Incidental meningioma active surveillance [Neurosurgery Wiki]

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====== Incidental meningioma active surveillance ======

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

===== Indications for Active Surveillance =====

[[Asymptomatic]] patients

Tumor discovered [[incidental]]ly

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

===== Surveillance Protocol (Typical Schedule) =====

[[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

===== Clinical Follow-up =====

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

===== Cohort studies =====

A population-based [[cohort_study|study]] explores the **[[prevalence]] and [[symptom]]atology of [[incidental]]ly found [[meningioma]]s** 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)
((de Dios E, Näslund O, Choudhry M, Berglund M, Skoglund T, Sarovic D, Rydén L, Kern S, Skoog I, Thurin E. Prevalence and symptoms of incidental meningiomas: a population-based study. Acta Neurochir (Wien). 2025 Apr 3;167(1):98. doi: 10.1007/s00701-025-06506-7. PMID: 40178655.))

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|headache]] or [[dizziness|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.

===== Retrospective Comparative Cohort Study with Propensity Score Matching =====

 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]]
((Hallak H, Mantziaris G, Pikis S, Islim AI, Peker S, Samanci Y, Nabeel AM, Reda WA, Tawadros SR, El-Shehaby AMN, Abdelkarim K, Emad RM, Mathieu D, Lee CC, Liscak R, Alvarez RM, Kondziolka D, Tripathi M, Speckter H, Bowden GN, Benveniste RJ, Lunsford LD, Jenkinson MD, Sheehan J. A retrospective comparison of active surveillance to stereotactic radiosurgery for the management of elderly patients with an incidental meningioma. Acta Neurochir (Wien). 2025 Feb 6;167(1):37. doi: 10.1007/s00701-025-06452-4. PMID: 39912992; PMCID: PMC11802698.))

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_study|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 [[case]]s.