Technical Nuances on Preoperative Embolization of Meningiomas: A Multi-center Experience

Introduction: The indications for preoperative embolization of meningiomas remain unclear. Key principles include identifying well-defined arterial pedicles, using superselective microinjections, preferring embolic agents with optimal visibility, avoiding ICA feeders when possible, and employing protective measures to prevent unintended embolization of eloquent regions. This study aims to clarify the suitability, feasibility, and safety of preoperative embolization in meningiomas.

Methods: A retrospective review of an institutional meningioma database spanning from 2004 to 2022 was conducted. The study included all patients who underwent angiographic evaluation for embolization, followed by embolization and subsequent surgical resection.

Results: We included 98 patients with a median age of 62 years (IQR, 53–69), 67.3% of whom were female. Meningiomas were located on the cortical convexity (54.1%), parasagittally (25.5%), and at the skull base (15.3%). The external carotid artery (ECA) was the dominant arterial supply (88.8%), primarily from the middle meningeal artery (91.8%), either unilaterally or bilaterally. Most procedures were performed via the femoral approach (69.4%) under conscious sedation (77.6%) using a microcatheter (88.8%). Liquid embolic agents, including Onyx and cyanoacrylates, were used in 93.9%. Only one intraprocedural focal neurological deficit occurred. Post-embolization, two cases of focal neurological deficits and two of intra-tumoral hemorrhage were observed. The median time from embolization to resection was 21.9 hours (IQR, 15.9–28.4), with resection lasting 239 minutes (IQR, 188–300) and median blood loss of 200 mL (IQR, 100–400). Anesthesia duration was 312 minutes (IQR, 248–408), with delayed emergence in 26.5%. Adjuvant radiosurgery was needed in 44.9%, and three patients had recurrence at a median of 171 days (IQR, 130.5–226.5), two of whom underwent additional radiosurgery.

Conclusion : By following rigorous protocols and employing meticulous techniques, we have achieved consistently favorable outcomes with minimal complications, underscoring the reliability and efficacy of this approach in our practice.