How should a pregnant patient with a meningioma be evaluated and managed, including imaging, treatment, and delivery planning?

Management of Meningioma in Pregnant Patients

Imaging Evaluation

MRI without gadolinium contrast is the imaging modality of choice for evaluating meningiomas during pregnancy. 1

Recommended Imaging Protocol

• Perform MRI without gadolinium as the primary diagnostic tool, as gadolinium crosses the placenta and should be avoided 1
• Ultrasound can be used as an adjunct modality but has limited utility for intracranial pathology 1
• Chest X-ray with abdominal shielding is safe if needed for staging, though rarely indicated for meningioma 1
• Avoid CT scans, PET scans, and bone scans throughout pregnancy due to ionizing radiation exposure 1

Key Imaging Features to Document

• Tumor size, location, and dural attachment site 2
• Presence and degree of mass effect or midline shift 3
• Peritumoral edema 3, 2
• Signs of increased intracranial pressure 3
• Proximity to eloquent brain regions or critical neurovascular structures 1, 2

Important caveat: SSTR-directed PET imaging is listed as a relative contraindication in pregnancy and should only be performed after careful risk-benefit analysis 1

Clinical Assessment and Monitoring

Immediate Neurological Evaluation

• Document Glasgow Coma Scale score to establish baseline and monitor for deterioration 3
• Assess for focal neurological deficits including weakness, sensory changes, cranial nerve palsies, or visual field defects 3
• Evaluate for signs of increased intracranial pressure: headache, vomiting, papilledema, altered consciousness 3
• Monitor for seizure activity, which requires immediate antiepileptic medication 3

Understanding Pregnancy-Related Tumor Behavior

Meningiomas may grow rapidly during pregnancy due to hormonal receptor expression, transforming typically slow-growing tumors into acute neurosurgical emergencies. 4, 5, 6

• Hormonal and vascular changes during pregnancy can accelerate tumor growth 6
• Symptoms may progress rapidly even in previously stable tumors 4, 5
• Tumor regression after delivery has been reported but is unpredictable 5

Treatment Decision Algorithm

Conservative Management (Observation)

Consider conservative management with close monitoring when:

• Patient is asymptomatic or has minimal symptoms controllable with medical therapy 5, 7
• Tumor is small without significant mass effect 7
• Gestational age is advanced (>32-34 weeks) and delivery is imminent 5, 6
• No signs of increased intracranial pressure or neurological deterioration 3, 7

Medical management during observation:

• Administer dexamethasone to reduce peritumoral edema if symptomatic 3
• Prescribe antiepileptic drugs if seizures occur 3
• Perform serial neurological examinations 8, 7
• Consider repeat MRI if clinical deterioration occurs 5

Urgent Neurosurgical Intervention During Pregnancy

Proceed with immediate neurosurgical consultation and intervention when:

• Progressive neurological deterioration despite medical management 3, 8
• Signs of impending herniation or severe mass effect 8
• Brainstem compression symptoms 3
• Rapid decline in Glasgow Coma Scale score 3
• Advanced or progressive visual impairment from skull base tumors 7

Surgical timing considerations:

• Urgent resection is reserved for malignancies, active hydrocephalus, and benign tumors with impending herniation 8
• Second trimester (14-28 weeks) is the safest period for non-obstetric surgery if intervention cannot be delayed 1
• Avoid surgery in first trimester due to organogenesis risks 1

Delivery Planning and Timing

The optimal strategy is to achieve fetal maturity before addressing the meningioma, targeting delivery at ≥37 weeks gestation whenever maternal condition permits. 1, 5, 7

Delivery Timing Algorithm:

For stable patients with controlled symptoms:

• Target full-term delivery (≥37 weeks) 1
• Plan elective cesarean section followed by tumor resection postpartum 4, 5, 7
• Coordinate multidisciplinary team including obstetrician, neurosurgeon, and neonatologist 1, 4, 8

For patients with progressive symptoms at 28-34 weeks:

• Consider early delivery (34-37 weeks) if maternal neurological status is deteriorating but not immediately life-threatening 1, 5, 6
• Perform cesarean section under epidural anesthesia to allow intraoperative neurological monitoring 4
• Plan tumor resection within hours to days after delivery depending on urgency 4, 5

