What is the recommended treatment for a torcular meningioma?

Treatment of Torcular Meningioma

For torcular meningiomas, the recommended treatment approach is a combination of surgical resection and radiation therapy, with the specific strategy determined by tumor size, symptoms, and venous sinus involvement. 1

Diagnostic Evaluation

• MRI with contrast is the gold standard for evaluating torcular meningiomas, revealing homogeneous dural-based enhancement, dural tail, and relationship to venous structures 2
• CT scan provides complementary information, particularly for calcified meningiomas, as it better visualizes calcifications that may not be clearly seen on MRI 3
• Somatostatin receptor (SSTR) PET imaging should be considered when tumor extension is unclear or for differentiation between recurrence and post-treatment changes 2

Treatment Algorithm Based on Tumor Characteristics

Surgical Management

• Complete surgical resection including dural attachment is the optimal treatment when feasible 2, 3
• For torcular meningiomas specifically, a planned staged approach may be necessary:
  • Initial debulking while preserving venous outflow through patent sinuses 1
  • Second-stage en bloc resection if the tumor fully occludes the venous confluence 1
• Modern surgical techniques including image-guided surgery (frameless stereotaxy) improve precision and may reduce surgical side effects 2

Radiation Therapy Options

• Stereotactic radiosurgery (SRS) is effective for residual or recurrent meningiomas, particularly those <3 cm in diameter 4
• For larger meningiomas or those with pre-existing edema, fractionated stereotactic radiotherapy (SRT) may be preferred 3
• External beam radiation therapy (EBRT) is indicated for WHO grade 3 (malignant) meningiomas after surgery and for subtotally resected WHO grade 2 (atypical) meningiomas 2
• Postsurgical adjuvant radiation therapy via fractionated external beam therapy has shown effectiveness for local control of torcular meningiomas 1

Special Considerations for Torcular Meningiomas

• Venous sinus involvement requires careful preoperative planning and assessment of collateral venous drainage 1, 5
• Radical removal may be possible when the sinus confluence is completely occluded and there is good collateral drainage 5
• Blood loss can be significant during surgery, particularly in patients with smaller blood volumes 3
• Preoperative angiography and possible embolization should be considered for extremely large tumors to minimize blood loss 6
• Post-operative swelling may occur and should be managed with high-dose steroids, head elevation, and close neurological monitoring 3

Treatment Decision Based on Tumor Size and Location

• Small (<3 cm) asymptomatic torcular meningiomas without significant mass effect may be observed with regular MRI surveillance 2
• Symptomatic torcular meningiomas or those showing growth should undergo surgical intervention when feasible 2, 1
• For tumors with extensive venous sinus involvement where complete resection carries high risk, a combination of subtotal resection followed by SRS/SRT is recommended 4, 1
• For WHO grade 2/3 tumors or incomplete resection, adjuvant radiation therapy is strongly recommended 2, 7

Post-Treatment Surveillance

• MRI without and with contrast every 6-12 months is recommended for follow-up 2
• After achieving stable disease status (typically after 5-10 years), follow-up intervals can be extended 3
• Clinical follow-up should include routine neurological examinations and assessment for signs of increased intracranial pressure 8