Do all meningiomas need surgery?

No. Many small meningiomas that are causing no symptoms can be safely observed with periodic imaging. Surgery is typically recommended when a meningioma is causing symptoms, growing on serial scans, reaching a size that poses a future risk, or in a location where continued growth would be dangerous. The decision to observe or treat depends on the specific tumor and the specific patient.

What causes meningiomas?

The cause of most meningiomas is not known. The few established risk factors include prior radiation exposure to the head, the genetic condition neurofibromatosis type 2, and being female. Female hormones are thought to play some role, though the exact mechanism is still under study. In the vast majority of cases, there is no identifiable cause.

Can a meningioma come back after it’s removed?

For completely removed Grade 1 meningiomas, recurrence is uncommon, and long-term outcomes are excellent. Tumors that can only be partially removed, and higher-grade meningiomas, have a higher chance of recurring, which is why radiation is sometimes recommended after surgery and why long-term follow-up imaging is standard regardless of grade.

Should I get a second opinion?

Yes, particularly because meningioma treatment decisions often involve a real judgment call between observation, surgery, and radiation. A second opinion with a neurosurgeon who treats meningiomas regularly can clarify whether immediate treatment is needed, whether a different approach might be preferable, and what the specific risks and benefits look like for your tumor.

Meningioma

The most common primary brain tumor in adults — frequently appropriate for observation rather than immediate intervention.

Overview

What Is a Meningioma?

A meningioma is a tumor that begins in the thin layers of tissue that cover and protect the brain and spinal cord. It’s the most common type of primary brain tumor in adults, and most meningiomas are benign and slow-growing. Many are found by accident on a scan done for another reason and never need to be removed.

Common symptoms, when they occur, include headaches, seizures, vision changes, hearing loss or ringing in one ear, weakness or numbness in one part of the body, and gradual changes in personality, memory, or behavior. Symptoms depend on where the meningioma is located and what nearby structures it affects.

Treatment depends on the size, location, and behavior of the tumor. Some meningiomas can be safely watched with periodic imaging, while others are best treated with surgery or focused radiation. Dr. Sherman has experience treating meningiomas at Rutgers Cancer Institute in New Brunswick, NJ.

Call our office at 732-235-6333 or send us a message.

The information on this page is general educational information and is not medical advice. It does not create a doctor-patient relationship or reflect a treatment recommendation for any individual. Treatment decisions require an individual evaluation by a qualified physician.

Many meningiomas are found incidentally and cause no symptoms at all. For patients who do have symptoms, they typically develop slowly over months or longer, because most meningiomas grow at a slow pace.

Here’s what makes symptoms worth investigating.

Persistent or new headaches. Headaches that are gradually worsening, worse in the morning, or come with nausea or vomiting warrant evaluation. A single bad headache is almost never a meningioma, but a pattern of new headaches over weeks or months is worth imaging.

New seizures. A first seizure in an adult always warrants brain imaging. Seizures are a common presenting symptom for meningiomas located along the outer surface of the brain.

Vision changes. Blurred vision, loss of peripheral vision, or double vision can be caused by meningiomas pressing on the optic nerves or the structures near them. Any new or progressive vision change not explained by a routine eye problem should be evaluated with imaging.

Hearing loss or ringing in one ear. Meningiomas at the skull base can affect hearing. One-sided hearing changes, ringing, or balance problems are worth investigating.

Weakness, numbness, or coordination changes. Meningiomas that press on specific areas of the brain can cause weakness, numbness, or trouble with fine motor control in one part of the body. Focal symptoms like these are worth evaluating.

Changes in personality, memory, or thinking. Subtle changes in judgment, memory, or behavior, particularly those noticed by family rather than the patient, can be an early sign of a meningioma in the frontal region. These changes are easy to dismiss as stress or aging and often warrant imaging if they persist.

Loss of smell. A meningioma at the base of the frontal lobes can affect the sense of smell. An unexplained loss of smell, particularly in combination with other subtle symptoms, is worth mentioning to a doctor.

When to treat it as an emergency. Sudden severe symptoms, loss of consciousness, sudden inability to speak, or a seizure that doesn’t stop should be treated as an emergency. Go to the nearest emergency room rather than waiting for an appointment.

For most meningioma symptoms, the pace of evaluation is measured in days to weeks, not hours. Meningiomas rarely cause sudden catastrophic symptoms, and in the vast majority of cases there is time for a careful workup and a thoughtful discussion of options before any decision about treatment is made.

Imaging

MRI of the brain with and without contrast is the standard imaging study for meningiomas. Meningiomas have a distinctive appearance on MRI, typically showing up as a well-defined mass attached to the meninges that enhances brightly and uniformly with contrast. Experienced neuroradiologists can often recognize a meningioma on imaging with a high degree of confidence, even before any tissue is examined.

In many cases, the combination of imaging features and location is enough to strongly suggest the diagnosis and to guide decisions about whether to observe, operate, or consider radiation without first obtaining tissue. This is different from many other brain tumors, where a biopsy is usually required to confirm the diagnosis before any treatment decision is made. For meningiomas, imaging alone is often diagnostic enough to plan next steps.

A CT scan may be added in certain cases, particularly for meningiomas at the skull base or those that involve bone. CT is better at showing how the meningioma relates to bony structures and whether there is any bone involvement, which can be important for surgical planning. For patients with symptoms that suggest the tumor may be affecting nearby blood vessels, a CT angiogram or MR angiogram may also be obtained.

