Is neurosurgical intervention medically indicated for a patient with a meningioma, experiencing numbness and tingling on one side of the face, and having a history of chronic sinusitis, with a family history of Bell's Palsy and Glioblastoma Multiforme (GBM), due to the size of the meningioma?

Neurosurgical Intervention for Meningioma with Facial Numbness and Tingling

Yes, neurosurgical intervention is medically indicated for this patient with a symptomatic meningioma causing facial numbness and tingling, as complete surgical resection remains the treatment of choice for symptomatic meningiomas when it can be achieved with minimal morbidity. 1

Primary Treatment Recommendation

Complete surgical resection including removal of the dural attachment is the definitive treatment for symptomatic meningiomas. 1, 2 The presence of unilateral facial numbness and tingling represents a clear neurological deficit directly attributable to the meningioma, making this a symptomatic tumor that warrants intervention. 2

• The goal should be Simpson grade I or II resection (complete removal with dural attachment), as extent of resection directly correlates with recurrence rates 3, 2
• Modern surgical techniques including image-guided surgery (frameless stereotaxy) improve precision and may reduce surgical complications 1, 4

Critical Surgical Planning Considerations

The location and size of the meningioma determine the surgical approach and potential need for specialized expertise. 1

• If the tumor involves the skull base, cavernous sinus, or petrous bone, referral to a neurosurgeon specialized in skull base surgery is necessary, potentially requiring joint procedures with ENT or maxillofacial surgeons 1
• Intraoperative electrophysiological monitoring of cranial nerves is recommended when operating near structures that could cause facial symptoms 1
• For extremely large tumors, preoperative angiography and possible embolization should be considered to minimize blood loss 1

When Surgery May Be Too Risky

Some meningiomas may be too difficult or dangerous to remove completely due to their location or involvement of vital structures. 1

• Tumors enveloping major vessels (carotid artery, venous sinuses) or involving vital neural structures may require alternative approaches 1
• Intracavernous meningiomas specifically may warrant multidisciplinary discussion regarding risks of surgical death or significant neurological deficits versus alternative therapies 1
• In such cases, stereotactic radiosurgery (SRS) offers 5-year progression-free survival rates of 86-99% and 10-year rates of 69-97%, with neurological preservation rates of 80-100% 1

Alternative Treatment Pathway

For meningiomas <3 cm in diameter located in surgically challenging areas, stereotactic radiosurgery can be considered as primary treatment or adjuvant therapy after subtotal resection. 1

• SRS has become accepted as standard treatment for cavernous sinus meningiomas typically less than 3 cm diameter 1
• The combination of microsurgery and SRS has been adopted to reduce surgical morbidity while achieving decompression and tumor debulking for large meningiomas in critical locations 1
• Patients who undergo upfront SRS (without prior surgery) have significantly higher improvement rates of pre-existing cranial nerve symptoms compared to those who had prior microsurgery 1

Immediate Perioperative Management

Initiate dexamethasone to reduce peritumoral edema given the symptomatic presentation with neurological deficits. 2

• Start antiepileptic medication if any seizure activity is suspected, as seizures occur in up to 30% of meningiomas 2
• MRI with contrast must be performed within 2 weeks prior to intervention as baseline for treatment planning 2
• Document baseline neurological status precisely, including characterization of facial sensory changes and assessment for signs of increased intracranial pressure 2

Critical Pitfalls to Avoid

Do not delay surgical consultation in a patient with progressive disabling symptoms, as this can lead to irreversible neurological deficits. 3, 2

• Do not underestimate the surgical complexity of meningiomas involving venous structures or skull base, as these require specialized neurosurgical expertise 3, 2
• Do not leave dural attachment behind during resection, as there is a higher reported incidence of recurrence 1
• The overall risk of death or nonfatal stroke after meningioma resection is approximately 6%, with permanent surgical morbidity ranging from 5-23% depending on tumor location 3

Adjuvant Treatment Decisions

Post-operative management depends on histopathological findings. 2

• WHO Grade I (benign) tumors require observation with MRI surveillance every 6-12 months 3, 2, 5
• WHO Grade II (atypical) tumors with subtotal resection may require external beam radiation therapy 2
• Radiotherapy is considered for WHO grade II/III tumors, multiple relapses, invasion of adjacent brain, or extensive invasion of other tissues 1

Family History Considerations

The family history of Bell's Palsy and GBM does not contraindicate surgery but warrants careful preoperative counseling about cranial nerve risks. The chronic sinusitis history is relevant for surgical planning if an anterior skull base approach is needed, but does not preclude neurosurgical intervention. 1