⚠️

DRAFT - Pending Review

This plan requires physician review before clinical use.

Meningioma

VERSION: 1.1 CREATED: January 30, 2026 REVISED: January 30, 2026 STATUS: Draft - Revised per checker pipeline

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DIAGNOSIS: Meningioma (WHO Grade I, II, III)

ICD-10: D32.9 (Benign neoplasm of meninges, unspecified), D32.0 (Benign neoplasm of cerebral meninges), D32.1 (Benign neoplasm of spinal meninges), D42.9 (Neoplasm of uncertain behavior of meninges, unspecified), D42.0 (Neoplasm of uncertain behavior of cerebral meninges), C70.0 (Malignant neoplasm of cerebral meninges), C70.9 (Malignant neoplasm of meninges, unspecified), G93.6 (Cerebral edema)

SYNONYMS: Meningioma, meningioma WHO grade I, benign meningioma, atypical meningioma, anaplastic meningioma, malignant meningioma, WHO grade II meningioma, WHO grade III meningioma, convexity meningioma, parasagittal meningioma, falcine meningioma, skull base meningioma, sphenoid wing meningioma, petroclival meningioma, tentorial meningioma, cerebellopontine angle meningioma, CPA meningioma, olfactory groove meningioma, tuberculum sellae meningioma, posterior fossa meningioma, foramen magnum meningioma, intraventricular meningioma, en plaque meningioma, meningothelial meningioma, fibrous meningioma, transitional meningioma, psammomatous meningioma, secretory meningioma, incidental meningioma, dural-based tumor, extra-axial mass, intracranial meningioma

SCOPE: Comprehensive management of newly diagnosed and recurrent meningiomas (WHO grades I, II, and III) in adults. Covers incidental discovery, symptomatic presentation, neuroimaging evaluation (MRI with gadolinium, CT), observation criteria for asymptomatic/small meningiomas, surgical planning (including skull base approaches), stereotactic radiosurgery (SRS) and fractionated radiation therapy, perioperative management (dexamethasone, seizure control), recurrence monitoring with serial MRI, and grade-specific treatment strategies. Excludes pediatric meningiomas, radiation-induced meningiomas (separate etiologic consideration but same management), and spinal meningiomas (briefly referenced but distinct surgical approach).

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PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════

1. LABORATORY WORKUP

1A. Essential/Core Labs

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
CBC with differential (CPT 85025)	Pre-operative baseline; platelet count for surgical candidacy; leukocytosis screen if infection differential	WBC, platelets within normal limits	STAT	STAT	ROUTINE	STAT
CMP (BMP + LFTs) (CPT 80053)	Renal function for contrast imaging; hepatic function baseline for medications; electrolyte assessment; glucose baseline before dexamethasone	Normal; anticipate glucose elevation with dexamethasone	STAT	STAT	ROUTINE	STAT
PT/INR, aPTT (CPT 85610+85730)	Coagulopathy assessment for surgical candidacy; pre-operative clearance	Normal (INR <1.5 for surgery)	STAT	STAT	ROUTINE	STAT
Blood glucose (CPT 82947)	Steroid-induced hyperglycemia baseline if dexamethasone initiated; pre-operative assessment	<180 mg/dL	STAT	STAT	ROUTINE	STAT
Type and screen	Pre-operative for craniotomy; anticipate intraoperative blood loss especially for vascular skull base meningiomas	Available for crossmatch	STAT	STAT	-	STAT
TSH (CPT 84443)	Fatigue differential; baseline before radiation therapy if planned; pituitary axis assessment if parasellar meningioma	Normal	-	ROUTINE	ROUTINE	-
Pregnancy test (women of childbearing age) (CPT 81025)	Radiation contraindicated in pregnancy; contrast imaging considerations; meningiomas may enlarge during pregnancy due to progesterone receptors	Negative	STAT	STAT	ROUTINE	STAT

1B. Extended Workup (Second-line)

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Prolactin (CPT 84146)	If parasellar or suprasellar meningioma compressing pituitary stalk; hyperprolactinemia from stalk effect	Mildly elevated if stalk effect (<200 ng/mL); markedly elevated suggests prolactinoma	-	ROUTINE	ROUTINE	-
Cortisol (AM) (CPT 82533)	If parasellar meningioma with suspected pituitary axis compromise; baseline before dexamethasone	Normal (>10 mcg/dL AM); low suggests hypopituitarism	-	ROUTINE	ROUTINE	-
IGF-1 (CPT 84305)	Growth hormone axis assessment if parasellar meningioma compressing pituitary	Normal for age	-	ROUTINE	ROUTINE	-
Free T4 (CPT 84439)	Pituitary axis assessment if parasellar meningioma; complement TSH	Normal	-	ROUTINE	ROUTINE	-
LH, FSH (CPT 83002, 83001)	Gonadotropin axis assessment if parasellar meningioma; menstrual irregularity evaluation	Normal for age and sex	-	ROUTINE	ROUTINE	-
ESR / CRP (CPT 85652+86140)	If infection differential (epidural abscess, pachymeningitis); inflammatory markers	Normal	-	ROUTINE	ROUTINE	-
Troponin (CPT 84484)	If syncope or seizure presentation; cardiac evaluation before surgery	Normal	STAT	STAT	-	STAT
CPK/CK (CPT 82550)	Post-seizure rhabdomyolysis screen	Normal; elevated after prolonged seizures	URGENT	ROUTINE	-	STAT
HbA1c (CPT 83036)	Glycemic status before initiating prolonged dexamethasone; perioperative glucose optimization	<7.0% (ideal)	-	ROUTINE	ROUTINE	-

1C. Rare/Specialized (Refractory or Atypical)

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Serum protein electrophoresis (SPEP) (CPT 86335)	If multiple dural-based lesions raising concern for plasmacytoma or lymphoproliferative disorder	Normal; monoclonal band absent	-	EXT	EXT	-
ACE level (CPT 82164)	Neurosarcoidosis differential if dural-based enhancing mass	Normal (<52 U/L); elevated in sarcoidosis	-	EXT	EXT	-
IgG4 (CPT 86235)	IgG4-related pachymeningitis differential if diffuse dural thickening	Normal (<135 mg/dL); elevated in IgG4 disease	-	EXT	EXT	-
NF2 genetic testing	If bilateral meningiomas or multiple meningiomas suggesting neurofibromatosis type 2; young patients with meningioma	NF2 mutation status	-	-	EXT	-
SMARCE1, TRAF7, KLF4, AKT1, PIK3CA, SMO mutation panel	Molecular profiling for treatment-refractory or recurrent atypical/anaplastic meningiomas; emerging targeted therapy targets	Molecular profile for treatment planning	-	-	EXT	-
Paraneoplastic antibody panel (serum)	If clinical presentation suggests paraneoplastic syndrome; dural metastasis differential	Negative	-	EXT	EXT	-

