Preoperative embolization of intracranial meningioma

Current evidence regarding the benefit of preoperative embolization (POE) of meningiomas is inconclusive. A systematic review and meta-analysis aimed to evaluate the safety profile of the procedure and to compare outcomes in embolized versus non-embolized meningiomas. PubMed was queried for studies after January 1990 reporting outcomes of POE. Pertinent variables were extracted and synthesized from eligible articles. Heterogeneity was assessed using I2, and random-effects model was employed to calculate pooled 95% CI effect sizes. Publication bias was assessed using funnel plots and Harbord's and Begg's tests. Meta-analyses were used to assess estimated blood loss and operative duration (mean difference; MD), gross-total resection (odds ratio; OR), and postsurgical complications and postsurgical mortality (risk difference; RD). Thirty-four studies encompassing 1782 preoperatively embolized meningiomas were captured. The pooled immediate complication rate following embolization was 4.3% (34 studies, n = 1782). Although heterogeneity was moderate to high (I2 = 35-86%), meta-analyses showed no statistically significant differences in estimated blood loss (8 studies, n = 1050, MD = 13.9 cc, 95% CI = -101.3 to 129.1), operative duration (11 studies, n = 1887, MD = 2.4 min, 95% CI = -35.5 to 30.8), gross-total resection (6 studies, n = 1608, OR = 1.07, 95% CI = 0.8-1.5), postsurgical complications (12 studies, n = 2060, RD = 0.01, 95% CI = -0.04 to 0.07), and postsurgical mortality (12 studies, n = 2060, RD = 0.01, 95% CI = 0-0.01). Although POE is relatively safe, no clear benefit was observed in operative and postoperative outcomes. However, results must be interpreted with caution due to heterogeneity and selection bias between studies. Well-controlled future investigations are needed to define the patient population most likely to benefit from the procedure 1).

Shah et al. analyzed new therapeutic options for the embolization of intracranial meningiomas, as well as the future of meningioma treatment through recent relevant cohorts and articles. They investigate various embolic materials, types of meningiomas amenable to embolization, imaging techniques, and potential imaging biomarkers that could aid in the delivery of embolic materials. They also analyze perfusion status, complications, and new technical aspects of endovascular preoperative embolization of meningiomas. A literature search was performed in PubMed using the terms “meningioma” and “embolization” to investigate recent therapeutic options involving embolization in the treatment of meningioma. They looked at various cohorts, complications, materials, and timings of meningioma treatment. Liquid embolic materials are preferable to particle agents because particle embolization carries a higher risk of hemorrhage. Liquid agents maximize the effect of devascularization because of deeper penetration into the trunk and distal tumor vessels. The 3 main imaging techniques, MRI, CT, and angiography, can all be used in a complementary fashion to aid in analyzing and treating meningiomas. Intraarterial perfusion MRI and a new imaging modality for identifying biomarkers, susceptibility-weighted principles of echo shifting with a train of observations (SW-PRESTO), can relay information about perfusion status and degrees of ischemia in embolized meningiomas, and they could be very useful in the realm of therapeutics with embolic material delivery. Direct puncture is yet another therapeutic technique that would allow for more accurate embolization and less blood loss during resection 2).

Preoperative embolization has been an option for adjunctive treatment of intracranial meningiomas, but it remains used in only a minority of cases 3).

Preoperative embolization appeared to be very useful in large tumors with pure or predominant external carotid artery supply (convexity meningiomas), in skull-base meningiomas, and in middle fossa and paracavernous meningiomas. It was also useful in falx and parasagittal meningiomas receiving blood supply from the opposite side and in posterior fossa meningiomas. CT low densities demonstrated after embolization did not always correlate with necrosis on microscopic examination, and large areas of infarction could be found despite normal CT. Embolic material was found on pathologic examination in 10%-30% of cases; fresh or recent ischemic and/or hemorrhagic necrosis consistent with technically successful embolization was demonstrated in 40%-60% of cases. With careful technique complications are rare 4).

A case of hemorrhage in a parasellar meningioma shortly after embolization of the dural cavernous carotid artery branches supplying the tumor. This represents the first report of hemorrhage within a meningioma resulting from embolization with small (50 to 150-microns) polyvinyl alcohol particles, as well as the first reported case of hemorrhage complicating meningioma embolization from internal rather than external carotid artery branch embolization. We also review previously reported cases of postembolization hemorrhage from meningiomas 5).

Jumah F, AbuRmilah A, Raju B, Jaber S, Adeeb N, Narayan V, Sun H, Cuellar H, Gupta G, Nanda A. Does preoperative embolization improve outcomes of meningioma resection? A systematic review and meta-analysis. Neurosurg Rev. 2021 Mar 16. doi: 10.1007/s10143-021-01519-z. Epub ahead of print. PMID: 33723970.
Shah A, Choudhri O, Jung H, Li G. Preoperative endovascular embolization of meningiomas: update on therapeutic options. Neurosurg Focus. 2015 Mar;38(3):E7. doi: 10.3171/2014.12.FOCUS14728. PubMed PMID: 25727229.
Shah AH, Patel N, Raper DM, et al. The role of preoperative embolization for intracranial meningiomas. J Neurosurg 2013;119: 364 –72
Manelfe C, Lasjaunias P, Ruscalleda J. Preoperative embolization of intracranial meningiomas. AJNR Am J Neuroradiol. 1986 Sep-Oct;7(5):963-72. PMID: 3096121.
Kallmes DF, Evans AJ, Kaptain GJ, Mathis JM, Jensen ME, Jane JA, Dion JE. Hemorrhagic complications in embolization of a meningioma: case report and review of the literature. Neuroradiology. 1997 Dec;39(12):877-80. Review. PubMed PMID: 9457715.
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