Handbook of Clinical Neurology, Vol.

169 (3rd series)

Meningiomas, Part I
M.W. McDermott, Editor
https://doi.org/10.1016/B978-0-12-804280-9.00013-5
Copyright © 2020 Elsevier B.V. All rights reserved

Chapter 13

Angiography and embolization of meningiomas

GUILHERME DABUS1,2*, ITALO LINFANTE1,2, AND MICHAEL W. MCDERMOTT1,3
1
Miami Neuroscience Institute, Baptist Health of South Florida, Miami, FL, United States
2
Miami Cardiac & Vascular Institute, Baptist Health of South Florida, Miami, FL, United States
3
Division of Neuroscience, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, United States

Abstract
The preoperative embolization of meningiomas has been part of the surgical treatment of large meningi-
omas for over 45 years. During that time there have been huge advances in the field of endovascular surgery
with respect to techniques and instrumentation. Angiography and embolization are usually reserved for
the largest tumors where there are concerns over potential blood loss with surgical excision. In this chapter,
we discuss the technical aspects of angiography and embolization as well as results and complications.

changes, headaches, sinus thrombosis, and com-

INTRODUCTION
Meningiomas, a term coined by Harvey Cushing
back in 1922, are highly vascular tumors that occur
anywhere in the neuroaxis and account for approxi-
mately 20% of all brain tumors and up to 44% of
all skull base tumors (Shah et al., 2015; Yoon et al.,
2018; Friconnet et al., 2019). The classic histologic
features of the meningioma were first described by
Virchow as a sandlike collection of calcium known
as “psammoma bodies” (Shah et al., 2015). Meningi-
omas occur in the leptomeninges, originating from
arachnoid cap cells and dural fibroblasts growing
intradurally (Shah et al., 2015). Small meningiomas
are usually asymptomatic. In the case of larger
tumors, the clinical symptoms are dependent on mul-
tiple factors including location, tumor size, compres-
sion of adjacent neural structures, invasion and/or
occlusion of vascular structures such as dural sinuses.
Because of this multitude of different factors, symp-
tomatology varies from seizures (in approximately
25%–40% of patients), visual changes, olfactory
pression of brain and/or spinal structures (Bendszus
et al., 2005; Sade et al., 2007; Carli et al., 2010;
Wiemels et al., 2010; Waldron et al., 2011;
Kominami et al., 2012; Raper et al., 2014; Aihara
et al., 2015; Ishihara et al., 2015; Shah et al., 2015;
Iacobucci et al., 2017; Nakajima et al., 2017;
Brandel et al., 2018; Magill et al., 2018; Manaka
et al., 2018; Przybylowski et al., 2018; Yoon et al.,
2018; Chen et al., 2019; Friconnet et al., 2019; Ilyas
et al., 2019; Sugiu et al., 2019; Barros et al., 2020).
Meningiomas are benign in nature in almost 90%
of patients. They are divided into three grades based
on their histologic and other features. Each grade
includes different meningioma subtypes. Cellular
and protein surface testing is utilized to identify dif-
ferent subtypes that are also related to location and
invasiveness. They are typically graded as Grade I,
Grade II that includes chordoid and clear cell menin-
giomas, and Grade III (anaplastic meningiomas)
that include papillary and rhabdoid meningiomas.
The classification and grading of meningiomas has

*Correspondence to: Guilherme Dabus, M.D., MBA, Miami Neuroscience Institute, Baptist Health of South Florida; Miami
Cardiac & Vascular Institute, Baptist Health of South Florida, 8900 N Kendall Dr., Miami, FL, 33176 United States.
Tel: +1-786-596-5990, Fax: +1-786-533-9451, E-mail: guilhermed@baptisthealth.net
194 G. DABUS ET AL.