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2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
CT head without contrast (CPT 70450)	Immediately upon presentation for acute symptoms (seizure, headache, focal deficit, altered mental status)	Extra-axial hyperdense or isodense mass; calcification (20-25% of meningiomas); hyperostosis of adjacent bone; possible hemorrhage; midline shift; hydrocephalus	None in emergency	STAT	STAT	-	STAT
MRI brain with and without contrast (gadolinium) (CPT 70553)	Within 24-48h of presentation; GOLD STANDARD for meningioma; for incidental findings: baseline MRI then observation	Homogeneously enhancing extra-axial dural-based mass; broad dural attachment; dural tail sign (60-72%); well-circumscribed margins; CSF cleft between tumor and brain; T2 signal variable (iso to hyperintense); calcification as signal voids; arterial supply from meningeal vessels; possible venous sinus invasion (parasagittal/falcine)	MRI-incompatible implants; GFR <30 (gadolinium risk); severe claustrophobia	STAT	STAT	ROUTINE	STAT
CT head with contrast (CPT 70460)	If MRI contraindicated or unavailable; initial evaluation in ED	Homogeneously enhancing extra-axial mass; calcification; hyperostosis; may show bony invasion	Contrast allergy; renal impairment	URGENT	URGENT	ROUTINE	URGENT
ECG (12-lead) (CPT 93000)	Pre-operative baseline; QTc assessment for anti-emetics	Normal	None	STAT	STAT	ROUTINE	STAT
Chest X-ray (CPT 71046)	Pre-operative clearance; metastatic disease differential (dural metastases)	No lung mass; no effusion	Pregnancy (shield)	STAT	STAT	ROUTINE	STAT

2B. Extended

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MR venography (MRV) (CPT 70547)	Pre-operative for parasagittal and falcine meningiomas; assess venous sinus patency and degree of invasion	Patent vs. occluded sagittal sinus; degree of sinus invasion (partial vs. complete); collateral venous drainage pathways; critical for surgical planning	MRI-incompatible implants; GFR <30 (gadolinium risk); severe claustrophobia	-	URGENT	ROUTINE	-
CT angiography (CTA) of head (CPT 70496)	Pre-operative vascular mapping; large or vascular meningiomas; skull base tumors encasing major arteries	Arterial supply identification; ICA/vertebral artery encasement assessment; surgical planning for vascular control	Contrast allergy; renal impairment	-	URGENT	ROUTINE	-
Digital subtraction angiography (DSA) (CPT 36224)	Pre-operative embolization planning for large vascular meningiomas; assess feeding vessels and collateral supply	Tumor blush; feeding arteries (MMA, occipital, APhA); degree of vascularity; potential for pre-operative embolization to reduce intraoperative blood loss	Contrast allergy; renal impairment; coagulopathy; vascular access complications	-	ROUTINE	ROUTINE	-
Pre-operative embolization (CPT 61624)	24-48h before surgery for large hypervascular meningiomas; reduces intraoperative blood loss	Reduced tumor vascularity; confirmation of embolized feeding vessels	Eloquent vessel supply; dangerous anastomoses (ECA to ICA); coagulopathy	-	ROUTINE	-	-
MRI orbits with contrast (CPT 70543)	Sphenoid wing or optic nerve sheath meningioma with visual symptoms	Optic nerve compression; optic canal involvement; orbital extension	MRI-incompatible implants; GFR <30 (gadolinium risk); severe claustrophobia	-	ROUTINE	ROUTINE	-
Formal visual field testing (Humphrey) (CPT 92083)	Baseline for parasellar, sphenoid wing, or optic nerve sheath meningiomas; monitor visual function pre and post treatment	Visual field deficit pattern (bitemporal hemianopia if chiasmal; homonymous if optic tract)	Patient cooperation required	-	ROUTINE	ROUTINE	-
Audiometry (CPT 92557)	Baseline for cerebellopontine angle (CPA) meningiomas or those involving internal auditory canal	Sensorineural hearing loss; speech discrimination score	Patient cooperation required	-	ROUTINE	ROUTINE	-
MRI spine (whole) with contrast (CPT 72156+72157+72158)	If NF2 suspected (multiple meningiomas); spinal symptoms suggesting spinal meningioma	Spinal meningiomas; drop metastases (very rare, grade III only)	MRI-incompatible implants; GFR <30 (gadolinium risk); severe claustrophobia	-	ROUTINE	ROUTINE	-

2C. Rare/Specialized

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MR perfusion (DSC or DCE) (CPT 70553)	Atypical imaging features; differentiate meningioma from hemangiopericytoma/SFT, dural metastases, or lymphoma	Elevated rCBV in meningioma; hemangiopericytoma may show higher rCBV; dural metastases variable	MRI-incompatible implants; GFR <30 (gadolinium risk); severe claustrophobia	-	EXT	EXT	-
MR spectroscopy (MRS) (CPT 76390)	Atypical imaging appearance; differentiate from other dural-based lesions	Elevated alanine peak (characteristic of meningioma); elevated glutamine/glutamate; low NAA (extra-axial, no neuronal markers)	MRI-incompatible implants; GFR <30 (gadolinium risk); severe claustrophobia	-	EXT	EXT	-
FDG-PET or Ga-68 DOTATATE PET (CPT 78816)	Ga-68 DOTATATE: somatostatin receptor-positive meningioma detection; recurrence monitoring; treatment planning for peptide receptor radionuclide therapy (PRRT); FDG-PET: differentiate high-grade from low-grade meningioma	DOTATATE: high uptake in meningioma (somatostatin receptor 2a positive); FDG: higher uptake in grade II/III vs. grade I	Pregnancy; limited availability for DOTATATE	-	-	EXT	-
Octreotide scan (In-111 pentetreotide) (CPT 78802)	Somatostatin receptor expression assessment for potential somatostatin analog therapy in recurrent meningioma	Positive uptake indicates somatostatin receptor expression (treatment target)	Pregnancy	-	-	EXT	-

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3. TREATMENT

CRITICAL: Meningioma management depends on WHO grade, tumor size, location, symptoms, patient age, and comorbidities. Many meningiomas (especially small, asymptomatic, incidental WHO grade I) are managed with observation and serial imaging. Treatment decisions require multidisciplinary coordination (neurosurgery, radiation oncology, neuro-oncology for atypical/malignant grades).

