BACKGROUND AND OBJECTIVE:: Meningiomas involving the foramen magnum (FM) region are rare and constitute 1% to 7% of intracranial meningiomas. Surgical excision is difficult in view of the complex anatomy and the proximity to critical neurovascular structures. Our aim was to analyze the clinical presentation and surgical outcome of patients operated for FM meningiomas. MATERIALS AND METHODS:: Thirty patients who underwent surgery for FM meningioma over a period of 21 years were studied retrospectively. Case records and imaging studies were reviewed for demographic data, presenting symptoms, tumor location, surgical approach, and postoperative complications. The outcome was assessed on the basis of the Glasgow Outcome Scale (GOS). RESULTS:: Twenty-three women and 7 men ranging in age between 18 and 75 years were diagnosed after a mean symptom duration of 20 months. The choice of surgical technique was guided by the tumor location (anterior: 6, lateral: 19, posterior: 5), the position of the vertebral artery, and the extent of dural attachment. Although 11 of the lateral meningiomas were resected through the posterior approach, 8 were operated by the posterolateral route. Five anterior meningiomas were operated by the posterolateral corridor, whereas 1 was excised by a posterior approach reaching the tumor from either side of the cervicomedullary junction. Radical resection was performed in 28 patients; 2 patients with extradural extension underwent subtotal removal. There were 2 postoperative deaths, of whom 1 patient died after a surgery for recurrent tumor. Of the 27 patients who came for follow-up, 18 had a GOS of 5, 6 patients were moderately disabled (GOS 4), and 3 were severely disabled (GOS 2 and 3). One patient underwent revision surgery for symptomatic recurrence. CONCLUSIONS:: Meticulous surgical planning is required for a safe and complete resection of FM meningiomas with minimal morbidity and mortality. Copyright © 2012 by Lippincott Williams & Wilkins.