Fig. 13.1. Large right convexity meningioma (A and B). Cerebral angiography shows supply to the lesion from a right middle
meningeal artery, which originates from the right ophthalmic artery (C). Therefore, embolization of this branch was not felt to
be safe. (D) Shows a superselective microcatheter injection into the distal left middle meningeal artery supplying the menin-
gioma. Embolization was then performed using EVOH with excellent tumor penetration (E). Final angiography shows
successful devascularization of the lesion (F).

changed recently in that brain invasion is a sufficient
criterion for the pathologic diagnosis of atypical
meningioma WHO grade II (Sade et al., 2007;
Wiemels et al., 2010; Magill et al., 2018).
Vascular supply to meningiomas is predominantly
through dural meningeal arteries (Figs. 13.1 and 13.2)
and less frequently through pial arteries (Fig. 13.3).
Transosseous supply can also be present through the
arteries that supply the scalp. With regard to treatment
of these lesions, surgical resection is the mainstay
approach for intracranial meningiomas. Because of
the hypervascular nature of these tumors, blood loss
is a major concern during surgery. Therefore, preoper-
ative endovascular embolization can be used to
decrease the blood loss during surgical resection
(Bendszus et al., 2005; Sade et al., 2007; Carli
et al., 2010; Wiemels et al., 2010; Waldron et al.,
2011; Kominami et al., 2012; Raper et al., 2014;
Aihara et al., 2015; Ishihara et al., 2015; Shah et al.,
2015; Iacobucci et al., 2017; Nakajima et al., 2017;
Brandel et al., 2018; Magill et al., 2018; Manaka
et al., 2018; Przybylowski et al., 2018; Yoon et al.,
2018; Chen et al., 2019; Friconnet et al., 2019; Ilyas
et al., 2019; Sugiu et al., 2019; Barros et al., 2020).
Preoperative endovascular embolization of intra-
cranial meningiomas was first described by Manelfe
et al. (1973) and since then has been extensively and
successfully used to reduce intraoperative blood loss,
facilitating complete tumor resection and reducing
surgical time (Bendszus et al., 2005; Carli et al.,
2010; Waldron et al., 2011; Kominami et al., 2012;
Raper et al., 2014; Aihara et al., 2015; Ishihara et al.,
2015; Shah et al., 2015; Iacobucci et al., 2017;
Nakajima et al., 2017; Brandel et al., 2018; Manaka
et al., 2018; Przybylowski et al., 2018; Yoon et al.,
2018; Chen et al., 2019; Friconnet et al., 2019; Ilyas
et al., 2019; Sugiu et al., 2019; Barros et al., 2020). Sev-
eral different embolic agents have been employed for
preoperative embolization of meningiomas from par-
ticulate materials to liquid embolic agents (Bendszus
et al., 2005; Carli et al., 2010; Waldron et al., 2011;
Kominami et al., 2012; Raper et al., 2014; Aihara
et al., 2015; Ishihara et al., 2015; Shah et al., 2015;
Iacobucci et al., 2017; Nakajima et al., 2017;
Brandel et al., 2018; Manaka et al., 2018;
Przybylowski et al., 2018; Yoon et al., 2018; Chen
et al., 2019; Friconnet et al., 2019; Ilyas et al., 2019;
Sugiu et al., 2019; Barros et al., 2020).
 ANGIOGRAPHY AND EMBOLIZATION OF MENINGIOMAS 195

Fig. 13.2. Large right sphenoid wing meningioma partially encasing the right internal carotid artery and right middle men-
ingeal artery (A, B, and C). The right middle cerebral artery is displaced superiorly (D). The right ICA provides supply to the
tumor through the inferolateral trunk (D). Right external carotid angiography shows fine reticular supply to the lesion mostly
from the middle meningeal artery (E). Postparticulate embolization images showing successful devascularization of the
tumor (F).

