Last updated: June 17, 2022

Summarytoggle arrow icon

Meningiomas are almost always benign, slow-growing brain tumors that arise from arachnoid cap cells of the arachnoid villi. As meningiomas may remain asymptomatic for long periods of time, they are often an incidental finding. Tumor compression can lead to a wide variety of neurological symptoms (i.e., headaches, seizures, paresthesias) that are generally specific to the structure(s) being compromised. Contrast imaging typically shows an enhanced round tumor with well-defined margins that often resembles a snowball. Management depends on the location and grade of the tumor, as well as patient-specific factors such as age, comorbidities, and accompanying symptoms. Treatment generally consists of surgical intervention, radiotherapy, or a combination of both. In some cases (e.g., asymptomatic elderly patients, or those with slow-growing meningiomas), a "watch and wait" approach with regular tumor monitoring may be safer than invasive therapy.

Definitiontoggle arrow icon

Meningiomas are a diverse group of brain tumors that arise from the arachnoid layer (specifically the arachnoid cap cells) and can therefore occur in any part of the CNS with a meningeal covering.

Epidemiologytoggle arrow icon

  • Most common benign primary brain tumor in adults [1][2]
  • Sex: > (2:1) [3]
  • Age: most common in patients > 65 years of age [4]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Clinical featurestoggle arrow icon

Clinical features based on meningioma location [6]
Location Frequency Clinical features
Supratentorial convex surface [8][9]
  • ∼ 20%
Parasagittal angle [10]
  • ∼ 19%
Falx cerebri [10]
  • ∼ 8%
Sphenoid wings [11]
  • ∼ 20%
Posterior cranial fossa [12]
  • ∼ 10%
Olfactory groove [13]
  • ∼ 10%
Foramen magnum [14]
  • ∼ 2%
Intraventricular [12]
  • < 1%
Spinal meningioma [15]
  • ∼ 10%

Diagnosticstoggle arrow icon

MRI (imaging modality of choice)

  • Plain MRI findings [16]
  • Contrast MRI findings [16]
    • Significant homogenous enhancement of the meningioma
    • Sunburst or spoke-wheel appearance [17]
    • Spinal meningioma: ginkgo-leaf sign [18]
      • The enhanced but distorted spinal cord takes the shape of the leaf, while the stretched non-enhancing dentate ligament forms the "stem" of the leaf.
      • Seen on an axial view of the spinal cord after contrast enhancement
    • En plaque meningioma: a rare benign subtype that is characterized by diffuse carpet-like growth along the dural layer

CT scan [19]

  • CT scans performed to investigate unexplained headaches or seizures are usually the first to pick up incidental meningiomas.
  • Findings

Brain tumor biopsy [6]

  • May be performed if the tumor is inoperable or imaging is inconclusive
  • Most meningiomas are removed surgically without a prior biopsy. [20]

Pathologytoggle arrow icon

Gross findings

  • Encapsulated, round, grayish-white tumor
  • Firm to hard consistency
  • Cross-sectional surface: gray, granular

Microscopic findings

  • Mesenchymal origin (arachnoid cap cells)
  • Whorls of meningothelial cells (onion peel arrangement) [21]
  • Psammoma bodies [22]
  • Increased vascularity [23]

WHO classification of meningiomas

  • There are 15 histological subtypes of meningiomas.
  • Most meningiomas are benign (WHO grade I) tumors.
WHO classification of meningiomas [6][22]
WHO grade Frequency Histopathological criteria Subtypes
Grade I (benign)
  • 80–85% of all meningiomas
  • Transitional (mixed type)
  • Meningothelial (classical meningioma)
  • Fibrous
  • Psammomatous
  • Angiomatous
  • Microcystic
  • Lymphoplasmacytic
  • Secretory
  • Metaplastic
Grade II (atypical)
  • 15–20% of all meningiomas
Grade III (malignant)
  • < 2% of all meningiomas

Treatmenttoggle arrow icon

  • Surgical resection: first-line treatment [22]
    • Preoperative embolization in the case of highly vascular tumors [23]
    • Skull base meningiomas have a high recurrence risk . [24]
  • Radiotherapy [22]
  • Active surveillance: consider in a slow-growing asymptomatic tumor in an elderly patient [6]

Prognosistoggle arrow icon

  • WHO grade I meningiomas: good prognosis, with a 5-year recurrence rate of 7–23% after resection [22][26]
  • WHO grade II and III meningiomas: poor prognosis, with a 5-year recurrence rate of ∼ 50% and ∼ 75% respectively after resection [22][26]
Meningioma recurrence rate based on the extent of tumor resection
Simpson grade [22] Extent of tumor resection [22] Recurrence rate after 10 years [27]
Grade I
  • Complete tumor resection
  • Resection of the underlying dura and abnormal bone
  • ∼ 5%
Grade II
  • Complete tumor resection
  • Cauterization of the dural attachment
  • ∼ 20%
Grade III
  • Complete tumor resection only
  • ∼ 30%
Grade IV
  • Subtotal resection
  • ∼ 35%
Grade V
  • 100%
  • MIB-1 index: an indirect measure of the rate of tumor growth [28][29]
    • MIB-1 is a monoclonal antibody used to assay the antigen Ki-67 (a nuclear protein seen in proliferating cells).
    • MIB-1 index > 4% is associated with a higher meningioma recurrence rate.

Referencestoggle arrow icon

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  2. Ostrom QT, Gittleman H, Fulop J, et al. CBTRUS Statistical Report: Primary Brain and Central Nervous System Tumors Diagnosed in the United States in 2008-2012. Neuro Oncol. 2015; 17 (suppl 4): p.iv1-iv62.doi: 10.1093/neuonc/nov189 . | Open in Read by QxMD
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  5. Perry A. Meningiomas. Elsevier ; 2010: p. 185-217
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  8. Kazemi NJ, Kaye AH. Convexity Meningiomas. Springer London ; 2009: p. 301-307
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  10. Elzarief AA, Ibrahim MF. Long-term follow-up of motor function deterioration following microsurgical resection of middle third parasagittal and falx meningioma. The Egyptian Journal of Neurology, Psychiatry and Neurosurgery. 2018; 54 (1).doi: 10.1186/s41983-018-0013-3 . | Open in Read by QxMD
  11. Del Toro E, Risbud A, Khosravani N, Vengerovich G, Archilla A. Sphenoid Wing Meningioma Presenting as Sudden Sensorineural Hearing Loss: A Case Report and Literature Review. Ear, Nose & Throat Journal. 2020: p.014556132090573.doi: 10.1177/0145561320905731 . | Open in Read by QxMD
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  14. Mostofi K. Foramen Magnum Meningioma: Some Anatomical and Surgical Remarks through Five Cases. Asian Spine Journal. 2015; 9 (1): p.54.doi: 10.4184/asj.2015.9.1.54 . | Open in Read by QxMD
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  18. Yamaguchi S, Takeda M, Takahashi T, et al. Ginkgo leaf sign: a highly predictive imaging feature of spinal meningioma. Journal of Neurosurgery: Spine. 2015; 23 (5): p.642-646.doi: 10.3171/2015.3.spine1598 . | Open in Read by QxMD
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