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CNS: Meningioma grading and RT indications

Free question published 28 September 2026

Central nervous systemMeningioma grading and RT indications

A 57-year-old woman undergoes surgery for a convexity meningioma causing seizures. The neurosurgeon achieves a Simpson grade IV (subtotal) resection because of adherence to the superior sagittal sinus. Histology shows an atypical meningioma, WHO grade 2. She has recovered well. What is the most appropriate postoperative management?

  1. AWhole-brain radiotherapy
  2. BAdjuvant temozolomide chemotherapy
  3. CImmediate re-operation to achieve Simpson grade I resection regardless of sinus involvement
  4. DWatch-and-scan with serial MRI and no radiotherapy
  5. EPostoperative fractionated radiotherapy to the residual tumour

Why E is correct

The EANO meningioma guideline recommends radiotherapy for WHO grade 2 (atypical) meningioma after a Simpson IV-V (incomplete) resection. With residual atypical tumour adherent to the sagittal sinus, postoperative fractionated radiotherapy is the appropriate adjuvant treatment to reduce recurrence risk; the role of radiotherapy after gross total resection of grade 2 tumours remains less certain in the absence of randomised trials.

And why the others are not

  • AIncorrect: meningioma is a localised tumour; whole-brain radiotherapy is not used.
  • BIncorrect: systemic chemotherapy such as temozolomide has no established role in first-line management of meningioma.
  • CIncorrect: aggressive re-operation jeopardising the sagittal sinus is not mandated; adjuvant radiotherapy addresses the residual tumour with lower morbidity.
  • DIncorrect: watch-and-scan is appropriate for incompletely resected WHO grade 1 tumours, not for an incompletely resected atypical grade 2 tumour.

Source EANO guideline on the diagnosis and management of meningiomas — Goldbrunner R, Stavrinou P, Jenkinson MD, et al. EANO guideline on the diagnosis and management of meningiomas. Neuro Oncol. 2021;23(11):1821-1834.

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