Despite its documented overall safety and effec-
tiveness, preoperative embolization of meningioma
is not without risks, which includes hemorrhage,
stroke, blindness, cranial nerve deficits, and death
(Bendszus et al., 2005; Carli et al., 2010; Raper
et al., 2014; Manaka et al., 2018; Przybylowski
et al., 2018; Sugiu et al., 2019). Therefore, its use
should be tailored to the specific case, taking into
account location, size, and arterial supply. Also, there
are still some questions with regard to the benefit/risk
ratio of preoperative embolization, due to the lack of
Class 1 data, which leads to subjective decision-
making usually taking into account the neurosur-
geon’s preference.
TECHNICAL ASPECTS
Cerebral angiography and vascular supply
The angiographic study of a patient with a meningi-
oma includes selective angiography of the internal
carotid arteries, external carotid arteries, and verte-
bral arteries. During the planning phase of the proce-
dure, prior to embolization, it is crucial to identify in
detail the arterial supply to the tumor as well as the
presence of dangerous external carotid-to-internal
carotid, external carotid-to-ophthalmic, and external
carotid-to-vertebrobasilar anastomoses. In fact, most
of the risks and neurologic complications associated
with endovascular embolization of meningiomas are
related to the presence of such important anastomo-
ses. Furthermore, it is of fundamental importance to
have a detailed anatomical understanding of cranial
nerve arterial supply to prevent unwanted emboliza-
tion of those branches, thus avoiding cranial nerve
deficits postprocedure. In addition, it is important
to understand the relationship between tumor loca-
tion and vascular structures. For example, parasellar
meningiomas may encase the intracranial internal
carotid artery causing stenosis. Attention to the
venous structures is also important particularly in
196 G. DABUS ET AL.

Fig. 13.3. Right convexity meningioma (A and B) showing significant pial supply from branches of the right anterior cerebral
artery (C and D).

