Stagnation and Progression: How Glymphatic Failure Promotes Meningioma Malignancy in Aging

Meningiomas in the elderly present a clinical paradox: despite typically benign histology, they frequently manifest disproportionate peritumoral brain edema (PTBE) and aggressive behavior. Traditional hormonal hypotheses fail to explain this age-specific malignancy. This review articulates a "Neuro-Glymphatic-Tumor Axis" as a working hypothesis, proposing that the senescent collapse of brain clearance infrastructure, rather than tumor genetics alone, may be a key driver of this progression. Specifically, the loss of astrocytic aquaporin-4 (AQP4) polarity and the atrophy of meningeal lymphatic vessels are hypothesized to create a critical "hydrodynamic mismatch." This systemic failure may trap oncogenic toxins, specifically HMGB1 and S100A4, potentially activating RAGE signaling, while simultaneously blocking antigen drainage, which could induce a state of "immunological ignorance." Consequently, the tumor microenvironment may become physically congested and immunologically suppressed. Translating this framework into practice, we suggest that assessing "glymphatic frailty" via functional MRI and exploring microenvironment-targeted strategies, including lymphatic-sparing surgery and AQP4 modulation, represent promising future directions for dismantling the cycle of edema and recurrence in the vulnerable geriatric population.