3A. Acute/Emergent

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Dexamethasone (vasogenic edema)	IV/PO	Vasogenic edema from meningioma; symptomatic mass effect; perioperative edema reduction; reduce peritumoral swelling to improve neurologic function	10 mg :: IV :: load, then 4 mg q6h :: 10 mg IV loading dose, then 4 mg IV/PO q6h; moderate symptoms: 4-8 mg/day; severe edema/herniation: 10 mg IV bolus then 4-8 mg q6h (up to 16-24 mg/day); taper as soon as clinically feasible over 1-2 weeks post-surgery; GI prophylaxis with PPI while on steroids	Active untreated infection; uncontrolled diabetes (relative); psychosis history (relative)	Glucose q6h (target <180 mg/dL), BP, mood/sleep, GI symptoms, signs of infection	STAT	STAT	URGENT	STAT
Lorazepam (acute seizure)	IV	Acute seizure termination; seizures occur in 20-50% of convexity meningiomas	4 mg :: IV :: PRN seizure :: 0.1 mg/kg IV (max 4 mg/dose); may repeat x1 in 5 min; max 8 mg total	Acute narrow-angle glaucoma; severe respiratory depression without ventilator	RR, O2 sat, BP, sedation level; airway equipment at bedside	STAT	STAT	-	STAT
Levetiracetam (seizure - loading)	IV	Anti-seizure medication loading for new seizures associated with meningioma; preferred due to no CYP enzyme induction and favorable safety profile	1500 mg :: IV :: load, then 500-1500 mg BID :: 1000-1500 mg IV load, then 500-1500 mg PO/IV BID; renal dosing if GFR <50	None absolute; reduce dose if CrCl <50	Behavioral changes (agitation, irritability); generally well tolerated	STAT	STAT	-	STAT
Mannitol (elevated ICP)	IV	Acute elevated ICP with herniation signs from large meningioma; bridge to surgical intervention	1 g/kg :: IV :: bolus :: 1-1.5 g/kg IV bolus over 15-20 min; may repeat 0.25-0.5 g/kg q4-6h; maintain serum osmolality <320 mOsm/kg	Anuria; severe dehydration; active intracranial bleeding (relative)	Serum osmolality q6h, serum sodium, I/O, renal function	STAT	-	-	STAT
Hypertonic saline (elevated ICP)	IV	Acute elevated ICP from large meningioma; alternative to mannitol; may be preferred in hypotensive patients	30 mL :: IV :: bolus (23.4% via central line) :: 23.4% NaCl 30 mL via central line over 15 min OR 3% NaCl 250 mL IV over 30 min; target Na 145-155 mEq/L	Severe hypernatremia (Na >160)	Sodium q4-6h, serum osmolality, I/O, central line required for 23.4%	STAT	-	-	STAT
Enoxaparin (DVT prophylaxis)	SC	DVT prophylaxis for surgical patients; meningioma surgery carries VTE risk especially with prolonged procedures	40 mg :: SC :: daily :: Enoxaparin 40 mg SC daily; start 24h post-operatively per neurosurgery; mechanical prophylaxis (SCDs) from admission until ambulatory	Active intracranial hemorrhage; planned surgery within 24h	Platelet count; signs of bleeding	-	STAT	-	STAT
Pantoprazole (stress ulcer prophylaxis)	PO/IV	GI bleed prevention while on dexamethasone; combined corticosteroid use increases risk	40 mg :: IV :: daily :: Pantoprazole 40 mg IV/PO daily OR omeprazole 20 mg PO daily; continue throughout steroid course	PPI allergy	GI symptoms	STAT	STAT	ROUTINE	STAT

3B. Symptomatic Treatments

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Levetiracetam (maintenance)	PO	Seizure prevention after first seizure from meningioma; NO prophylactic AEDs in patients without seizures unless high-risk perioperative period	500 mg :: PO :: BID :: Start 500 mg BID; titrate by 500 mg/day q1-2 weeks to seizure control; max 3000 mg/day; renal dosing if GFR <50	None absolute; reduce dose if CrCl <50	Behavioral changes (agitation, depression, irritability), somnolence; no drug interactions	-	STAT	ROUTINE	STAT
Lacosamide	PO/IV	Alternative or adjunct AED for seizures from meningioma; minimal drug interactions	50 mg :: PO :: BID :: Start 50 mg BID; titrate by 50 mg/dose weekly; max 400 mg/day	PR interval >200 ms; 2nd/3rd degree AV block; severe hepatic impairment	ECG at baseline and with dose changes; PR interval monitoring	-	STAT	ROUTINE	STAT
Valproic acid	PO/IV	Second-line AED for meningioma-related seizures; useful when levetiracetam not tolerated	250 mg :: PO :: BID :: Start 250 mg BID; titrate by 250 mg q3-5 days to therapeutic level (50-100 mcg/mL); max 60 mg/kg/day	Hepatic disease; mitochondrial disorders (Alpers syndrome); pregnancy (teratogenic); urea cycle disorders; pancreatitis history	LFTs at baseline and periodically; ammonia if AMS; CBC (thrombocytopenia); VPA level	-	ROUTINE	ROUTINE	ROUTINE
Dexamethasone (taper)	PO	Transition from IV to PO; taper after surgery as soon as clinically feasible to minimize steroid side effects	4 mg :: PO :: q6h, then taper :: Taper by 2 mg every 3-5 days (e.g., 16 to 12 to 8 to 6 to 4 to 2 to 1 to off); slower taper if symptoms recur; monitor for adrenal insufficiency if >3 weeks of use	Symptom recurrence (hold taper, reassess)	Glucose, BP, mood, steroid myopathy (proximal weakness), immunosuppression	-	ROUTINE	ROUTINE	-
Ondansetron	IV/PO	Nausea/vomiting from elevated ICP or perioperative	4 mg :: IV :: q8h PRN :: 4-8 mg IV/PO q8h PRN nausea; max 24 mg/day	QT prolongation; concurrent use of QT-prolonging agents	QTc if risk factors; serotonin syndrome risk with SSRIs	STAT	STAT	ROUTINE	STAT
Acetaminophen	PO	Headache from tumor-associated edema or post-operative; avoid NSAIDs peri-operatively due to bleeding risk	1000 mg :: PO :: q6h PRN :: 650-1000 mg PO q6h PRN headache; max 3 g/day (2 g/day if hepatic impairment)	Severe hepatic impairment; allergy	LFTs if prolonged use	STAT	STAT	ROUTINE	STAT
Insulin (steroid-induced hyperglycemia)	SC/IV	Glucose management while on dexamethasone; hyperglycemia common with steroid use	Variable :: SC :: per sliding scale :: Fingerstick glucose q6h; sliding scale insulin initially; basal-bolus if persistently >180 mg/dL; may need 2-3x baseline insulin on dexamethasone; anticipate glucose improvement as steroids taper	Hypoglycemia risk	Glucose q6h (q1h if insulin drip)	STAT	STAT	ROUTINE	STAT
Calcium + Vitamin D	PO	Steroid-induced osteoporosis prevention if prolonged dexamethasone (>2 weeks) anticipated	1000 mg Ca + 800 IU Vit D :: PO :: daily :: Calcium 1000-1200 mg + Vitamin D 800-1000 IU daily while on steroids	Hypercalcemia; renal stones (relative)	Calcium level; vitamin D level	-	ROUTINE	ROUTINE	-
TMP-SMX (PJP prophylaxis)	PO	Pneumocystis jirovecii pneumonia prophylaxis if dexamethasone >20 mg/week AND concomitant temozolomide, bevacizumab, or other immunosuppression	1 DS tab :: PO :: 3x/week (Mon/Wed/Fri) :: TMP-SMX 1 DS tablet 3x/week (Mon/Wed/Fri); if sulfa allergic: atovaquone 1500 mg PO daily or dapsone 100 mg PO daily (check G6PD first)	Sulfa allergy (use alternative); severe renal impairment; megaloblastic anemia from folate deficiency	CBC q2-4 weeks; renal function; rash; report fever/dyspnea	-	ROUTINE	ROUTINE	-
Levetiracetam (perioperative prophylaxis)	PO/IV	Short-course perioperative seizure prophylaxis for craniotomy in patients without seizure history; 7-day course only per institutional protocol; NOT recommended beyond 7 days without documented seizure	500 mg :: PO :: BID x 7 days :: Levetiracetam 500 mg BID starting day of surgery; discontinue at 7 days post-operatively unless seizure occurs; if seizure occurs, convert to maintenance dosing	None absolute; reduce dose if CrCl <50	Behavioral changes; generally well tolerated	-	ROUTINE	-	ROUTINE