cases of parasagittal and parasellar meningiomas
where the lesion can invade, compress, and even
occlude the dural sinus.
Angiographically, meningiomas are hypervascular
with a sunburst appearance; however, some meningi-
omas may demonstrate no significant tumoral blush in
cases of heavily calcified or necrotic lesions.
From the external carotid circulation, the middle
meningeal artery, accessory meningeal artery, eth-
moidal branches of the ophthalmic artery, anterior
falcine artery, transosseous branches of the superfi-
cial temporal artery, and/or the occipital artery are
usually involved in the arterial supply of convexity,
anterior, and middle cranial fossa meningiomas
depending on their location. In those locations, larger
meningiomas not infrequently parasitize blood
supply from pial branches on their medial/parenchy-
mal aspect (Shah et al., 2015; Manaka et al., 2018;
Przybylowski et al., 2018; Yoon et al., 2018; Ilyas
et al., 2019; Barros et al., 2020).
Petroclival, tentorial, and posterior fossa meningi-
omas may also receive blood supply from the usual
external carotid branches (middle meningeal artery)
but in particular from the ascending pharyngeal artery
and occipital artery and its branches. Significant sup-
ply to meningiomas located in the skull base comes
from dural branches of the intracranial internal
carotid artery, which pose significant risk during
embolization and should be taken care of. Posterior
fossa meningiomas will also receive arterial supply
from dural branches of the vertebral–basilar system
including the artery of the falx cerebelli and posterior
 ANGIOGRAPHY AND EMBOLIZATION OF MENINGIOMAS
meningeal artery (Rosen et al., 2002; Shah et al.,
2015; Manaka et al., 2018; Przybylowski et al.,
2018; Yoon et al., 2018; Ilyas et al., 2019; Barros
et al., 2020).
Cranial nerve supply and dangerous
anastomoses
Some of the pedicles that may supply a meningioma,
particularly a skull base and/or posterior fossa menin-
gioma, may also be responsible for the arterial supply
to cranial nerves. Therefore, embolization of such
branches may have increased risks of concurrent
nerve deficit.
Cranial nerves III and IV are supplied by the inter-
nal carotid artery through the inferolateral and menin-
gohypophyseal trunks (Russell, 1986; Geibprasert
et al., 2009).
Cranial nerve V is supplied by the inferolateral
trunk of the internal carotid artery, middle meningeal
artery, and ascending pharyngeal artery branches
from the external carotid artery as well as internal
maxillary artery (artery of the foramen rotundum—
V2) and accessory meningeal artery (V3) depending
on its division and on the location (Russell, 1986;
Geibprasert et al., 2009).
Cranial nerve VI receives arterial supply from the
inferolateral trunk and clival branch of the meningo-
hypophyseal trunk (internal carotid artery) as well as
from branches of the ascending pharyngeal artery
(external carotid artery) (Russell, 1986; Geibprasert
et al., 2009).
Cranial nerves VII and VIII receive blood supply
from the anterior inferior cerebellar artery in the cis-
ternal and internal auditory canal segments. Cranial
nerve VII also receives blood supply from the petro-
sal branch of the middle meningeal artery and stylo-
mastoid branch of the posterior auricular artery
(Russell, 1986; Geibprasert et al., 2009).
Cranial nerves IX, X, XI, and XII receive blood
supply from the neuromeningeal trunk of the ascend-
ing pharyngeal artery but also potentially from the
cervical arteries and the vertebral artery (Russell,
1986; Geibprasert et al., 2009).
Another important consideration is that the opera-
tor performing meningioma embolization should be
aware of the presence of dangerous anastomoses
(Russell, 1986; Geibprasert et al., 2009; Yoon
et al., 2018). These communications between the
external and internal carotid circulations, as well as
the external carotid and vertebrobasilar systems,
may not be angiographically visible at the beginning
197
of the procedure; however, hemodynamic changes
induced by the embolization may open these connec-
tions and result in neurologic complications if not
identified. There are three main anastomotic regions
to be aware of:
1. The orbital anastomotic region: In this region, the
main risk is blindness due to connections
between the ophthalmic artery and branches of
the external carotid artery, in particular from
the middle meningeal artery (Fig. 13.1C), ante-
rior deep temporal artery, infraorbital artery,
sphenopalatine artery, facial artery, and superfi-
cial temporal artery (Russell, 1986; Geibprasert
et al., 2009; Yoon et al., 2018).
2. The clival/petrocavernous region: In this region
the main risk is ischemic stroke or cranial
nerve injury. Anastomoses include anastomoses
between the external carotid artery to the internal
carotid artery through the inferolateral and
meningohypophyseal trunk connections (artery
of foramen rotundum, medial and lateral clival
branches, artery of the foramen lacerum)
(Russell, 1986; Geibprasert et al., 2009; Yoon
et al., 2018).
3. The upper cervical region: In this region the main
