Management of Symptomatic Falcine Meningioma

Immediate Clinical Assessment and Stabilization

The American Academy of Neurology recommends documenting baseline neurological status immediately, including precise characterization of left-sided weakness, evaluation for subtle sensory changes or visual field defects, assessment for signs of increased intracranial pressure, and detailed seizure characterization versus migraine aura differentiation 1
Initiate dexamethasone to reduce peritumoral edema given the symptomatic presentation with neurological deficits and daily headaches, as recommended by the American Association of Neurological Surgeons 1, 2
Start antiepileptic medication for the suspected focal seizures, as seizures occur in up to 30% of meningiomas and require immediate treatment, according to the British Journal of Neurosurgery 3, 1

MRI with contrast is mandatory and should be performed within 2 weeks prior to any intervention as baseline for treatment planning, as recommended by the American College of Radiology 2, 4
Look for homogeneous dural-based enhancement with characteristic "dural tail sign", degree of peritumoral edema, mass effect and cortical buckling, and relationship to eloquent cortex and vascular structures 2, 4

Complete surgical resection with removal of dural attachment is the treatment of choice for this symptomatic meningioma, as recommended by the Congress of Neurological Surgeons 2, 3
The goal is complete resection (Simpson grade I or II) as extent of resection directly correlates with recurrence rates, according to the American Association of Neurological Surgeons 2

Post-operative management depends on histopathological findings, with WHO Grade I (benign) tumors requiring observation with MRI surveillance every 6-12 months, as recommended by the National Comprehensive Cancer Network 2
WHO Grade II (atypical) tumors with subtotal resection may require external beam radiation therapy, according to the American Society for Radiation Oncology 2

Depression and fatigue require concurrent attention, with consideration of psychiatric consultation for depression management during perioperative period, as recommended by the American Psychiatric Association 1
Seizure management involves continuing antiepileptic medication perioperatively, with duration of post-operative antiepileptic therapy determined based on seizure control and surgical findings 1

Do not delay surgical consultation in a patient with progressive disabling symptoms, as recommended by the American Academy of Neurology 1, 4
Do not underestimate surgical complexity of parasagittal/falcine meningiomas due to potential involvement of superior sagittal sinus, risk of venous infarction, and need for specialized neurosurgical expertise 1, 4