Comparison of Embolic Agents in Preoperative Embolization for Intracranial Meningiomas: Multicenter Adjusted Analysis of 275 Cases

Introduction: Preoperative embolization has been used for intracranial meningiomas for nearly four decades, with varying preferences for embolic materials and limited comparative data on their efficacy.

Methods: Consecutive patients who underwent preoperative embolization for meningioma across 12 centers (2013–2024) were included and classified by embolic material: (a) particles, (b) liquid agents, and (c) coils. Primary outcomes included estimated blood loss (EBL), procedural complications, surgery duration, Gross Total Resection (GTR), unplanned rescue surgery, mRS, and mortality. An initial unadjusted analysis and adjusted multivariate regression were conducted. Additional subgroup analyses compared each pair of embolic materials. Confounding variables controlled for included age, sex, BMI, smoking, comorbidities, prior surgery, pre-treatment antithrombotics, WHO grade, tumor location, maximal diameter, and baseline mRS.

Results: 275 patients (median age 47, 62.9% female) were included. The mean maximum tumor diameter was 32.9 ± 10.1 mm, with 61% classified as WHO I. Liquid agents were most frequently used (42.5%), predominantly Onyx (37.5%), followed by particles (38.9%) and coils (18.5%). Compared to particles and coils, EBL was significantly lower in the Onyx group (median 250 mL, IQR: [150-500] vs. 350 [205-638] and 375 [200-700] mL, respectively), significantly associated with shorter surgical duration (266 [196-390] vs. 430 [307-651] and 347 [224-500] minutes, respectively; P < 0.001) and higher rates of GTR (81.2% vs. 56.1% and 58.8%, respectively; P < 0.001). Unplanned rescue surgery rates were reduced in the Onyx group (6.8% vs. 15% and 21.6% for particles and coils, respectively). Multivariate regression showed that Onyx was associated with reduced EBL (β = -0.122, P < 0.001), shorter surgical duration (β = -0.215, P < 0.001), higher odds of GTR (OR 3.19, 95% CI: 1.73–5.89, P < 0.001), and lower odds of unplanned rescue surgery (OR 0.36, 95% CI: 0.15–0.88, P = 0.024). There were no significant differences between embolic agents in procedural complications, mRS, or mortality rates.

Conclusion : Onyx, a liquid embolic agent, reduces ESL, leading to shorter surgery duration, higher GTR rates, and fewer retreatments, with comparable safety across embolic agents.