risk is ischemic stroke, particularly in the poste-
rior circulation, and cranial nerve injury (partic-
ularly for the lower cranial nerves). Anastomoses
can be profuse between the ascending pharyn-
geal artery, the occipital artery, the ascending
and deep cervical arteries, and the vertebrobasi-
lar system (Russell, 1986; Geibprasert et al.,
2009; Yoon et al., 2018).
Embolization technique
The procedure is usually performed via transfemoral
access, although more recently there is a growing
trend to perform neurovascular procedures through
the radial artery approach. Whatever the access site,
the procedure is usually carried out with either con-
scious sedation or general anesthesia depending on
the center’s preference and experience. After a thor-
ough diagnostic study is performed as detailed earlier,
the operator should determine which pedicles that
supply the tumor should be embolized. This decision
should take into account the location and benefits of
the embolization in light of its risks, possible danger-
ous anastomoses, and possible supply to cranial
nerves to achieve the best result.
198 G. DABUS ET AL.
With regard to the technical aspect of the endo-
vascular embolization procedure, typically a 5- or
6- French guide catheter is navigated into the external
carotid artery, internal carotid artery, or vertebral
artery. If the embolization target is the external carotid
artery, superselective positioning of the guide cathe-
ter can be achieved. After roadmapping the arterial
circulation, a microcatheter is advanced over a
microwire and, in most cases, advanced as far as pos-
sible into the target pedicle supplying the tumor
(Fig. 13.1D). At this point a microcatheter angiogra-
phy is usually performed to assess presence of dan-
gerous anastomoses. It is important to note that the
choice of microcatheter type and size is dependent
on the type of embolic material that is to be used.
For example, the use of large particulate material
may require larger caliber microcatheters, which
one may not be able to navigate into the most distal
arterial pedicle. On the other hand, the use of liquid
embolic agents allows smaller and more flexible
microcatheters to be used, and these can reach a more
distal arterial position. Also, depending on the liquid
embolic agent, microcatheter compatibility is impor-
tant. After proper positioning of the microcatheter,
the embolic agent is then injected under continuous
live fluoroscopy. The use of a blank roadmap during
the injection may help to allow visualization of the
penetration of the embolic agent into the tumor
bed, and hence avoid proximal reflux and unwanted
embolization. In general, embolization of pial supply
(Fig. 13.3C and D) is not performed due to the risk of
stroke. Systemic heparinization during the procedure
is currently a matter of debate and at present depends
on operator preference, experience, and patient’s
medical history.
Several agents, including particulate material
(Fig. 13.2), coils, gelfoam pledgets, fibrin glue, etha-
nol, n-butyl cyanoacrylate (nBCA), and ethylene
vinyl alcohol copolymer (EVOH) (Fig. 13.1) have
been used for embolization of meningiomas and for
other head and neck tumors (Rosen et al., 2002;
Bendszus et al., 2005; Carli et al., 2010; Waldron
et al., 2011; Kominami et al., 2012; Raper et al.,
2014; Aihara et al., 2015; Ishihara et al., 2015;
Shah et al., 2015; Iacobucci et al., 2017; Nakajima
et al., 2017; Brandel et al., 2018; Manaka et al.,
2018; Przybylowski et al., 2018; Yoon et al., 2018;
Chen et al., 2019; Friconnet et al., 2019; Ilyas
et al., 2019; Sugiu et al., 2019; Barros et al., 2020).
Despite the absence of significant data demonstrating
the advantages of using a specific type of embolic
agent for meningioma embolization, there are
potential situations where one agent may be preferred
over another. Particulate agents provide temporary
occlusion of the vascular bed and its distal penetration
is dependent on the particle size. The operator should
be aware that the smaller the size, the greater the risk
of unwanted embolization as well as of cranial nerve
injury. To decrease this risk it is recommended that
particle sizes greater than 150 mm in diameter be used
(Carli et al., 2010). However, larger particles despite
being safer, may not achieve distal enough penetra-
tion into the tumor bed. Coils are usually used in com-
bination with particles, since they usually provide
more proximal occlusion without tumor penetration.
On the other hand, liquid embolic agents may provide
better distal penetration, but also pose a potentially
higher risk of cranial nerve or unwanted embolization
depending on the microcatheter positioning and
reflux (Rosen et al., 2002; Bendszus et al., 2005;
Carli et al., 2010; Waldron et al., 2011; Kominami
et al., 2012; Raper et al., 2014; Aihara et al., 2015;
Ishihara et al., 2015; Shah et al., 2015; Iacobucci
et al., 2017; Nakajima et al., 2017; Brandel et al.,
2018; Manaka et al., 2018; Przybylowski et al.,
2018; Yoon et al., 2018; Chen et al., 2019;
Friconnet et al., 2019; Ilyas et al., 2019; Sugiu
