VERSION: 1.1
CREATED: January 30, 2026
REVISED: January 30, 2026
STATUS: Approved
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)
CPT CODES: 85025 (CBC with differential), 80053 (CMP (BMP + LFTs)), 82947 (Blood glucose), 84443 (TSH), 81025 (Pregnancy test (women of childbearing age)), 84146 (Prolactin), 82533 (Cortisol (AM)), 84305 (IGF-1), 84439 (Free T4), 84484 (Troponin), 82550 (CPK/CK), 83036 (HbA1c), 86335 (Serum protein electrophoresis (SPEP)), 82164 (ACE level), 86235 (IgG4), 70450 (CT head without contrast), 70553 (MRI brain with and without contrast (gadolinium)), 70460 (CT head with contrast), 93000 (ECG (12-lead)), 71046 (Chest X-ray), 70547 (MR venography (MRV)), 70496 (CT angiography (CTA) of head), 36224 (Digital subtraction angiography (DSA)), 61624 (Pre-operative embolization), 70543 (MRI orbits with contrast), 92083 (Formal visual field testing (Humphrey)), 92557 (Audiometry), 76390 (MR spectroscopy (MRS)), 78816 (FDG-PET or Ga-68 DOTATATE PET), 78802 (Octreotide scan (In-111 pentetreotide))
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).
PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting
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
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
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).
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
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
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
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
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
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
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
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
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)
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
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
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)
═══════════════════════════════════════════════════════════════
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
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
Diffuse dural thickening and enhancement; may mimic en plaque meningioma; often involves other organs (pancreas, salivary glands, orbits); responds to corticosteroids initially
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
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
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
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
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.