Active surveillance is a non-interventional management strategy where the tumor is closely monitored with regular imaging and clinical assessments instead of immediate treatment.

Asymptomatic patients

Tumor discovered incidentally

Small size (< 2–3 cm)

No mass effect or brain edema

No radiological signs of aggressiveness (e.g., brain invasion, rapid growth)

The patient has significant comorbidities or advanced age

The tumor is located in an eloquent or high-risk area for surgery

Baseline MRI with contrast to characterize the tumor

Follow-up MRI at 6 months

If stable → annual imaging for 5 years

If still stable → consider imaging every 2–3 years

Lifelong monitoring is most cases, especially in younger patients

Regular neurological exams

Monitor for new symptoms: headache, seizures, focal deficits, cognitive changes

Reassess management if:

Tumor grows (commonly defined as >2 mm/year)

New or worsening symptoms appear

Advantages of Active Surveillance Avoids risks of surgery or radiation

Preserves the quality of life in asymptomatic individuals

Many meningiomas remain stable for years or a lifetime

When to Reconsider Treatment Radiological progression (volume increase, edema, mass effect)

Symptom development

Patient preference changes

Tumor in surgically accessible location with low expected morbidity

A population-based study explores the prevalence and symptomatology of incidentally found meningiomas in a specific aging population—the 70-year-olds participating in the Gothenburg H70 Birth Cohort Study. The authors analyzed MRIs from 792 individuals and found a 1.8% prevalence of incidental meningiomas, with a notable gender skew (12 of the 14 cases were female) ¹⁾

One of the key strengths of this work is its community-based sampling, which reduces the referral bias often present in hospital-based series. It also adds valuable information to the growing body of literature supporting a more conservative treatment approach in asymptomatic or minimally symptomatic individuals, especially in the elderly.

The study challenges the reflexive assumption that nonspecific symptoms like headache or dizziness are attributable to small, incidentally found meningiomas. This is crucial, as overattribution can lead to unnecessary neurosurgical interventions, with accompanying risks and psychological burden.

On the flip side, the small absolute number of identified meningiomas (n=14) limits the statistical power to detect nuanced associations between clinical variables and tumor presence. Furthermore, the authors did not perform longitudinal follow-up to assess tumor growth or symptom progression, which could be relevant in determining the true clinical impact of these incidental findings.

In summary, this study provides solid evidence that supports watchful waiting in many cases of incidental meningioma, particularly in elderly women. It underscores the need for clinical restraint and careful consideration before attributing symptoms or deciding on intervention.

Hallak et al. employ a retrospective study design with propensity score matching to balance confounding factors between patients undergoing stereotactic radiosurgery (SRS) and those under active surveillance ²⁾

Key findings include:

• Superior radiological control in the SRS group (97.37%) compared to observation (71.93%), with a statistically significant advantage (p < 0.01).
• Neurological safety appears slightly compromised in SRS (1.39% new deficits), while no new deficits occurred under surveillance.
• The need for surgical resection was low in both arms, slightly higher in the observation group (3.5% vs 0.9%), though not statistically significant (p = 0.063).
• A trend toward lower mortality in the SRS group (9.65% vs 18.42%) was noted, yet without reaching statistical significance (p = 0.06). Notably, no deaths in the observation group were directly attributed to meningioma progression.

From a clinical decision making perspective, the study underscores the value of personalized management. While SRS offers more robust tumor control, the marginal increase in risk of neurological complication, coupled with a non-significant impact on survival or surgical rescue, suggests watchful waiting remains a valid approach—especially in patients with limited life expectancy or comorbidities.

Future prospective trials with functional outcomes, quality-of-life metrics, and cost-effectiveness analyses are needed to refine treatment algorithms. Nevertheless, this article adds weight to current trends toward de-escalation in certain low-risk neurosurgical cases.