Radiosurgery for Intracranial Meningiomas: A Review of Anatomical Challenges and an Update on The Evidence

Radiation has been used to treat meningiomas since the mid-1970s. Traditionally, radiation was reserved for patients unfit for major surgery or those with surgically inaccessible tumors. With an increased quantity and quality of imaging and an aging population, there has been a rise in incidentally diagnosed meningiomas in patients with smaller tumors at the time of diagnosis. Deciding if, how, and when to intervene must be determined on a case-by-case basis. Anatomical location and adjacent vital structures are crucial for decision-making. Prior review articles have detailed outcomes of radiosurgery in broad anatomical regions such as the skull base, but there has been a deluge of recent research on increasingly specific anatomical subregions. This review synthesizes information regarding specific anatomical subregions, including anatomical challenges, radiosurgical outcomes, and unique considerations. We utilized the highest levels of evidence available for each region, discuss details of published research, and explore future directions. Meningioma management remains individualized based on patient comorbidities, tumor location/characteristics, symptomatic burden, and patient age. In addition to SRS’s established role for surgically inaccessible, recurrent, and high-grade meningiomas, the use of SRS as upfront management for small asymptomatic meningiomas is increasingly investigated. For all sub-regions reported, radiosurgical intervention resulted in high tumor control rates and acceptably low adverse radiation events.