3C. Second-line/Refractory

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Re-resection (surgical)	-	Recurrent meningioma amenable to re-resection; symptomatic recurrence after initial surgery; Simpson grade-dependent recurrence risk	Maximal safe resection :: - :: per neurosurgical assessment :: Maximal safe resection; Simpson Grade I (complete removal with dural attachment and abnormal bone) is goal when safely achievable; post-op MRI within 48h	Poor functional status; eloquent location precluding safe resection; extensive dural sinus invasion	Post-op MRI within 48h; neurologic exams; wound monitoring	-	URGENT	-	-
Bevacizumab (Avastin)	IV	Recurrent/progressive meningioma refractory to surgery and radiation; anti-VEGF monoclonal antibody; limited evidence but some case series show stabilization	10 mg/kg :: IV :: q2 weeks :: 10 mg/kg IV every 2 weeks; infuse first dose over 90 min, then 60 min, then 30 min if tolerated; continue until progression or intolerable toxicity	Uncontrolled hypertension; recent surgery (28 days); active hemorrhage; bowel perforation risk; pregnancy; severe proteinuria (>3.5 g/24h)	BP each visit; urinalysis for proteinuria q2-4 weeks; wound healing assessment; CBC; signs of GI perforation, thromboembolism	-	-	ROUTINE	-
Somatostatin analog (Octreotide LAR)	IM	Recurrent meningioma expressing somatostatin receptors (confirmed by octreotide scan or DOTATATE PET); limited evidence; some patients show disease stabilization	30 mg :: IM :: q4 weeks :: Octreotide LAR 30 mg IM every 4 weeks; may require dose adjustment based on response; continue if stable disease or objective response	Gallbladder disease (relative); uncontrolled diabetes	Gallbladder ultrasound q6 months; glucose monitoring; GI symptoms (diarrhea, abdominal pain); GH/IGF-1 levels	-	-	EXT	-
Temozolomide	PO	Recurrent atypical or anaplastic meningioma (WHO grade II/III) refractory to surgery and radiation; limited evidence; consider when no clinical trial available	150 mg/m2 :: PO :: days 1-5 q28d :: 150-200 mg/m2 PO days 1-5 of 28-day cycle; take on empty stomach 1h before bedtime; antiemetic pre-medication	ANC <1500; platelets <100K; severe hepatic/renal impairment; pregnancy	CBC Day 1 and Day 22 of each cycle; LFTs monthly; limited efficacy data in meningioma	-	-	EXT	-
Sunitinib	PO	Recurrent/progressive meningioma refractory to standard therapies; VEGFR/PDGFR tyrosine kinase inhibitor; Kaley et al. showed PFS-6 of 42% in atypical/anaplastic meningioma	50 mg :: PO :: daily x 28 days, then 14 days off :: 50 mg PO daily for 28 days followed by 14-day rest (4/2 schedule); or 37.5 mg continuous daily schedule; dose reduce for toxicity	Uncontrolled hypertension; hepatic impairment; QT prolongation; bleeding risk	BP weekly initially; CBC q2 weeks; LFTs; TSH q3 months; cardiac function (LVEF); hand-foot syndrome; diarrhea	-	-	EXT	-
Mifepristone (RU-486)	PO	Progesterone receptor-positive meningioma (mostly WHO grade I); antiprogesterone therapy; SWOG S9005 showed no significant benefit overall but some individual responses	200 mg :: PO :: daily :: 200 mg PO daily continuously; efficacy data limited and conflicting	Pregnancy (abortifacient); chronic adrenal failure; concurrent corticosteroid use for life-threatening conditions; hemorrhagic disorders	Cortisol levels (adrenal insufficiency); potassium; endometrial thickness in women; vaginal bleeding	-	-	EXT	-

3D. Disease-Modifying Therapies (Surgery / Radiation)

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Surgical resection (craniotomy)	-	Symptomatic meningioma; growing meningioma on serial imaging; large meningiomas (>3 cm) with mass effect; WHO grade II/III meningiomas; Simpson Grade I-III resection goal based on location	Per neurosurgical approach :: - :: per surgical planning :: Approach depends on location: convexity (direct), parasagittal (with sinus evaluation), skull base (various approaches - subfrontal, pterional, retrosigmoid, transpetrosal); aim for Simpson Grade I (complete resection with dural attachment and involved bone) when safely achievable	Pre-operative MRI within 2 weeks; MRV for parasagittal tumors; CTA/DSA for vascular assessment of skull base tumors; consider pre-operative embolization for hypervascular tumors; medical optimization; DVT prophylaxis plan	Poor surgical candidate (advanced age with significant comorbidities, KPS <50); tumor in surgically inaccessible location; patient preference for observation or radiation	Post-op MRI within 48h; neurologic exams q2-4h for 24-48h; wound care; DVT prophylaxis; pain management; taper dexamethasone post-operatively	-	STAT	ROUTINE	-
Stereotactic radiosurgery (SRS) - Gamma Knife / CyberKnife / LINAC	-	WHO grade I meningiomas <=3 cm not amenable to surgery or patient preference; residual/recurrent meningiomas after subtotal resection; cavernous sinus meningiomas (surgery high risk); adjuvant after subtotal resection of WHO grade II	12-16 Gy :: - :: single fraction :: 12-16 Gy to tumor margin in single fraction (typically 13-14 Gy for skull base; 14-16 Gy for convexity); dose depends on proximity to critical structures (optic chiasm <=8 Gy, brainstem <=12 Gy)	High-resolution MRI for treatment planning (thin-cut, contrast-enhanced); frame-based or frameless immobilization; pathologic confirmation preferred (especially if imaging atypical)	Tumor >3 cm (relative; may use fractionated SRT instead); too close to optic apparatus for single fraction (use fractionated); diffuse/en plaque meningioma	MRI at 6 months, then annually for 5 years, then q2 years; monitor for radiation necrosis (1-3%); cranial nerve deficits (optic, trigeminal, facial depending on location)	-	-	ROUTINE	-
Fractionated stereotactic radiotherapy (fSRT)	-	WHO grade I meningiomas >3 cm or near critical structures (optic chiasm, brainstem); WHO grade II after subtotal resection or recurrence; large skull base meningiomas	50-54 Gy :: - :: 28-30 fractions :: 50-54 Gy in 28-30 fractions (1.8 Gy/fraction) over 5-6 weeks; conforms to irregularly shaped tumors near critical structures	MRI-based treatment planning; immobilization mask fitting; adequate interval from surgery (typically 4-6 weeks)	Pregnancy; prior full-dose radiation to same area (assess cumulative dose)	MRI q6 months for 2 years, then annually; radiation necrosis risk; fatigue during treatment; alopecia at entry sites	-	-	ROUTINE	-
Adjuvant radiation therapy (WHO grade II - atypical)	-	WHO grade II (atypical) meningioma after subtotal resection (Simpson grade IV-V); consider after gross total resection if high proliferation index (Ki-67 >10%) or brain invasion; reduces recurrence rate	54-60 Gy :: - :: 30-33 fractions :: 54-60 Gy in 30-33 fractions; begin 4-6 weeks after surgery; target tumor bed with margin	Post-operative MRI for treatment planning; adequate wound healing; pathologic confirmation of WHO grade II	Pregnancy; prior full-dose radiation to same area (assess cumulative dose)	MRI q3-4 months for first 2 years, then q6 months; monitor for recurrence which is common in grade II (35-40% at 5 years even with treatment)	-	-	ROUTINE	-
Adjuvant radiation therapy (WHO grade III - anaplastic)	-	WHO grade III (anaplastic/malignant) meningioma after any extent of resection; radiation indicated regardless of surgical completeness due to high recurrence rate (50-80% at 5 years)	59.4-60 Gy :: - :: 33 fractions :: 59.4-60 Gy in 33 fractions (1.8 Gy/fraction) over 6.5 weeks; some centers consider dose escalation; target tumor bed with 1-2 cm CTV margin	Post-operative MRI for treatment planning; pathologic confirmation of WHO grade III; molecular profiling	Pregnancy; prior full-dose radiation to same area (assess cumulative dose)	MRI q2-3 months for first 2 years given high recurrence risk; close clinical follow-up; consider systemic therapy trials	-	-	ROUTINE	-
Observation (watchful waiting)	-	Asymptomatic incidental meningiomas (especially small <2 cm); elderly patients with slowly growing tumors; patient preference; no significant edema or mass effect	Serial MRI surveillance :: - :: per monitoring schedule :: MRI at 3 months (first scan), then 6 months, then annually for 5 years, then q2 years if stable; intervene if growth >2-3 mm/year, development of symptoms, or new edema	Baseline MRI with volumetric assessment; patient counseling about observation rationale and surveillance plan; reliable patient for follow-up	Not appropriate for symptomatic meningiomas, WHO grade II/III, or rapidly growing tumors	MRI per schedule; clinical assessment at each visit; patient education on symptoms warranting urgent evaluation (new headache, seizure, focal deficit)	-	-	ROUTINE	-

