**4. Treatment strategies**

Treatment of intracranial meningiomas generally include observation, microsurgery, radiotherapy in terms of fractionated radiotherapy in terms of conventional radiotherapy, intensity-modulated radiotherapy (IMRT) or volumetric arch therapy (VMAT), proton therapy or stereotactic radiosurgery or radiotherapy (SRS/SRT) [3–5]. Chemotherapy is indicated in some selected refractory cases. Microsurgery remains the best option for symptomatic intracranial meningiomas if complete resection can be achieved with low morbidity. Based on the well-known Simpsons grading system, the extent of tumor resection correlates with the tumor recurrence rate (**Table 3**). Nevertheless, total excision together with dural origin is seldom possible, particularly in cases with involvement or encasement of important neurovascular structures around skull base.

Stereotactic radiosurgery or radiotherapy can be of curative intent when adopted as a primary treatment, in postoperative cases when there is residual disease or high risk of relapse especially in WHO grade II or III cases, or of palliative intent when the disease is beyond cure [6, 7]. European Association of Neuro-oncology (EANO) had published their suggested flowchart in treatment guidelines (**Figure 1**) [8]. There was a review of patients with meningioma between 2010 and 2012 under the National Cancer Database. A total of 802 patients were included, of which 173 patients received SRS/SRT (22%) and 629 patients (78%) received external beam


#### **Table 3.**

*Simpson grading system on meningioma resection.*

#### **Figure 1.**

*The European Association of Neuro-oncology (EANO) treatment guideline flowchart for intracranial meningioma.*

radiation therapy (EBRT). The 3-year overall survive rate of 2 treatments were similar (97.3% in SRS/SRT group and 93.4% in EBRT group) [9].

This chapter is intended to have an overview of radiosurgery as treatment of intracranial meningiomas.
