Recurrent Grade I Parafalcine Meningioma: Management Challenges and Genomic Insights.

While World Health Organization (WHO) grade I meningiomas are typically slow growing and associated with favorable prognoses, a subset may exhibit unexpectedly aggressive behavior and resistance to conventional treatment approaches. Recurrent grade I meningiomas, in particular, are associated with a poorer prognosis despite their benign histological classification, underscoring the need for advanced genomic and radiomic analyses to refine diagnostic accuracy. We present a case of a 52-year-old female with a grade I parafalcine meningioma initially deemed nonaggressive, but ultimately recurred multiple times over several years despite undergoing repeated craniotomies and several courses of radiosurgery. Notable tumor characteristics included its supratentorial location, high Ki-67 proliferative index, and NF-2 genetic alteration, which are all factors associated with decreased progression-free survival in grade I meningioma patients. The patient remains clinically stable eight months post salvage stereotactic radiation therapy (SRT). This case highlights the intricate surgical and radiotherapeutic decisions involved in managing recurrent grade I meningiomas, reinforcing the importance of multidisciplinary evaluation and individualized treatment strategies.