Management of Pseudoangina Caused by Torcular Meningioma

Diagnostic Evaluation

MRI with contrast is the gold standard for evaluating torcular meningiomas, revealing homogeneous dural-based enhancement, dural tail, and relationship to venous structures 1, 2
CT scan provides complementary information, particularly for calcified meningiomas, which are present in up to 50% of cases 1, 2
Somatostatin receptor (SSTR) PET imaging should be considered when tumor extension is unclear or for differentiation between recurrence and post-treatment changes 1, 3

Pseudoangina from torcular meningiomas typically presents as a difficult-to-describe headache, which is a prominent feature of posterior fossa meningiomas 4, 5
This pain can mimic cardiac angina but originates from compression or irritation of pain-sensitive structures near the torcular region 1
Symptoms may be exacerbated by increased intracranial pressure, which commonly occurs with torcular meningiomas 4, 3

Complete surgical resection including dural attachment is the optimal treatment when feasible 1, 2
For tumors with extensive venous sinus involvement where complete resection carries high risk, a combination of subtotal resection followed by stereotactic radiosurgery (SRS) is recommended 1
Modern surgical techniques including image-guided surgery improve precision and may reduce surgical side effects 1

Stereotactic radiosurgery (SRS) is effective for residual or recurrent meningiomas, particularly those <3 cm in diameter 1
For larger meningiomas or those with pre-existing edema, fractionated stereotactic radiotherapy (SRT) may be preferred 1
External beam radiation therapy (EBRT) is indicated for WHO grade 3 (malignant) meningiomas after surgery and for subtotally resected WHO grade 2 (atypical) meningiomas 2

High-dose steroids (dexamethasone) can help reduce peritumoral edema and alleviate pseudoangina symptoms prior to definitive treatment 3
Analgesics may be used for symptomatic relief, but definitive treatment of the underlying meningioma is necessary for long-term resolution 1
Post-operative swelling may temporarily worsen symptoms and should be managed with steroids, head elevation, and close neurological monitoring 1

MRI without and with contrast every 6-12 months is recommended for follow-up 1, 2
After achieving stable disease status (typically after 5-10 years), follow-up intervals can be extended 1
Clinical follow-up should include assessment for recurrence of pseudoangina symptoms and signs of increased intracranial pressure 1

Recurrence rates are higher with subtotal resection, necessitating adjuvant radiation therapy 2