider somatostatin receptor PET imaging in complex cases where diagnosis is uncertain 1