In clinical work, we often encounter some elderly patients suffering from meningioma. These patients often have some common features that the focal symptoms caused by the tumor are often mild, but rather the intracranial meningioma is found during routine screening at the neurology consultation for some non-specific symptoms such as dizziness, headache, head swelling, memory loss, tinnitus, unstable walking, etc. These tumors are often located in mute areas of neurological function or are small, and how to treat them is often a particular concern of the patient’s relatives. Does the tumor need to be treated or not? This question is often the central concern of the family. Meningioma and auditory neuroma are different in their natural history of development. Meningioma will definitely grow, while auditory neuroma has a 6% chance of shrinking, only the growth rate of different meningiomas is different. Currently, the life expectancy of the nation is getting higher and higher, so from the medical point of view, patients with meningioma must be treated. Which treatment method should be adopted for these tumors? Which treatment is more suitable for elderly patients, surgery or r-knife. Neurosurgeons and r-knife surgeons may have completely different answers. r-knife treatment of meningiomas includes three possibilities: shrinkage, no further growth, and ineffectiveness. Therefore, it is not possible to predict the outcome of treatment before it is given. rKnife itself is a form of radiation therapy and still has its inherent radiological damage, only that damage is minimized. With surgery, the operator must assess the risks and effects of the procedure. In elderly patients, we hope that there will be at least no recurrence after surgery because they no longer have the next opportunity for surgery. I once saw an elderly patient with a meningioma with a tumor of about 2 cm, located next to the sagittal sinus and partially approaching the sagittal sinus. At that time I said to this patient: surgery can be done, I don’t think it is particularly risky, but in terms of the extent of resection, I can only remove the tumor nodules, and for the sagittal sinus I can electrocoagulate part of the wall, and even then, from the point of view of recurrence prevention, I can’t guarantee that the tumor won’t recur, so I recommend to continue observation and wait for the sagittal sinus to be pressed closed before surgery, or to use r-knife treatment and then observation. Therefore the treatment plan should be individualized for these patients. Should the treatment of meningioma be under observation or direct surgery first? From a medical safety perspective, for elderly patients, we always want to obtain evidence of tumor growth before surgery. After all, the risk of perioperative cardiovascular and cerebrovascular accidents is much greater in the elderly than in younger people. However, in terms of the natural history of meningioma, if there is no severe cardiopulmonary, hepatic or renal dysfunction such that the patient cannot tolerate surgery, it is best to operate promptly after detection. However, it must be emphasized that a detailed evaluation of systemic function should be done before surgery, which is much riskier than in younger people and may also induce cardiovascular accidents after surgery.