How is pseudoangina caused by a torcular meningioma managed?

Management of Pseudoangina Caused by Torcular Meningioma

Surgical resection is the primary treatment for torcular meningiomas causing pseudoangina, with complete removal including dural attachment being optimal when feasible. 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 1, 2
• CT scan provides complementary information, particularly for calcified meningiomas, which are present in up to 50% of cases 1, 2
• Somatostatin receptor (SSTR) PET imaging should be considered when tumor extension is unclear or for differentiation between recurrence and post-treatment changes 1, 3

Understanding Pseudoangina in Torcular Meningiomas

• Pseudoangina from torcular meningiomas typically presents as a difficult-to-describe headache, which is a prominent feature of posterior fossa meningiomas 4
• This pain can mimic cardiac angina but originates from compression or irritation of pain-sensitive structures near the torcular region 1
• Symptoms may be exacerbated by increased intracranial pressure, which commonly occurs with torcular meningiomas 4, 3

Treatment Algorithm

Surgical Management

• Complete surgical resection including dural attachment is the optimal treatment when feasible 1, 2
• For tumors with extensive venous sinus involvement where complete resection carries high risk, a combination of subtotal resection followed by stereotactic radiosurgery (SRS) is recommended 1, 5
• Modern surgical techniques including image-guided surgery improve precision and may reduce surgical side effects 1
• Special consideration must be given to venous drainage patterns, as torcular meningiomas often involve multiple venous sinuses 6

Radiation Therapy Options

• Stereotactic radiosurgery (SRS) is effective for residual or recurrent meningiomas, particularly those <3 cm in diameter 1
• For larger meningiomas or those with pre-existing edema, fractionated stereotactic radiotherapy (SRT) may be preferred 1
• 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

Management of Pseudoangina Symptoms

• High-dose steroids (dexamethasone) can help reduce peritumoral edema and alleviate pseudoangina symptoms prior to definitive treatment 3
• Analgesics may be used for symptomatic relief, but definitive treatment of the underlying meningioma is necessary for long-term resolution 1
• Post-operative swelling may temporarily worsen symptoms and should be managed with steroids, head elevation, and close neurological monitoring 1

Special Considerations for Torcular Meningiomas

• Blood loss can be significant during surgery, particularly with large or highly vascular tumors 1, 7
• Preservation of venous drainage is critical - complete occlusion of venous sinuses should be confirmed preoperatively if sinus resection is planned 6, 7
• Collateral venous drainage must be assessed before attempting radical resection involving major sinuses 8, 6
• Risk of peritumoral hemorrhage exists with torcular meningiomas, which can complicate management 8

Post-Treatment Surveillance

• MRI without and with contrast every 6-12 months is recommended for follow-up 1, 2
• After achieving stable disease status (typically after 5-10 years), follow-up intervals can be extended 1
• Clinical follow-up should include assessment for recurrence of pseudoangina symptoms and signs of increased intracranial pressure 1

Surgical Outcomes

• Simpson grade I resection (complete tumor removal with excision of dural attachment) offers the best long-term outcomes 9, 7
• For tumors with extensive sinus involvement, staged approaches may be necessary 5
• Recurrence rates are higher with subtotal resection, necessitating adjuvant radiation therapy 2, 7