How should I manage a patient with mesial frontal‑lobe gliosis and postoperative edema after repeat resection of a falcine meningioma who now has frontal‑executive dysfunction (poor initiation, distractibility, needs repeated prompting) but preserved short‑term memory, naming, auditory comprehension, and sentence production?

Management of Frontal-Executive Dysfunction Following Repeat Falcine Meningioma Resection

Initiate high-dose dexamethasone (10 mg IV, then 4 mg every 6 hours) to address the postoperative mesial frontal edema, as this is the primary reversible cause of the executive dysfunction you are observing. 1, 2

Immediate Medical Management of Postoperative Edema

The frontal-executive syndrome (poor initiation, distractibility, need for repeated prompts) with preserved memory, language, and comprehension is classic for mesial frontal lobe dysfunction from gliosis and edema following your TONES procedure.

Corticosteroid therapy:

• Administer dexamethasone 10 mg IV initially, followed by 4 mg every 6 hours 1, 2
• Patients with clinical or radiological evidence of brain edema should be treated with the minimal effective dose, regularly re-evaluated 3
• Continue high-dose steroids with gradual taper over 1-2 weeks as swelling improves 1
• Methylprednisolone and prednisolone should be prescribed as single daily doses in the morning if switching from dexamethasone 3

Adjunctive measures for edema control:

• Elevate head of bed to 30-45 degrees to promote venous drainage 1
• Implement fluid restriction and osmotic diuretics if cerebral edema persists 1
• Maintain euvolemia to ensure adequate cerebral perfusion 1

Monitoring and imaging:

• Obtain serial MRI (or CT if MRI not possible) to monitor progression of swelling and rule out hematoma 1
• Close neurological monitoring for signs of deterioration or increased intracranial pressure 1

Cognitive Rehabilitation and Supportive Care

Neuropsychological intervention:

• The cognitive deficits you describe (executive dysfunction with preserved memory and language) are typical for frontal meningiomas and often improve postoperatively 4, 5, 6
• Meningioma patients demonstrate cognitive dysfunction in multiple domains preoperatively, but a large proportion (56% in one study) show postoperative improvement 4
• Surgery for frontal meningiomas does not impair cognitive functioning and may lead to improvements in attentional and executive functions over 4-9 months 6

Practical management strategies:

• Provide structured environment with minimal distractions to compensate for attentional deficits 3
• Use external cues and written instructions rather than relying on verbal prompts alone 3
• Cognitive rehabilitation should target executive functioning and attention domains specifically 3

Prophylaxis Against Complications

Thromboembolic prophylaxis:

• Administer prophylactic low-molecular weight heparin and compression stockings, as thromboembolism occurs frequently in brain tumor patients 3
• After 4-5 days post-surgery, therapeutic anticoagulation can be prescribed for thromboembolic complications without undue hemorrhagic risk 3

Gastrointestinal protection:

• Use H2-receptor blockers or proton pump inhibitors to prevent gastrointestinal complications in patients receiving high-dose corticosteroids 3

Seizure management:

• Antiepileptic prophylaxis is NOT indicated unless the patient has had seizures 3
• If seizures occur, use levetiracetam or lamotrigine as first-line agents due to efficacy and tolerability 3
• Avoid enzyme-inducing anticonvulsants 3

Expected Timeline and Prognosis

Recovery trajectory:

• Most patients with post-skull base surgery complications experience complete recovery with appropriate management 1
• Cognitive improvement typically occurs over 3-12 months postoperatively 4, 5, 6
• Postoperative cognitive assessment at 3 months showed 44% of meningioma patients scored low/very low in cognitive domains, compared to 69% preoperatively 4

Critical pitfall to avoid:

• Do not attribute permanent neuropsychological deficits to surgery; these should be interpreted as tumor-induced rather than surgery-induced 5
• The mesial frontal location and gliosis suggest the deficit is from the tumor's original location and postoperative edema, not surgical damage 5, 6

Long-term Monitoring

Follow-up assessment:

• Repeat neuropsychological testing at 3-6 months to document improvement trajectory 4, 6
• Continue monitoring for signs of recurrence, as extent of resection is the single most important predictor of outcome in falcine meningiomas 7
• Longer-term follow-up is recommended to identify predictors of cognitive improvement after surgery 4