Management of Meningioma
Primary Treatment Approach
Complete surgical resection with removal of the dural attachment is the optimal treatment for most meningiomas when feasible, as this provides the best chance for cure. 1
Treatment Algorithm by Clinical Presentation
Asymptomatic Small Meningiomas (<30 mm)
- Observation with serial MRI surveillance is recommended for asymptomatic lesions less than 30 mm 1
- Surgery should be considered if the tumor is accessible and potential neurological consequences exist despite lack of symptoms 1
- MRI surveillance should be performed every 6-12 months initially, with the possibility of extending intervals after achieving stable disease (typically 5-10 years) 1, 2
Symptomatic Meningiomas
- Surgery is the first-line treatment if the tumor is accessible 1
- Modern image-guided surgery (frameless stereotaxy) improves surgical precision and may reduce complications 1, 2
- Following surgery, adjuvant treatment depends on:
Radiation Therapy Options
Stereotactic Radiosurgery (SRS)
- Effective for residual or recurrent meningiomas, particularly those <3 cm in diameter 2
- Can be used as definitive monotherapy for grade 1 lesions in patients who are poor surgical candidates or have tumors in eloquent locations 3, 4
Fractionated Stereotactic Radiotherapy (SRT)
- Preferred for larger meningiomas (>3 cm) or those with pre-existing edema 2
- Conventional fractionation doses of 50-55 Gy are recommended 5
- Dose increases to 60 Gy should only be considered for WHO grade III meningiomas 5
External Beam Radiation Therapy (EBRT)
- Mandatory for WHO grade 3 meningiomas after surgery 1
- Required for subtotally resected WHO grade 2 meningiomas 1
- Treatment should be delivered daily, 5 days per week 5
Special Population Considerations
Pediatric Meningiomas
- Striking the balance between radiotherapy toxicity on the developing brain versus risk of recurrence is the most challenging aspect 5
- Pediatric meningiomas exhibit peculiarities that distinguish them from adult counterparts, particularly in very young children 5
- Currently, there is no recommendation to support the use of chemotherapy in children or adults 5
- All pediatric patients should be referred to geneticists for screening of conditions like NF-2, which often presents years after meningioma diagnosis 5
- MRI surveillance should be undertaken annually for at least 10 years since late recurrences are not uncommon 5
Complex Location Meningiomas (Skull Base, Torcular, Intraventricular)
- For tumors with extensive venous sinus involvement where complete resection carries high risk, a combination of subtotal resection followed by SRS/SRT is recommended 2
- Specialized surgical expertise is required for skull base and intraventricular locations 6
- Blood loss can be significant, particularly in intraventricular meningiomas and in patients with smaller blood volumes 2, 6
- Post-operative swelling should be managed with high-dose steroids, head elevation, and close neurological monitoring 2
Advanced Treatment Options
Peptide Receptor Radionuclide Therapy (PRRT)
- Shows promising results for treatment-refractory meningiomas 1
- Somatostatin receptor (SSTR) PET imaging must be performed prior to PRRT to confirm target expression 1
- Should be considered when tumor extension is unclear or for differentiation between recurrence and post-treatment changes 1, 2
Diagnostic Imaging Requirements
Primary Imaging
- MRI with contrast is the gold standard for meningioma evaluation 1, 2, 6
- Post-contrast T1-weighted imaging is the single most important sequence for tumor detection 1
- Typical features include homogeneous dural-based enhancement, dural tail sign, and CSF cleft between tumor and brain 1, 6
Complementary Imaging
- CT scan provides complementary information for calcified meningiomas and surgical planning of skull base anatomy 1, 2
- CT is significantly inferior to MRI and frequently misses small lesions, particularly in the internal auditory canal or cerebellopontine angle 1
- SSTR PET imaging provides superior detection sensitivity when tumor extension is unclear on conventional MRI 1
Post-Treatment Surveillance
Follow-up Imaging Schedule
- MRI without and with contrast every 6-12 months is recommended for WHO grade 1 meningiomas 1, 2
- After achieving stable disease (typically 5-10 years), follow-up intervals can be extended 2
- The post-radiotherapy MRI should be considered the "new baseline" rather than the postsurgical MRI 1
Long-term Monitoring
- Clinical follow-up should include routine neurological examinations and assessment for signs of increased intracranial pressure 2
- Recurrence rates for completely resected benign meningiomas can be up to 20% within 25 years, indicating the need for long-term follow-up 1
Critical Pitfalls to Avoid
- Not all enhancing dural-based lesions are meningiomas—brain metastases, gliomas, and primary CNS lymphoma can mimic meningiomas 6
- Underestimating the potential for significant blood loss during surgery, particularly with large or intraventricular tumors 6
- Overlooking the need for specialized surgical expertise for complex locations such as skull base or intraventricular meningiomas 6
- Relying on CT alone for excluding meningioma, as negative CT does not rule out the diagnosis, particularly for smaller or non-calcified lesions 1