What is the recommended management for a patient with a 1.4x1.1x1.2 cm meningioma of the interhemispheric falx, presenting with left-sided weakness, daily low-grade headaches, severe fatigue, suspected focal seizures, depression, and loss of ability to work?

Management of Symptomatic Falcine Meningioma with Disabling Neurological Deficits

This patient requires urgent neurosurgical consultation for surgical resection given the significant neurological symptoms (left-sided weakness causing inability to work), daily headaches, severe fatigue, and suspected seizures from a 1.4 cm falcine meningioma. 1, 2

Immediate Clinical Assessment and Stabilization

Document baseline neurological status immediately including:

• Precise characterization of left-sided weakness (motor strength grading, functional impact) 1
• Evaluation for subtle sensory changes or visual field defects 1
• Assessment for signs of increased intracranial pressure (headache pattern, vomiting, papilledema) 1
• Detailed seizure characterization versus migraine aura differentiation 1

Initiate dexamethasone to reduce peritumoral edema given the symptomatic presentation with neurological deficits and daily headaches. 1, 2

Start antiepileptic medication for the suspected focal seizures, as seizures occur in up to 30% of meningiomas and require immediate treatment. 3, 1

Diagnostic Imaging Requirements

MRI with contrast is mandatory and should be performed within 2 weeks prior to any intervention as baseline for treatment planning. 2, 4 Look for:

• Homogeneous dural-based enhancement with characteristic "dural tail sign" 2, 4
• Degree of peritumoral edema (present in 40-80% of cases, particularly with symptomatic tumors) 4
• Mass effect and cortical buckling 4
• Relationship to eloquent cortex and vascular structures 2

Treatment Decision Algorithm

Primary Treatment: Surgical Resection

Complete surgical resection with removal of dural attachment is the treatment of choice for this symptomatic meningioma. 2, 5 The rationale is compelling:

• Symptomatic presentation with disabling deficits (inability to work) mandates intervention rather than observation 2, 5
• Falcine/parasagittal location is among the most common sites (50% of meningiomas) and typically surgically accessible 6
• Size of 1.4 cm makes this amenable to complete resection with acceptable surgical risk 2
• Complete resection is often curative for WHO grade I meningiomas (which represent 90% of cases) 7, 5

Surgical Considerations for Falcine Meningiomas

Modern surgical techniques should be employed including:

• Image-guided surgery (frameless stereotaxy) to improve precision and reduce morbidity 2
• Intraoperative neurophysiological monitoring given proximity to motor cortex 5
• Anticipation of potential significant blood loss (falcine meningiomas can be highly vascular) 1, 4

The goal is complete resection (Simpson grade I or II) as extent of resection directly correlates with recurrence rates—completely resected benign meningiomas have up to 20% recurrence at 25 years versus higher rates with subtotal resection. 2, 8

Adjuvant Treatment Decisions

Post-operative management depends on histopathological findings:

• WHO Grade I (benign) with complete resection: Observation with MRI surveillance every 6-12 months 2
• WHO Grade II (atypical) with subtotal resection: External beam radiation therapy 2, 9
• WHO Grade III (anaplastic): Adjuvant radiation therapy regardless of resection extent 2, 9

Management of Associated Symptoms

Depression and fatigue require concurrent attention:

• These symptoms may improve significantly after tumor resection and resolution of mass effect 6
• Consider psychiatric consultation for depression management during perioperative period
• Fatigue may be multifactorial (tumor burden, depression, seizure medication side effects, steroid effects)

Seizure management:

• Continue antiepileptic medication perioperatively 1
• Duration of post-operative antiepileptic therapy should be determined based on seizure control and surgical findings 7

Critical Pitfalls to Avoid

Do not delay surgical consultation in a patient with progressive disabling symptoms—"watchful waiting" is only appropriate for asymptomatic elderly patients with significant comorbidities, not a working-age patient with functional impairment. 6, 5

Do not underestimate surgical complexity of parasagittal/falcine meningiomas due to:

• Potential involvement of superior sagittal sinus 6
• Risk of venous infarction if bridging veins are compromised 5
• Need for specialized neurosurgical expertise 1, 4

Do not assume all symptoms are tumor-related—depression requires independent assessment and may need specific psychiatric intervention beyond tumor treatment. 6

Alternative Treatment Considerations

Stereotactic radiosurgery or radiotherapy could be considered only if:

• Surgical risk is deemed unacceptably high due to medical comorbidities 7, 5
• Patient refuses surgery after informed consent discussion 5

However, surgery remains strongly preferred given the symptomatic presentation with disabling deficits and accessible location. 2, 5 Radiation as primary treatment is typically reserved for asymptomatic small tumors showing growth, or surgically inaccessible locations (skull base, cavernous sinus). 2, 7

Expected Outcomes

With complete resection of a WHO Grade I meningioma:

• Ten-year survival exceeds 80% 6
• Neurological symptoms (weakness, headaches, seizures) typically improve or resolve 6, 7
• Return to work is achievable in most patients with successful resection and rehabilitation 5

The combination of surgical resection, appropriate perioperative medical management, and addressing concurrent depression offers this patient the best chance for symptom resolution and return to functional independence. 2, 5