For patients with life-threatening neurological deterioration:

• Perform emergency cesarean delivery if fetus is viable (≥24 weeks) 6
• Proceed immediately to tumor resection after delivery 4, 6
• If fetus is pre-viable (<24 weeks), prioritize maternal life with immediate tumor resection 1, 8

Delivery Method Considerations:

• Cesarean section is preferred to allow controlled timing and immediate transition to neurosurgery 4, 5, 6
• Epidural anesthesia during cesarean allows assessment of maternal neurological function intraoperatively 4
• Avoid prolonged labor and vaginal delivery in patients with increased intracranial pressure 8

Surgical Approach and Anesthetic Considerations

Neurosurgical Principles

• Complete resection with removal of dural attachment is the optimal treatment when feasible 1, 2
• Image-guided surgery (frameless stereotaxy) improves precision and may reduce complications 1
• Skull base and intraventricular locations require specialized neurosurgical expertise 1, 3, 2
• Anticipate potential for significant blood loss, particularly with large hemispheric or intraventricular tumors 1, 3

Anesthetic Management During Pregnancy

The major challenge is balancing neuroanesthetic goals with obstetric requirements to avoid uterine hypoperfusion and fetal hypoxia. 8

• Maintain stable maternal hemodynamics throughout the procedure 8
• Ensure adequate uteroplacental perfusion 8
• Coordinate fetal monitoring with obstetric team if surgery performed during pregnancy 8, 7
• Have neonatal resuscitation team available if emergency delivery becomes necessary 8

Postpartum Management

Timing of Tumor Resection After Delivery

• Perform tumor resection within 6-9 days postpartum for patients who underwent early delivery for maternal indications 4, 5
• Earlier intervention (within hours) may be necessary if acute deterioration occurs after delivery 4
• Monitor closely for postpartum neurological changes as tumor behavior may change after hormonal shifts 5

Adjuvant Therapy Considerations

• Radiation therapy (including proton therapy) can be safely administered postpartum 5
• For WHO grade II/III tumors or incomplete resection, consider radiotherapy per standard guidelines 1, 2
• PRRT remains investigational and should only be considered for treatment-refractory cases with positive SSTR expression 1

Critical Pitfalls to Avoid

• Do not assume meningiomas will remain stable during pregnancy—rapid growth can occur due to hormonal influences 4, 5, 6
• Do not delay imaging with MRI (without gadolinium) when neurological symptoms develop—early diagnosis is critical 1, 4
• Do not use gadolinium contrast during MRI in pregnancy unless benefits clearly outweigh risks after multidisciplinary discussion 1
• Do not attempt vaginal delivery in patients with uncontrolled increased intracranial pressure—cesarean section is safer 8
• Do not underestimate the complexity of these cases—multidisciplinary team involvement (neurosurgery, obstetrics, anesthesia, neonatology) is essential 1, 4, 8, 7, 6
• Do not confuse meningioma symptoms with eclampsia or other pregnancy complications—maintain high index of suspicion for intracranial pathology 6

Multidisciplinary Team Coordination

A multidisciplinary meeting is critical and strongly recommended when managing pregnant patients with meningioma. 4, 8, 7, 6

Essential Team Members:

• Neurosurgeon with expertise in tumor resection 4, 8, 7
• Maternal-fetal medicine specialist or high-risk obstetrician 1, 4, 8, 6
• Neuroanesthesiologist 4, 8
• Neonatologist 1, 8, 7
• Neuro-oncologist for adjuvant therapy planning 2

Key Discussion Points:

• Maternal neurological status and trajectory 4, 7
• Gestational age and fetal viability 1, 5, 6
• Risks of delaying treatment versus risks of early delivery 1, 4, 7
• Optimal timing and sequence of delivery and tumor resection 4, 5, 7
• Anesthetic approach balancing maternal and fetal safety 8

Long-Term Follow-Up

• Perform MRI surveillance every 6-12 months for WHO grade I meningiomas postpartum 2, 9
• Monitor for tumor recurrence, which can occur in up to 20% of completely resected benign meningiomas within 25 years 2
• Counsel regarding future pregnancies and potential for tumor recurrence or growth with subsequent pregnancies 5, 6