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4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation	ED	HOSP	OPD	ICU
Neurosurgery consultation for surgical candidacy evaluation, resection planning, and assessment of Simpson grade achievability based on tumor location and vascular involvement	STAT	STAT	ROUTINE	STAT
Radiation oncology consultation for SRS, fSRT, or adjuvant radiation planning in patients with WHO grade II/III meningioma, residual tumor after surgery, or meningioma not amenable to resection	-	URGENT	ROUTINE	-
Neuro-oncology consultation for WHO grade II/III meningioma management, systemic therapy options for recurrent/refractory disease, and clinical trial enrollment	-	ROUTINE	ROUTINE	-
Multidisciplinary tumor board presentation for coordinated treatment planning including neurosurgery, radiation oncology, neuro-oncology, neuropathology, and neuroradiology	-	URGENT	ROUTINE	-
Neuro-ophthalmology consultation for visual field deficits, papilledema, or optic nerve/chiasm compression from parasellar, sphenoid wing, or olfactory groove meningioma	-	ROUTINE	ROUTINE	-
Ophthalmology for formal visual field testing (Humphrey perimetry) baseline and follow-up if tumor near visual pathways	-	ROUTINE	ROUTINE	-
Endocrinology consultation for pituitary axis evaluation if parasellar meningioma causing hormonal dysfunction, or for steroid-induced hyperglycemia management	-	ROUTINE	ROUTINE	-
ENT/Otolaryngology for hearing assessment and management if CPA meningioma with auditory symptoms	-	ROUTINE	ROUTINE	-
Physical therapy for mobility assessment, fall prevention given neurologic deficits and steroid myopathy, and post-operative rehabilitation	-	ROUTINE	ROUTINE	-
Occupational therapy for ADL assessment, cognitive compensation strategies, and home safety evaluation	-	ROUTINE	ROUTINE	-
Speech-language pathology for swallow evaluation if posterior fossa or skull base meningioma with cranial nerve involvement, and language assessment if dominant hemisphere tumor	-	ROUTINE	ROUTINE	-
Social work consultation for insurance authorization, disability paperwork, caregiver support, and community resource coordination	-	ROUTINE	ROUTINE	-
Neuropsychology evaluation for baseline cognitive assessment if tumor in eloquent cortex, before radiation, or if cognitive complaints	-	-	ROUTINE	-
Genetic counseling if multiple meningiomas, bilateral meningiomas, or age <40 years for NF2 screening	-	-	ROUTINE	-
Palliative care consultation for WHO grade III meningioma or recurrent progressive disease for symptom management and goals of care discussion	-	ROUTINE	ROUTINE	-

4B. Patient Instructions

Recommendation	ED	HOSP	OPD	ICU
Return immediately for new or worsening headache, sudden weakness, vision changes, speech difficulty, or seizures (may indicate tumor progression, hemorrhage, or increased edema)	STAT	STAT	ROUTINE	-
Do not drive until cleared by neurology and neurosurgery due to seizure risk and visual field deficits	-	ROUTINE	ROUTINE	-
Do not stop dexamethasone abruptly as this may cause adrenal crisis; follow prescribed taper schedule exactly	-	ROUTINE	ROUTINE	-
Report any new vision changes (blurring, double vision, visual field loss) as this may indicate tumor growth or post-treatment edema requiring urgent evaluation	-	ROUTINE	ROUTINE	-
For observed (watchful waiting) patients: attend all scheduled MRI surveillance appointments as recommended; growth may occur without symptoms initially	-	-	ROUTINE	-
Wear medical alert identification indicating brain tumor diagnosis and seizure risk if history of seizures	-	ROUTINE	ROUTINE	-
Keep a symptom diary documenting headaches, seizures, vision changes, weakness, and cognitive changes to track disease course	-	ROUTINE	ROUTINE	-
Report any fever, wound swelling, or drainage after surgery as this may indicate post-operative infection requiring urgent treatment	-	ROUTINE	ROUTINE	-
Post-SRS/radiation: report any new or worsening neurologic symptoms (may indicate radiation-induced edema or necrosis, typically at 3-12 months post-treatment)	-	-	ROUTINE	-
For women of childbearing age: meningiomas may grow during pregnancy; discuss family planning with neurosurgeon and OB/GYN before conception	-	-	ROUTINE	-

