Meningioma

Our Approach to Managing Meningioma

Observe wisely. Operate precisely. Protect permanently.

Meningioma management begins with a fundamental question that not every brain tumour demands: does this tumour need treatment at all, right now? A small, incidentally discovered convexity meningioma in a 75-year-old with no symptoms may never require surgery or radiation in the patient's lifetime, making watchful waiting with serial MRI the most appropriate and least harmful strategy. A symptomatic parasagittal meningioma causing progressive leg weakness in a 50-year-old demands urgent surgical resection. The clinical decision-making is as important as the technical execution.

At Shree Hospitals, our approach to benign brain tumour diagnosis and long term management places equal value on knowing when not to operate and when to act decisively. Our skull base meningioma specialists bring decades of experience in managing the full anatomical spectrum of meningioma locations, ranging from straightforward convexity lesions to the most complex skull base, petroclival, and cavernous sinus tumours.

1. Meningioma Characterisation & Risk Stratification

Precise diagnostic classification forms the backbone of effective oncological decision-making. Every patient undergoes advanced imaging and diagnostic evaluation to guide treatment planning:

• MRI brain with gadolinium contrast as the diagnostic imaging of choice, showing the characteristic dural tail and homogeneous enhancement
• CT bone window imaging to identify hyperostosis and bony invasion relevant to surgical planning
• MR angiography to assess tumour blood supply and proximity to major dural venous sinuses
• PET imaging with gallium-DOTATATE for skull base meningioma specialist pre-surgical planning, targeting somatostatin receptor-expressing meningioma
• WHO grading on histopathology: Grade 1 (benign, 90%), Grade 2 (atypical), and Grade 3 (anaplastic or malignant)
• Molecular markers, including TRAF7, KLF4, AKT1, and SMO mutations relevant to emerging targeted therapies

2. Active Surveillance (Watch, Wait, and Protect)

Not every meningioma requires immediate intervention:

• Annual MRI surveillance for small, asymptomatic Grade 1 meningiomas, as up to 50% show no growth over 5 years
• Surveillance frequency adjusted based on tumour location, size, and growth rate at each review
• Intervention triggered by symptomatic change, significant growth (greater than 3 mm per year), or development of intracranial pressure from tumour signs
• Clear explanation to patients and families of surveillance rationale to avoid unnecessary surgery while maintaining safety
• Meningioma specialist-led reviews ensuring surveillance decisions are revisited appropriately as clinical circumstances evolve

3. Microsurgical Resection

Surgery remains the definitive treatment for symptomatic or growing meningiomas:

• Simpson Grade I resection featuring complete removal of tumour, involved dura, and adjacent bone, associated with less than 5% recurrence at 10 years
• Skull base approaches, including pterional, retrosigmoid, transpetrosal, and orbitozygomatic craniotomies for complex skull base meningioma specialist cases
• Embolisation of highly vascular meningiomas 24 to 48 hours pre-operatively to reduce intraoperative blood loss significantly
• Neuromonitoring throughout surgery, including cranial nerve monitoring for skull base tumours adjacent to facial, trigeminal, and lower cranial nerves
• Intraoperative neuronavigation for precise tumour localisation and surgical corridor planning
• Endoscope-assisted approaches for parasellar and intraventricular meningiomas to reduce surgical invasiveness

4. Stereotactic Radiosurgery

For small to medium meningiomas in eloquent or surgically inaccessible locations, meningioma surgery and radiosurgery care in Mumbai at Shree Hospitals offers advanced radiation precision:

• Single-session radiosurgery (SRS), highly effective for meningiomas below 3 cm in diameter, achieving over 90% local control at 10 years
• Fractionated stereotactic radiotherapy (FSRT) for larger tumours or those adjacent to the optic apparatus, dividing dose to protect sensitive structures
• Post-operative radiosurgery for subtotally resected or high-grade meningiomas to reduce meningioma recurrence and surveillance burden
• Cavernous sinus meningiomas, where radiosurgery is preferred over surgery in most cases to preserve cranial nerve function

5. Management of Atypical & Malignant Meningioma

Grade 2 and Grade 3 meningiomas require more aggressive treatment:

• Maximal surgical resection followed by adjuvant radiotherapy as standard for WHO Grade 2 atypical meningioma
• Radiotherapy mandatory following any resection of WHO Grade 3 anaplastic meningioma
• Systemic therapy (hydroxyurea, somatostatin analogues, bevacizumab) for progressive unresectable meningioma
• Close meningioma recurrence and surveillance MRI programme every 6 months for atypical and malignant grades
• Tumour board review at each recurrence to determine optimal salvage strategy

6. Long-Term Surveillance & Hormonal Considerations

Continuous longitudinal care to preserve quality of life and handle disease progression promptly:

• Meningiomas express progesterone and oestrogen receptors, meaning hormonal factors including oral contraceptives and hormone replacement therapy may influence growth
• Hormonal counselling for women of reproductive age with known meningioma, giving guidance on contraceptive choices and pregnancy planning
• Structured meningioma recurrence and surveillance MRI programme for all treated patients, held annually for 5 years and every 2 years thereafter
• Neurological rehabilitation for patients with post-operative deficits, including physiotherapy, speech therapy, and occupational therapy
• Quality of life monitoring, assessing fatigue, cognitive function, and mood at every follow-up as part of Meningioma treatment in Mumbai, India