Meningioma Management Guidelines

Introduction to Meningioma Treatment

The American College of Neurological Surgeons recommends complete surgical resection with removal of the dural attachment as the optimal treatment for most meningiomas when feasible, as this provides the best chance for cure 1
Observation with serial MRI surveillance is recommended for asymptomatic lesions less than 30 mm, with surgery considered if the tumor is accessible and potential neurological consequences exist despite lack of symptoms 1

MRI with contrast is the gold standard for meningioma evaluation, with post-contrast T1-weighted imaging being the single most important sequence for tumor detection 1
CT scan provides complementary information for calcified meningiomas and surgical planning of skull base anatomy, but is significantly inferior to MRI and frequently misses small lesions 1
MRI without and with contrast every 6-12 months is recommended for WHO grade 1 meningiomas, with follow-up intervals extendable after achieving stable disease (typically 5-10 years) 1, 2

Surgery is the first-line treatment for symptomatic meningiomas if the tumor is accessible, with modern image-guided surgery (frameless stereotaxy) improving surgical precision and reducing complications 1, 2
External Beam Radiation Therapy (EBRT) is mandatory for WHO grade 3 meningiomas after surgery, and required for subtotally resected WHO grade 2 meningiomas 1
Stereotactic Radiosurgery (SRS) is effective for residual or recurrent meningiomas, particularly those <3 cm in diameter, while Fractionated Stereotactic Radiotherapy (SRT) is preferred for larger meningiomas (>3 cm) or those with pre-existing edema 2, 3

Pediatric meningiomas exhibit peculiarities that distinguish them from adult counterparts, particularly in very young children, with a need to balance radiotherapy toxicity on the developing brain versus risk of recurrence 3
All pediatric patients should be referred to geneticists for screening of conditions like NF-2, which often presents years after meningioma diagnosis, with MRI surveillance undertaken annually for at least 10 years due to the risk of late recurrences 3

Peptide Receptor Radionuclide Therapy (PRRT) shows promising results for treatment-refractory meningiomas, with Somatostatin receptor (SSTR) PET imaging necessary prior to PRRT to confirm target expression 1, 2
Not all enhancing dural-based lesions are meningiomas, with brain metastases, gliomas, and primary CNS lymphoma able to mimic meningiomas, highlighting the need for accurate diagnosis and specialized surgical expertise for complex locations 4