Parasagittal meningiomas, especially when associated with the middle or posterior third of the superior sagittal sinus, pose difficult management challenges. Initial surgical excision is associated with high morbidity and frequent tumor recurrence after subtotal resection. Neurological deficits are cumulative when multiple resections are required. No consistent management approach exists for patients with such tumors. In addition to observation, management options include resection, stereotactic radiosurgery, or fractionated radiation therapy used alone or in combination.

Sixteen centers where resection, gamma knife radiosurgery, and/or radiation therapy were available provided management data on 203 patients with histologically benign meningiomas from the time of initial diagnosis through follow-up after radiosurgery. The timing of resections, parameters of radiosurgery, rates of tumor control, morbidity, and functional patient outcomes were studied. The median follow-up duration in this study was 3.5 years (maximum, 33 yr after presentation and 6 yr after radiosurgery).

The tumors were located in the anterior superior sagittal sinus in 52 patients, at the middle of the sinus in 91, and at the posterior portion of the sinus in 60. The mean tumor volume at the time of radiosurgery was 10 cc. In patients who underwent radiosurgery as the primary therapy (n = 66), the 5-year actuarial tumor control rate was 93 +/- 4%. No clinical failure (need for additional therapy or worsened neurological function) occurred in patients who had smaller tumors (<7.5 cc) and who had never undergone resection (n = 41). The 5-year control rate for patients with previous surgery was only 60 +/- 10%; the control rate for the radiosurgery-treated volume was 85%. Most failures resulted from remote tumor growth. Multivariate analyses identified significantly decreased tumor control with increasing tumor volume (P = 0.002) and previous neurological deficits (P = 0.002). The rate of transient, symptomatic edema after radiosurgery was 16%, was more common with larger tumors, and occurred within 2 years. Of 33 patients who were employed at the time of radiosurgery for whom a minimum of 1 year of follow-up data were available, 30 remained employed (91%). A decrease in functional status after radiosurgery was noted in only 3 of 33 (9%) employed and 7 of 77 (9%) unemployed patients.

In patients with smaller tumors (<3 cm in diameter) and patent sagittal sinuses, we advocate radiosurgery alone as the first surgical procedure. Patients with larger tumors and those with progressive neurological deficits resulting from brain compression should first undergo resection. Planned second-stage radiosurgery should be performed soon afterward for any residual tumor nodule or neoplastic dural remnant. Multimodality management may enhance long-term tumor control, reduce the need for multiple resections, and maintain the functional status of the patient.