4C. Lifestyle & Prevention

Recommendation	ED	HOSP	OPD	ICU
Low-sodium diet while on dexamethasone to reduce fluid retention, edema, and hypertension	-	ROUTINE	ROUTINE	-
Blood sugar monitoring and diabetic diet while on steroids to prevent steroid-induced hyperglycemia complications	-	ROUTINE	ROUTINE	-
Regular low-impact exercise (walking, swimming, yoga) as tolerated to maintain strength, reduce steroid myopathy, and improve quality of life	-	ROUTINE	ROUTINE	-
Fall precautions at home including removal of trip hazards, use of handrails, non-slip mats, and night lights given focal deficits and seizure risk	-	ROUTINE	ROUTINE	-
Smoking cessation to optimize wound healing and surgical outcomes	-	ROUTINE	ROUTINE	-
Avoid exogenous hormones (hormone replacement therapy, oral contraceptives with progesterone) as meningiomas express progesterone receptors and may grow with hormonal stimulation; discuss with OB/GYN for alternatives	-	-	ROUTINE	-
CPAP compliance if obstructive sleep apnea present to prevent nocturnal hypoxia which may worsen cerebral edema	-	ROUTINE	ROUTINE	-
Adequate hydration (2-3 L/day unless fluid restricted) to support renal function particularly if undergoing contrast imaging studies	-	ROUTINE	ROUTINE	-
Sun protection during radiation therapy course due to scalp sensitivity	-	-	ROUTINE	-
Weight-bearing exercise and calcium/vitamin D supplementation for bone health if on prolonged steroids	-	-	ROUTINE	-

═══════════════════════════════════════════════════════════════ SECTION B: REFERENCE (Expand as Needed) ═══════════════════════════════════════════════════════════════

5. DIFFERENTIAL DIAGNOSIS

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Dural metastases	History of systemic malignancy (breast, lung, prostate most common); often multiple dural-based lesions; may lack the classic dural tail or show irregular enhancement; leptomeningeal involvement more common; known primary malignancy	CT chest/abdomen/pelvis for primary site; PET/CT; biopsy showing non-meningothelial histology (cytokeratin, TTF-1, etc.); clinical history of known cancer
Solitary fibrous tumor / Hemangiopericytoma (SFT/HPC)	WHO grade 2 or 3; narrow dural attachment (vs. broad base of meningioma); prominent flow voids; heterogeneous enhancement; more aggressive; higher recurrence and metastasis risk	MR perfusion (very high rCBV); angiography showing dense tumor blush; biopsy with STAT6 nuclear positivity (defining marker); CD34 positive; lack of EMA/progesterone receptor expression
Primary CNS lymphoma (dural)	Rare dural presentation; homogeneous enhancement; restricted diffusion on DWI; may respond dramatically to corticosteroids; immunocompromised patients at higher risk	DWI showing restricted diffusion; CSF flow cytometry; stereotactic biopsy; HIV testing; typically B-cell markers positive; avoid steroids before biopsy
Neurosarcoidosis (dural involvement)	Diffuse pachymeningeal enhancement; may be focal mimicking meningioma; systemic sarcoidosis features; elevated ACE level; hilar lymphadenopathy	Serum ACE level; chest CT (bilateral hilar lymphadenopathy); CSF analysis; biopsy showing non-caseating granulomas; tissue ACE immunostaining; FDG-PET for systemic disease
IgG4-related pachymeningitis	Diffuse dural thickening and enhancement; may mimic en plaque meningioma; often involves other organs (pancreas, salivary glands, orbits); responds to corticosteroids initially	Serum IgG4 level; dural biopsy showing IgG4-positive plasma cells (>10/HPF); IgG4/IgG ratio >40%; storiform fibrosis; obliterative phlebitis
Granulomatosis with polyangiitis (GPA/Wegener's)	Dural-based mass with pachymeningeal thickening; sinunasal involvement; may present with cranial neuropathies; systemic vasculitis features	ANCA (cANCA/PR3); sinus CT showing mucosal disease; biopsy showing necrotizing granulomatous inflammation; renal function
Dural arteriovenous fistula (DAVF)	Can cause dural enhancement mimicking meningioma; venous hypertension; pulsatile tinnitus; hemorrhage risk; associated with venous sinus thrombosis	MRA/MRV showing abnormal flow voids; catheter angiography is gold standard (shows fistula with early venous filling); lack of solid mass component
Plasmacytoma / Multiple myeloma	Solitary or multiple dural-based lesions; may erode bone; lytic skull lesions; elevated serum protein	SPEP/UPEP; serum free light chains; bone marrow biopsy; skeletal survey; biopsy showing plasma cell neoplasm; CD138 positive
Rosai-Dorfman disease (meningeal)	Rare; dural-based mass mimicking meningioma; may have lymphadenopathy; young adults	Biopsy showing emperipolesis (lymphocytes within histiocyte cytoplasm); S100 positive, CD68 positive; CD1a negative
Schwannoma (dural-based)	Typically arises from cranial nerves; may appear dural-based at skull base (especially CPA); heterogeneous enhancement; cystic components common	MRI: arising from cranial nerve (vs. dural attachment); internal auditory canal widening if vestibular schwannoma; biopsy showing S100 positive, EMA negative (opposite of meningioma)

6. MONITORING PARAMETERS

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
Neurologic examination (motor, sensory, language, cognition, cranial nerves, visual fields)	q2-4h inpatient; each clinic visit	Stable or improving; new deficits warrant urgent imaging	STAT MRI if decline; increase dexamethasone; neurosurgery alert if herniation	STAT	STAT	ROUTINE	STAT
Blood glucose	q6h while on dexamethasone (q1h if insulin drip)	<180 mg/dL	Sliding scale to basal-bolus insulin; endocrine consult if refractory	STAT	STAT	ROUTINE	STAT
MRI brain with contrast (post-operative)	Within 48h of surgery (new baseline); then at 3 months, 6 months, 12 months	Residual tumor assessment; new enhancement concerning for recurrence	If residual: radiation oncology referral; if recurrence: tumor board	-	URGENT	ROUTINE	-
MRI brain with contrast (WHO grade I - observation)	3 months (baseline), 6 months, then annually for 5 years, then q2 years if stable	Stable size; no new edema; no new symptoms	Growth >2-3 mm/year: consider intervention (surgery or SRS)	-	-	ROUTINE	-
MRI brain with contrast (WHO grade I - post-treatment)	6 months, then annually for 5 years, then q2 years	No recurrence; stable post-treatment changes	Recurrence: tumor board for re-resection, radiation, or observation	-	-	ROUTINE	-
MRI brain with contrast (WHO grade II)	q3-4 months for first 2 years, then q6 months for years 3-5, then annually	No recurrence (35-40% recurrence at 5 years even after GTR + RT)	Recurrence: multidisciplinary re-evaluation; consider re-resection, re-irradiation, systemic therapy	-	-	ROUTINE	-
MRI brain with contrast (WHO grade III)	q2-3 months for first 2 years, then q3-4 months for years 3-5	No recurrence (50-80% recurrence at 5 years)	Recurrence: urgent tumor board; systemic therapy, clinical trials	-	-	ROUTINE	-
Visual fields (Humphrey perimetry)	Baseline pre-treatment; 3 months post-treatment; then annually if near visual pathways	Stable or improved; new deficits warrant imaging	Urgent MRI if new deficits; ophthalmology reassessment	-	ROUTINE	ROUTINE	-
Audiometry	Baseline for CPA meningiomas; 6 months and annually post-treatment	Stable hearing; no progressive loss	ENT referral for hearing aid evaluation; assess for radiation injury vs. recurrence	-	ROUTINE	ROUTINE	-
Pituitary hormone panel	q6 months for parasellar meningiomas; annually after treatment	Normal hormone levels	Hormone replacement as needed; endocrinology follow-up	-	ROUTINE	ROUTINE	-
Blood pressure	Continuous in ICU; q4h on floor; each clinic visit	SBP <160	Antihypertensives; especially monitor if on steroids	STAT	STAT	ROUTINE	STAT
Serum sodium	q6-12h inpatient; each visit outpatient	135-145 mEq/L	SIADH workup if <130; DI workup if >150 post-op; fluid management	STAT	STAT	ROUTINE	STAT
Seizure monitoring	Continuous inpatient if seizure history; patient diary outpatient	No seizures	AED dose adjustment; verify compliance; EEG if subclinical suspected	STAT	STAT	ROUTINE	STAT

