1.

Can you explain why it is recommend to do the surgery 7 days after embolization
procedure? How about we perform it before or after 7 days of embolization?

First of all we have to know the aim of performing embolization. The aim of performing
embolization include devascularization of the tumor to prevent higher intraoperative blood
loss by occluded the feeder, and to achieve gross total resection by softening and making
tumor being necrosis so that its easy to remove. Embolization likely causes necrosis,
ischemic changes, and microvascular fibrinoid changes. Hypoxia caused by disruption of
tumoral blood supply also causes changes in protein expression consistent with angiogenesis
and promotion of the growth of the tumor.
Actually there is much controversy regarding the interval between embolization and surgery.
Some studies reported that no significant difference in tumor resection when interval varied
from several hours til weeks. But recent studies reported that ideal interval is 7 days after
embolization. Oka reported that in 7 until 9 days after embolization allow the greatest degree
of tumor softening which is important for safe and easy tumor removal. Ellis reported that 7-
day interval as the cut off to predict the efficacy of tumor devascularization. Nania reported
the same, that 7 day interval is associated with maximizes the degree of tumor necrosis, and
at the sama time minimizes intraoperative blood loss, duration of surgery, and LOS.
Operating too soon may not allow for adequate occlusion of blood supply and may lead to
longer operation time, smaller area of necrosis and tumor softening, larger blood transfused,
and operating too long may increase the chance that collateral to occluded area will be
recreated.

2. Why in this patient, we only performed incomplete embolization?

As we know that in this case, the tumors got feeder not only from branch of ECA, but also
branches from ICA (MCA). We only performed embolization in ECA, because the branches
of ICA are typically more difficult to access and are associated with a higher risk of
parenchymal infarct. So at that time we only performed embolization in MMA only.

3. Learning from this case, what actions should we take to prevent postoperative hemorrhage
after tumor resection surgery?
1. Preoperative:
a. Cease any antiplatelet and anticoagulant therapy for an adequate period
b. Stop alcohol consumption;
c. Ensure platelet count, function, and coagulation parameters are normal; and
d. Optimize medical management of preexisting conditions, particularly hypertension.
2. Intraoperative:
a. Avoid hypertension and excessive blood loss;
b. Replace blood losses promptly and sufficiently;
c. Aim for gross total resection of tumor wherever possible;
d. Meticulous technique and hemostasis including dural tenting, appropriate use of
electrocoagulation and topical hemostats; and
e. Slow, gentle wean from general anesthesia.
3. Postoperative:
a. Avoid hypertension;
b. Replace blood losses adequately;
c. Avoid upright patient positioning in the initial phase;
d. Close clinical monitoring in the rst 6 h postsurgery;
e. Consider ICP monitoring or early postoperative imaging. ICP monitoring may be useful if
there have been significant problems with hemostasis during surgery, if the lesion has been
very vascular, if blood loss has been great during surgery, or if the patient needs to remain
sedated and/or ventilated after surgery.

4. In your presentation, you said that there was increased incidence of POH occurs after
surgery of meningioma? Can you explain why?
There is an increased incidence of POH occurs after surgery of meningioma. As we know
that, meningioma is one of the intracranial tumor that highly vascularized. It has high
expression of VEGF (vascular endothelial growth factor) in tumor tissue. VEGF is a protein
secreted by the tumor that play a role in neovascularity and peritumoral edema. VEGF
increases the permeability of tumor vessels, plasma extravasation, and angiogenesis of the
tumor. So it make this tumor highly vascularized.

5. In your opinion, should we perform postoperative imaging routinely or based on the

clinical evaluation of the patient only?
The role and timing of of postoperative imaging before any clinical manifestation or
deterioration is controversial.
In Germany, before 2000, a post operative CT was performed only after they found
neurological deterioration after surgery, but after 2000 they performed a routine postoperative
CT. Previous authors have described routine imaging within 24–48 h of surgery, and up to 7
days post-procedure as a screening tool. Other studies, using clinical deterioration as a
criterion, have identified 6 h as a critical period within which an acute postoperative bleed
may become clinically evident. Whilst a threshold of 6 h may allow for less intensive
observation and better reallocation of resources (e.g. intensive care beds) after this initial
phase, the phenomenon of delayed haematoma formation suggests that continued regular
observations, albeit less frequent, are necessary.
NCCN recommend to do postoperative imaging for meningioma within 24-48 hours after
surgery, especially if there have been significant problems with hemostasis during surgery, if
the lesion has been very vascular, if blood loss has been great during surgery, because
there’is a significant risk for developing POH.