CIO 2022-4 Preoperative Endovascular Embolization of Intracranial Meningiomas

Purpose: The purpose is to report on technical considerations involved in preoperative embolization of intracranial meningiomas. We present four cases to highlight the associated vascular anatomy, with a focus on identifying dangerous anatomic pathways to avoid complications related to nontarget embolization.

Materials and Methods: The same neurointerventional radiologist performed all four procedures. The common carotid arteries, internal carotid arteries, and external carotid arteries (ECAs) were interrogated with particular attention to the superficial temporal artery (STA) and middle meningeal artery (MMA). Excelsior SL-10 (Stryker) and Excelsior XT-27 microcatheters (Stryker) were used in combination with Synchro 0.014-inch microwires (Stryker) to identify dural feeders and avoid dangerous anastomotic pathways. Embolization was performed with 150- to 250-micron, 300-micron, or 500-micron Embosphere particles (Merit Medical). Images were reviewed on Centricity PACS (GE Healthcare). Neurosurgical outcomes were reviewed in Meditech Electronic Health Records (Meditech). All patient information was handled in compliance with the Health Insurance Portability and Accountability Act.

Results: Cerebral angiography revealed meningiomas supplied from branches of the ECAs, STAs, and MMAs. The interventional endpoint of stagnant tumor flow was achieved in three cases. Complete embolization was limited by an ophthalmic artery arising from the middle meningeal artery in one case. All patients underwent successful neurosurgical resection. Estimated intraoperative blood loss ranged from 100 to 200 cc. Postoperative hemoglobin decreases of 1.1 g/dL, 1.2 g/dL, 1.3 g/dL, and 2.0 g/dL were reported. No complications occurred in the described patient cohort.

Conclusions: Preoperative embolization of intracranial meningiomas is an important adjunct therapy that helps limit blood loss and reduce perioperative risk. The ideal interventional endpoint is a lack of contrast blush within the tumor; however, complete embolization is often limited because of multiple dural feeders containing dangerous anastomotic pathways. An understanding of these anatomic pathways is critical to avoiding devastating consequences related to nontarget embolization.