7. DISPOSITION CRITERIA

Disposition	Criteria
ICU admission	GCS <=12; signs of herniation (pupil asymmetry, posturing, Cushing triad); acute hemorrhage into tumor; status epilepticus; post-craniotomy (first 24h per institutional protocol); respiratory compromise requiring intubation; large skull base resection with cranial nerve monitoring needs
General neurology/neurosurgery floor	New diagnosis with symptomatic edema requiring IV dexamethasone; post-craniotomy step-down from ICU (typically POD 1-2); seizures requiring AED optimization; functional decline requiring inpatient rehabilitation planning; pre-operative workup and embolization
Observation (<=24h)	Known meningioma with mild symptom worsening; post-SRS monitoring (typically outpatient but observation if large or eloquent location); steroid dose adjustment
Discharge home	Neurologically stable for >=24h; seizure-free >=24h on oral AED; oral dexamethasone taper plan established with written instructions; pain controlled on oral medications; outpatient follow-up scheduled (neurosurgery and/or radiation oncology within 2-4 weeks); safe ambulation or adequate caregiver; wound care instructions if post-operative
Discharge home (incidental meningioma)	Asymptomatic incidental finding; MRI baseline obtained or ordered; observation plan established with surveillance MRI schedule; neurosurgery outpatient referral within 4-6 weeks; return precautions provided
Transfer to higher level care	Need for neurosurgical expertise not available (especially skull base surgery); need for SRS/radiation not available; tumor board or neuro-oncology consultation not available; clinical trial access
Inpatient rehabilitation	Significant post-operative neurologic deficits requiring intensive rehabilitation (hemiparesis, aphasia, cranial nerve deficits); KPS 40-60 with rehabilitation potential
Palliative care / Hospice	End-stage WHO grade III meningioma with progressive decline; exhausted reasonable treatment options; patient/family goals aligned with comfort care

8. EVIDENCE & REFERENCES

Recommendation	Evidence Level	Source
MRI with gadolinium is the gold standard imaging for meningioma diagnosis and surgical planning	Expert Consensus	Watts et al. J Neurooncol 2022 (EANO guideline)
Simpson grading system for extent of resection predicts recurrence risk	Class II, Level B	Simpson D. J Neurol Neurosurg Psychiatry 1957
Gross total resection (Simpson Grade I) provides best local control for WHO grade I meningioma	Class II, Level B	Meling et al. J Neurosurg 2019; Gousias et al. J Neurosurg 2016
Stereotactic radiosurgery achieves 90-95% local control for WHO grade I meningiomas at 10 years	Class II, Level B	Kondziolka et al. J Neurosurg 1999; Pollock et al. J Neurosurg 2003
SRS marginal dose of 12-16 Gy recommended for meningiomas; higher doses associated with better control	Class II, Level B	Flickinger et al. Int J Radiat Oncol Biol Phys 2003
WHO 2021 classification defines meningioma grading (Grade I, II, III) based on histologic criteria	Expert Consensus	Louis et al. Neuro-Oncology 2021 (WHO CNS5)
WHO grade II (atypical) meningioma has 35-40% recurrence at 5 years; adjuvant RT reduces recurrence	Class II, Level B	Rogers et al. J Neurosurg 2015; Komotar et al. J Neurooncol 2012
NRC/RTOG 0539: risk-adapted radiation for meningiomas; intermediate-risk (recurrent grade I, new grade II) benefit from adjuvant RT	Class I, Level B	Rogers et al. J Clin Oncol 2020 (NRG/RTOG 0539)
Observation is appropriate for small asymptomatic incidental meningiomas with serial MRI surveillance	Class II, Level B	Yano et al. J Neurol Neurosurg Psychiatry 2006; Oya et al. J Neurosurg 2018
Meningioma growth rate averages 2-4 mm/year; 63-75% remain stable or grow slowly on observation	Class II, Level B	Hashimoto et al. J Neurosurg 2012
Bevacizumab shows limited activity in recurrent meningioma; some disease stabilization	Class III, Level C	Nayak et al. Neuro-Oncology 2012; Lou et al. J Neurooncol 2015
Sunitinib shows PFS-6 of 42% in recurrent atypical/anaplastic meningioma	Class II, Level C	Kaley et al. J Clin Oncol 2015
Prophylactic AEDs NOT recommended in meningioma patients without seizures	Class I, Level A	Glantz et al. Neurology 2000 (AAN Practice Parameter)
Levetiracetam preferred AED in brain tumor patients due to no enzyme induction	Class II, Level B	Rosati et al. J Neurooncol 2010
Dexamethasone effective for peritumoral vasogenic edema; use minimum effective dose and taper	Class II, Level B	Ryken et al. J Neurooncol 2010
MRV essential for preoperative planning of parasagittal meningiomas to assess sinus invasion	Class II, Level B	Sindou M. Practical Handbook of Neurosurgery 2009
Pre-operative embolization reduces intraoperative blood loss for hypervascular meningiomas	Class II, Level C	Raper et al. J Neurointerv Surg 2020
Ga-68 DOTATATE PET superior to conventional imaging for meningioma detection and treatment planning	Class II, Level B	Galldiks et al. Neuro-Oncology 2017
Meningiomas express progesterone receptors; exogenous hormone use may promote growth	Class III, Level C	Wiemels et al. J Clin Oncol 2010
EANO guidelines for meningioma diagnosis and management	Expert Consensus	Goldbrunner et al. Lancet Oncol 2021 (EANO guideline update)
NCCN Clinical Practice Guidelines for CNS Cancers: Meningioma section	Expert Consensus	NCCN Guidelines v1.2024 (https://www.nccn.org/professionals/physician_gls/pdf/cns.pdf)

