1. Treatment

2. Medical Care Radiotherapy Stereotactic Radiosurgery Surgical Care

3. Medical Care Conventional chemotherapy and hormonal therapy – Ineffective – Restricted either to perioperation or when after all other means of treatment have failed Chemotherapy – Reserved for malignant cases after failure of surgery and radiotherapy to control the disease – Temozolomide - no effect against recurrent meningiomas – Hydroxyurea - suggested to shrink unresectable and recurrent meningiomas – Combination of interferon alpha and 5 fluorouracil synergistically reduces meningioma cell proliferation in culture Corticosteroids – Used preoperatively and postoperatively – Has significantly decreased the mortality and morbidity rates associated with surgical resection Antiepileptic drugs - started preoperatively in supratentorial surgery and continued postoperatively for no less than three months COX 2 inhibitors - being studied for possible treatment of recurrent meningiomas

4. Radiotherapy Tumors that lie beneath the hypothalamus, along the medial part of the sphenoid bone and parasellar region, or anterior to the brainstem are the most difficult to remove surgically Used as adjuvant therapy for incompletely resected, high grade, and/or recurrent tumors Carefully planned radiation therapy – beneficial in cases that are inoperable and when the tumor is incompletely removed or shows malignant characteristics Used as primary treatment in some cases – optic nerve meningiomas, and in some unresectable tumors. Smaller tumors at the base of the skull can be obliterated or greatly reduced in size by focused radiation

5. Stereotactic Radiosurgery Provides excellent tumor control with minimal toxicity Mainly used for small (< 3 cm in diameter) residual or recurrent lesions – When surgery is considered to carry a significantly high risk or morbidity Advocated as an effective management for small meningiomas and for meningiomas involving the skull base or the cavernous sinus Used primarily to prevent tumor progression Tumor control rate - 94%

6. Surgical Care Surgical resection has been the preferred treatment for meningiomas Most meningiomas have well-defined borders – Enabling the surgeon to dissect the tumor capsule from the arachnoid lining of the adjacent brain, blood vessels, and cranial nerves Complete removal can be accomplished without needing to sacrifice functional tissue. – Surgery is often curative – Associated with the preservation of, if not improvements in, the neurological condition

7. Principles in Meningioma Resection All involved or hyperostotic bone should be removed The dura involved by the tumor as well as a dural rim that is free from tumor should be resected (Duraplasty) Dural tails that are apparent on MRI are best removed, even though some may not be involved with the tumor. Make a provision for harvesting a suitable dural substitute (pericranium or fascia lata) If feasible, always start by coagulating the arterial feeders to the meningioma

8. Surgical Care Surgical excision should afford permanent cure Recurrence is likely if removal is incomplete, as is often the case For some the growth rate is so slow that there may be a latency of many years A few show malignant qualities – High mitotic index, nuclear atypia, marked nuclear and cellular pleomorphism, and invasiveness of brain – Their regrowth is then rapid if they are not completely excised