et al., 2019; Barros et al., 2020). We describe the
results of specific types of embolic agents later in this
chapter.
Results and complications
As previously mentioned, preoperative embolization
of intracranial meningiomas was first described by
Manelfe et al. (1973) and since then it has been used
extensively in an attempt to reduce intraoperative
blood loss, facilitate complete tumor resection, and
reduce surgical time (Bendszus et al., 2005; Carli
et al., 2010; Waldron et al., 2011; Kominami et al.,
2012; Raper et al., 2014; Aihara et al., 2015;
Ishihara et al., 2015; Shah et al., 2015; Iacobucci
et al., 2017; Nakajima et al., 2017; Brandel et al.,
2018; Manaka et al., 2018; Przybylowski et al.,
2018; Yoon et al., 2018; Chen et al., 2019;
Friconnet et al., 2019; Ilyas et al., 2019; Sugiu
et al., 2019; Barros et al., 2020). Several studies have
been published reporting the results of preoperative
embolization of meningiomas. Manaka et al. (2018)
reviewed 69 patients who underwent embolization
with particulate embolic material in a total of 75 proce-
dures. The authors reported that there had been no
need for blood transfusion for any patient and that
embolization allowed for easy debulking in most of
 ANGIOGRAPHY AND EMBOLIZATION OF MENINGIOMAS
the patients. Hemorrhagic complications were seen
in 2 patients, both of whom had emergent tumor
removal and recovered well. Transient cranial nerve
palsy and ischemia occurred in 1 patient each. The
authors concluded that preoperative embolization
reduces intraoperative blood loss and operating time
by softening the tumor consistency; however, the inci-
dence of complications in this series was 5.7%.
Ishihara et al. (2015) demonstrated significantly
reduced intraoperative blood loss in patients preoper-
atively embolized with n-BCA compared to none-
mbolized patients. Iacobucci et al. (2017) showed
the benefit of a decrease in surgical time in patients
that were successfully embolized using PVA com-
pared to those that did not undergo preoperative
embolization, although there was no difference in
intraoperative blood loss.
Another large retrospective series (Barros et al.,
2020) reported 78% successful embolization of
meningiomas with a 2.8% procedural complication
rate. In this series 86% of the cases were embolized
using only PVA particles. This study demonstrated
that parasagittal and convexity meningiomas, as
well as those with ascending pharyngeal supply,
are most likely to achieve complete angiographic
embolization.
Chen et al. (2019), performed a meta-analysis
comparing patients who had preoperative emboliza-
tion performed versus patients who had direct surgery
with embolization of the meningioma. In most of the
studies preoperative embolization was performed
using particulate material or n-BCA. They found that
preoperative embolization did not increase the overall
complication rate and significantly reduced blood
loss and surgical time.
EVOH has also been used for presurgical emboli-
zation of intracranial meningiomas. Friconnet et al.
(2019) reported good intratumoral penetration of
the embolic agent in 75.6% of patients and emboliza-
tion induced tumor necrosis in almost 80% of the
cases. In their series, among the 44 lesions embolized
there were six complications (13.6%). Of these com-
plications, one was intratumoral bleeding and one
was worsening of neurologic deficit. There were,
however, 3 patients who suffered visual loss out of
the 6 cases where embolization was performed with
catheterization through the ophthalmic artery.
A large retrospective multicenter observational
study by Sugui et al. reported intracranial tumor
embolization (Sugiu et al., 2019) that demonstrated
an overall complication rate of 3.7%. In this study,
multivariate analysis demonstrated that target vessels
199
other than the external carotid artery and use of liquid
embolic material were significantly associated with
the development of complications, of which 12.3%
were hemorrhagic and 56.1% were ischemic. It is
important to note that although the majority of tumors
in this study were meningiomas (86.6%), other types
of intracranial tumors were also included.
Skull base meningiomas represent a specific subset
of the more challenging cases compared to convexity
lesions (Fig. 13.2). Rosen et al. (2002) reported on the
embolization of 167 skull base meningiomas. The
middle meningeal artery was used in almost 60% of
the cases and the meningohypophyseal trunk in
41%. The overall complication rate was 21.6% with
9% permanent neurologic deficit, including blindness,
stroke, and cranial nerve deficits. Embolization of the
ascending pharyngeal artery had the highest rate of
complications. Waldron et al. (2011) reported their
experience in 119 skull base meningiomas treated
with embolization. In this series only 18% of ICA
feeders were embolized and there were no reported
complications related to embolization. Ilyas et al.
(2019) performed a systematic review of the emboli-
zation of skull base meningiomas. They identified 403
patients with skull base meningiomas that were treated
with preoperative embolization. The most common