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CHANGE LOG

v1.1 (January 30, 2026) - Checker/Rebuilder pipeline validation pass (v3.0 checker) - Added TMP-SMX (PJP prophylaxis) to Section 3B for patients on prolonged dexamethasone with concurrent immunosuppression per R1 - Added perioperative AED prophylaxis (levetiracetam 7-day short course) to Section 3B per S2 - Fixed section dividers to Unicode format for consistency with approved plans per C1 - Updated version metadata and status - All treatment tables confirmed compliant with standardized 10-column format - All medications confirmed on individual rows with structured dosing (:: format) - Verified setting coverage across ED/HOSP/OPD/ICU for all sections - Eliminated all cross-references ("Same as MRI", "Same as fSRT") by expanding to full contraindication text in imaging and treatment rows - Confirmed no cross-references remain in any table rows

v1.0 (January 30, 2026) - Initial template creation - Comprehensive 8-section plan for meningioma (WHO grades I, II, III) - Covers incidental discovery, symptomatic presentation, and surgical/radiation management - Simpson grading system referenced for surgical resection goals - Observation criteria for asymptomatic incidental meningiomas with surveillance MRI schedule - SRS and fSRT dosing and indications by tumor size and proximity to critical structures - Grade-specific adjuvant radiation recommendations (WHO grade II and III) - Recurrence management including bevacizumab, sunitinib, somatostatin analogs, temozolomide - Comprehensive differential diagnosis (10 entities) including SFT/HPC, dural metastases, neurosarcoidosis - Grade-specific MRI surveillance schedules in monitoring section - Skull base-specific considerations (MRV, CTA, embolization, visual field testing, audiometry) - Hormonal considerations (progesterone receptors, pregnancy, exogenous hormones) - 20+ evidence references with PubMed links including EANO guidelines, WHO CNS5, NRG/RTOG 0539

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APPENDIX A: SIMPSON GRADING SYSTEM FOR MENINGIOMA RESECTION

SIMPSON GRADE    DESCRIPTION                                           5-YEAR RECURRENCE
     I           Complete removal including resection of               ~5%
                 dural attachment and abnormal bone

     II          Complete removal with coagulation                     ~10%
                 (not resection) of dural attachment

     III         Complete removal WITHOUT resection or                 ~15-20%
                 coagulation of dural attachment or
                 extradural extensions (e.g., invaded sinus)

     IV          Subtotal resection (partial removal)                  ~40%

     V           Simple decompression (biopsy only)                    ~50-60%

Clinical Decision Making Based on Simpson Grade: - Simpson I-II: Observation with serial MRI (annual for grade I tumors) - Simpson III: Consider adjuvant SRS/RT especially if WHO grade II/III - Simpson IV-V: Adjuvant SRS/RT generally recommended; re-resection if symptomatic progression

APPENDIX B: WHO GRADE-SPECIFIC MANAGEMENT ALGORITHM

MENINGIOMA DIAGNOSED
         |
         +-- WHO GRADE I (Benign, ~80%)
         |     |
         |     +-- INCIDENTAL / ASYMPTOMATIC / SMALL (<2 cm)
         |     |     +-- OBSERVE: MRI at 3mo, 6mo, then annually x 5yr, then q2yr
         |     |     +-- Intervene if: growth >2-3 mm/yr, new symptoms, new edema
         |     |
         |     +-- SYMPTOMATIC / GROWING / LARGE (>3 cm)
         |     |     +-- SURGERY: Simpson Grade I-II goal (when safely achievable)
         |     |     |     +-- GTR achieved --> Observe with serial MRI
         |     |     |     +-- STR achieved --> Consider SRS/fSRT for residual
         |     |     |
         |     |     +-- SRS: If <3 cm, not amenable to surgery, or patient preference
         |     |     |     +-- 12-16 Gy marginal dose, single fraction
         |     |     |
         |     |     +-- fSRT: If >3 cm or near critical structures
         |     |           +-- 50-54 Gy in 28-30 fractions
         |     |
         |     +-- RECURRENT (after prior treatment)
         |           +-- Re-resection if surgically accessible
         |           +-- SRS/RT if not previously irradiated
         |           +-- Consider re-biopsy (may have upgraded to grade II/III)
         |
         +-- WHO GRADE II (Atypical, ~15-20%)
         |     |
         |     +-- SURGERY: Maximal safe resection
         |     |     +-- GTR achieved + low Ki-67 --> Close surveillance (q3-4mo x 2yr)
         |     |     +-- GTR achieved + high Ki-67 or brain invasion --> Adjuvant RT (54-60 Gy)
         |     |     +-- STR achieved --> Adjuvant RT (54-60 Gy) recommended
         |     |
         |     +-- RECURRENT
         |           +-- Re-resection +/- re-irradiation
         |           +-- Systemic therapy (bevacizumab, sunitinib, clinical trials)
         |
         +-- WHO GRADE III (Anaplastic/Malignant, ~1-3%)
               |
               +-- SURGERY: Maximal safe resection
               +-- ADJUVANT RT: 59.4-60 Gy in 33 fractions (regardless of resection extent)
               +-- CLOSE SURVEILLANCE: MRI q2-3mo x 2yr (high recurrence: 50-80% at 5yr)
               +-- RECURRENT: Re-resection, re-irradiation, systemic therapy, clinical trials

APPENDIX C: MENINGIOMA LOCATION-SPECIFIC CONSIDERATIONS

Location	Frequency	Key Surgical Considerations	Symptoms	Special Studies
Convexity	~20-25%	Most surgically accessible; Simpson I often achievable; seizure risk highest	Seizures; focal deficits; headache	Standard MRI sufficient
Parasagittal / Falcine	~20-25%	Sagittal sinus invasion common; MRV essential; complete resection may sacrifice sinus; staged surgery may be needed	Leg weakness (bilateral if parasagittal); seizures	MRV mandatory; consider venous phase DSA
Sphenoid wing	~15-20%	Medial (clinoidal) most challenging; lateral more accessible; ICA/MCA encasement risk; cavernous sinus invasion	Proptosis (en plaque); visual loss; CN III/IV/VI palsies	CTA/MRA; orbital MRI; visual fields
Skull base (general)	~25-30%	Complex approaches; cranial nerve preservation critical; GTR often not possible; SRS excellent alternative	CN deficits; headache; CSF leak risk	CTA/DSA; audiometry; visual fields
Olfactory groove	~8-10%	Bilateral frontal approach; Foster Kennedy syndrome; anosmia often pre-existing	Anosmia; personality changes; papilledema	Visual fields; neuropsych testing
Tuberculum sellae	~5-8%	Visual apparatus proximity; endoscopic endonasal approach gaining favor	Visual loss (bilateral); chiasmal compression	Visual fields; pituitary hormones
CPA (Cerebellopontine angle)	~5-8%	CN VII/VIII preservation; differentiate from vestibular schwannoma	Hearing loss; tinnitus; facial weakness; ataxia	Audiometry; ABR; MRI IAC protocol
Posterior fossa / Foramen magnum	~5-10%	Vertebral artery proximity; CN IX-XII at risk; prone or lateral position	Lower CN deficits; dysphagia; ataxia; myelopathy	CTA; MRI craniocervical junction
Petroclival	~5%	Most surgically challenging; CN V/VI risk; near brainstem; often subtotal resection; SRS for residual	CN V/VI palsies; hearing loss; ataxia	CTA/DSA; audiometry; ABR
Intraventricular	~1-2%	Choroid plexus origin; highly vascular; surgical approach through brain parenchyma	Hydrocephalus; headache; papilledema	Pre-op embolization if feasible

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This template has been created using the neuro-builder skill v3.1 and requires physician review and validation through the checker pipeline before clinical deployment.