Tissue Diagnosis

A definitive diagnosis of meningioma, including the WHO grade and subtype, requires examining tissue under a microscope. In practice, this happens when a meningioma is surgically removed, either because it is causing symptoms, growing on serial imaging, or in a location where treatment is needed. The tissue removed during surgery is sent to a neuropathologist, who confirms the diagnosis, determines the grade, and identifies the specific subtype.

Stereotactic needle biopsy is rarely used for meningiomas because most are either observed without any tissue sampling or removed surgically when treatment is needed. The imaging appearance and location of a suspected meningioma is usually sufficient to guide the initial management plan.

Meningioma treatment depends on a few key factors: the tumor’s size and location, whether it’s causing symptoms, whether it’s growing on serial imaging, the patient’s overall health and age, and the likelihood of achieving a safe and complete removal if surgery is considered. For many patients, the right answer is not immediate intervention.

Observation (Watchful Waiting)

A significant number of meningiomas, particularly small ones found incidentally that are causing no symptoms, are best managed with careful observation rather than immediate treatment. This is not a default to inaction. It is an active management strategy based on the fact that many meningiomas grow very slowly or not at all, and some never require treatment.

Observation involves periodic MRI scans to watch for any growth, typically starting with a repeat scan several months after the initial finding and then at regular intervals. If the tumor remains stable and the patient remains symptom-free, observation can continue indefinitely. If the tumor begins to grow or cause symptoms, the plan shifts to active treatment.

Observation is most often appropriate for small meningiomas without symptoms, meningiomas in older patients where the tumor is unlikely to cause problems during the patient’s lifetime, and tumors in locations where surgery would carry significant risk and the tumor is not yet justifying that risk.

Surgery

Surgery is the primary treatment when a meningioma is causing symptoms, growing on serial imaging, reaching a size that poses a future risk, or in a location where continued growth would be dangerous. The goal of surgery is to remove the entire tumor along with any involved dura (the outer layer of the meninges) and, when possible, any affected bone. Complete removal of a benign (Grade 1) meningioma is often curative, with low rates of recurrence and excellent long-term outcomes.

The difficulty of meningioma surgery depends almost entirely on location. Meningiomas on the convexity (the outer surface of the brain) are often straightforward to remove completely. Meningiomas at the skull base, particularly those involving the cavernous sinus, the optic nerves, or major blood vessels, are among the most technically demanding operations in neurosurgery and require specialized experience. For meningiomas located in or near areas of the brain that control speech or movement, awake craniotomy can be used to map brain function in real time during the operation and protect essential functions.

Stereotactic Radiosurgery

Stereotactic radiosurgery uses focused, high-dose radiation to treat meningiomas without an incision. It is particularly useful in three situations: small meningiomas in locations where surgery would carry significant risk, residual tumor left behind after a partial surgical resection, and recurrent meningiomas after previous surgery. Radiosurgery is typically delivered in a single session or a small number of sessions and has a strong track record for controlling the growth of small to moderate-sized meningiomas over the long term.

Radiation Therapy

Conventional fractionated radiation therapy, delivered in small daily doses over several weeks, is sometimes used for meningiomas that are too large for radiosurgery, for higher-grade meningiomas after surgery, or for tumors in locations where radiosurgery is not ideal. It is most commonly used as an addition to surgery rather than as a primary treatment.

How the Plan Gets Made

For meningiomas, the treatment decision is often as much about when to treat as what to do. Many patients who are told they have a meningioma benefit most from a careful evaluation by a neurosurgeon who treats meningiomas regularly and can give a clear recommendation about whether to observe, operate, or consider radiation. The question is rarely “which treatment” in isolation. It’s “what’s the right approach for this specific tumor, in this specific patient, at this specific time.”

Treatments commonly used for this conditionBrain Tumor Surgery, Stereotactic Radiosurgery, and Awake Craniotomy.

Technology

Using XR Technology To Advance Medical Care

Dr. Sherman integrates VR and AR visualization into surgical planning and patient education, giving patients a clearer picture of their diagnosis and the approach to treatment.

Common Questions About Meningiomas

Most meningiomas are not cancerous. Approximately 80 percent are WHO Grade 1, which means they are benign, slow-growing, and often curable with complete surgical removal. About 15 to 18 percent are WHO Grade 2 (atypical), which are somewhat more aggressive and more likely to recur. A small number, around 1 to 3 percent, are WHO Grade 3 (anaplastic or malignant) and behave more like cancer. The grade can only be determined by examining tumor tissue under a microscope.

Recovery depends on the size and location of the tumor and the complexity of the surgery. For most uncomplicated meningioma surgeries, patients spend a few days in the hospital and return to most daily activities over the course of four to six weeks. Recovery from more complex skull base surgeries can take longer. Follow-up imaging is typically done several months after surgery to confirm complete removal and then at intervals to monitor for any recurrence.

Next Step

Newly Diagnosed or Seeking a Second Opinion?

Dr. Sherman is accepting new patients at Rutgers Cancer Institute in New Brunswick, New Jersey. Whether you’ve just been told you have a meningioma or you’re looking for another perspective on whether and when to treat, a consultation is the first step toward understanding your options.

Schedule a Consultation 732-235-6333