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CNS: Meningioma observation

Free question published 20 October 2026

Central nervous systemMeningioma observation

A 68-year-old woman undergoes MRI for unrelated headaches, which incidentally shows a 1.4 cm right frontal convexity meningioma with typical homogeneous enhancement and no oedema. She has no neurological symptoms and no seizures. What is the most appropriate initial management?

  1. AUpfront stereotactic radiosurgery
  2. BUpfront fractionated external beam radiotherapy
  3. CImmediate surgical resection aiming for Simpson grade I
  4. DObservation with serial MRI surveillance
  5. EBiopsy followed by adjuvant radiotherapy

Why D is correct

The EANO meningioma guideline recommends observation as the first therapeutic option in asymptomatic patients with newly diagnosed or slow-growing meningiomas. An incidental, small, asymptomatic convexity meningioma in an older patient is best managed with serial MRI, reserving intervention for growth or new symptoms.

And why the others are not

  • AIncorrect: upfront radiosurgery is not first-line for an asymptomatic lesion suitable for observation.
  • BIncorrect: fractionated radiotherapy is not indicated as initial management of an asymptomatic incidental meningioma.
  • CIncorrect: surgery is not indicated for a small asymptomatic incidental meningioma; it carries unnecessary operative risk.
  • EIncorrect: biopsy and adjuvant radiotherapy are inappropriate for a typical asymptomatic meningioma that can simply be observed.

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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