What is the best course of treatment for an elderly female patient with a meningeoma (tumor of the meninges) and complaints of dizziness for 2 weeks?

Management of Elderly Female with Meningioma and Dizziness

The most appropriate initial approach is to determine whether the dizziness is causally related to the meningioma through detailed symptom characterization (timing, triggers, associated symptoms) and neurological examination, as dizziness in this context may represent either meningioma-related neurological dysfunction requiring intervention or an unrelated peripheral vestibular disorder requiring different management. 1, 2

Initial Diagnostic Assessment

Characterize the Dizziness Pattern

The quality of dizziness matters less than timing and triggers for determining etiology 2:

• Episodic vertigo triggered by head position changes suggests benign paroxysmal positional vertigo (BPPV), not meningioma-related 2
• Continuous disequilibrium or imbalance may indicate meningioma mass effect, particularly if the tumor involves the cerebellum, brainstem, or motor cortex 3
• Vertigo with unilateral hearing loss suggests Meniere disease rather than meningioma 2
• Episodic vertigo without triggers may indicate vestibular neuritis 2

Critical Neurological Examination

Perform focused assessment to distinguish peripheral from central causes 2:

• HINTS examination (head-impulse, nystagmus, test of skew) differentiates peripheral from central vestibular pathology 2
• Dix-Hallpike maneuver identifies BPPV 2
• Complete neurological examination assessing for focal deficits, cranial nerve dysfunction, motor weakness, or ataxia that would suggest meningioma-related symptoms 3
• Orthostatic blood pressure measurement to exclude presyncope 2

Review Meningioma Characteristics

Obtain or review recent brain MRI with contrast (within 2 weeks) to assess 1:

• Tumor location: Convexity tumors cause seizures; skull base tumors cause cranial nerve deficits; parasagittal tumors cause motor deficits 1
• Mass effect: Presence of edema, midline shift, or compression of critical structures 1
• Tumor size: Small (<30 mm) versus larger lesions requiring different management approaches 1

Treatment Algorithm Based on Assessment

If Dizziness is Unrelated to Meningioma (Peripheral Vestibular Disorder)

Treat the vestibular disorder specifically 2:

• BPPV: Perform canalith repositioning procedure (Epley maneuver) 2
• Meniere disease: Initiate salt restriction and diuretics 2
• Vestibular neuritis: Prescribe vestibular suppressant medications and vestibular rehabilitation 2

Manage the meningioma separately based on standard criteria 1:

• Asymptomatic small meningioma (<30 mm): Observation with MRI every 6-12 months 1
• Symptomatic or growing meningioma: Proceed to surgical evaluation 1

If Dizziness is Meningioma-Related (Central Etiology)

Symptomatic meningiomas require intervention 1, 4:

For Surgically Accessible Tumors

• Complete surgical resection with removal of dural attachment is the optimal treatment when feasible 5, 1
• Modern image-guided surgery (frameless stereotaxy) improves precision and reduces complications 5
• Gross total resection is often curative for WHO grade I meningiomas 4

For Surgically Inaccessible or High-Risk Patients

Stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (SRT) are appropriate alternatives 5:

• 5-year progression-free survival rates of 86-99% with SRS 5
• Neurological preservation rates of 80-100% post-SRS 5
• Consider SRT for larger tumors, those with brainstem extension, or pre-existing edema to minimize complications 5

For Elderly Patients with Significant Comorbidities

Observation may be appropriate even for symptomatic tumors 5, 1:

• Asymptomatic incidental meningiomas in elderly patients can be managed with watch-and-scan strategy 4
• Consider advanced age and comorbidities when weighing surgical risks 1

Common Pitfalls to Avoid

Do not assume dizziness is automatically caused by the meningioma 2: The temporal relationship (2 weeks of dizziness) and tumor characteristics must support causality. Many elderly patients have concurrent peripheral vestibular disorders that are readily treatable 2.

Do not order unnecessary imaging or laboratory tests for dizziness evaluation 2: The history, timing, triggers, and physical examination (including HINTS and Dix-Hallpike) provide sufficient diagnostic information in most cases 2.

Do not delay surgical referral if neurological examination reveals progressive deficits 3: Atypical symptom progression, new focal neurological signs, or worsening imbalance warrant urgent neurosurgical evaluation regardless of initial symptom presentation 3.

Avoid empiric corticosteroids without clear indication 5, 6: While steroids may reduce peritumoral edema, they should be reserved for specific situations (symptomatic mass effect, perioperative management) and tapered to the lowest effective dose, as they may decrease efficacy of certain treatments 5.

Surveillance Strategy

If observation is chosen 1:

• MRI with contrast every 6-12 months for WHO grade I meningiomas 1
• Clinical follow-up with neurological examination to monitor for symptom progression 1
• Somatostatin receptor PET imaging may distinguish tumor recurrence from post-treatment changes if intervention occurs 1