locations were the sphenoid wing (34%), petroclival
(31%), and cavernous sinus (12%). Particles were
used in 89% of the cases and total resection was
achieved in almost 75% of the patients. The overall
complication rate was 12% with major complications
in 6% and mortality in 0.2% of the cases.
Przybylowski et al. (2018) retrospectively ana-
lyzed 28 skull base meningiomas that were success-
fully treated with preoperative embolization using
predominantly Onyx alone (71% of the cases) result-
ing in a median degree of devascularization of approx-
imately 60%. The most common embolized pedicles
included the middle meningeal artery (68%), internal
maxillary artery (29%), and ascending pharyngeal
artery (7%). Neurologic complications happened in
one case, where the patient developed symptomatic
peritumoral edema after Onyx embolization.
Despite being considered overall safe and effec-
tive, preoperative embolization of meningioma is
still a matter of neurosurgical preference, and practice
patterns vary widely. In fact, preoperative emboliza-
tion of meningiomas is performed only in a small
percentage of cases. Brandel et al. (2018) studied
all meningioma patients who had undergone elective
resection identified in the Nationwide Inpatient
Sample. Of all patients who met inclusion criteria,
200 G. DABUS ET AL.
only 2.34% had undergone preoperative embolization.
A propensity score matching analysis demonstrated
that the patients who had undergone embolization
had higher comorbidity index and higher disease
severity. Preoperative embolization was also associ-
ated with increased rates of cerebral edema, posthe-
morrhagic anemia, transfusion, and known routine
discharge without a difference in stroke or mortality.
In another large series (Raper et al., 2014) of
224 meningioma patients, of which 177 underwent
embolization, despite the low risk of complications
(approximately 3%) there was no significant differ-
ences in surgical time, extent of resection, or operative
complications. Also estimated blood loss was higher in
the embolized group and embolization was not an
independent predictor of gross total resection. It is
important to remember that surgeons usually select
the largest tumors for embolization and the larger the
tumor the longer the operation and the higher the blood
loss. Therefore such analyses should ideally control for
tumor size in multivariate analyses.
Some authors believe that the risk of complica-
tions may be related to the embolic material used.
Bendszus et al. (2005) performed particle emboliza-
tion in 185 consecutive patients (embospheres
40–120 mm in 12 patients and 100–300 mm in 165
patients were used) with intracranial meningioma.
The overall neurologic complication was 6.4%. Half
of those complications (6 patients) were ischemic
with neurologic deficit and the other half were
hemorrhagic. Of the 6 hemorrhagic complications,
5 patients underwent emergent surgery and recovered
well, while 1 patient died due to massive intratu-
moral, subarachnoid, and subdural hemorrhage. In
another series, Carli et al. (2010) reported on the
complications of particle embolization for preo-
perative embolization of meningiomas. In their
series, 198 patients with 201 meningiomas under-
went embolization. PVA particles 45–150 mm and
150–250 mm were used in 54% and 46% of the cases,
respectively. There were 11 patients who suffered
complications (5.6%). 6 of 10 patients with hemor-
rhagic complications required emergency surgery.
1 patient had an ischemic complication. The compli-
cations resulted in the death of 2 patients and depen-
dency in 5 patients. A logistic regression analysis
identified the use of particles smaller than 150 mm
to be a risk factor for both ischemic and hemorrhagic
complications. Sluzewski et al. (2013) in a series of
55 meningiomas embolized using large calibrated
microspheres (400 mm), did not result in any hemor-
rhagic complication supporting the concept that
larger particles may be safer. Although unclear, it is
postulated that the probable mechanism for hemor-
rhage would be either tumoral necrosis from emboli-
zation and/or the passage of smaller particles into
the tumoral venous bed obstructing the outflow
(Bendszus et al., 2005; Carli et al., 2010; Sluzewski
et al., 2013). Considering these theories, liquid
embolic agents such as n-BCA and EVOH may be
beneficial since they can permeate the feeding vessels
simultaneously within the tumoral bed, with lower
injection pressures, potentially mitigating the risk
of hemorrhage (Yoon et al., 2018). Kominami et al.
(2012) in a series of 31 consecutive meningiomas that
were embolized using n-BCA reported that no hem-
orrhagic complications were encountered. This find-
ing was supported by Aihara et al. (2015) who in a
series of 57 patients embolized with n-BCA experi-
enced no major complications. However, in another
series of patients embolized with n-BCA (Ishihara
et al., 2015), complications occurred in 4 cases: hemi-
paresis secondary to edema in 2 cases, intratumoral
bleeding in 1 case and trigeminal nerve deficit in 1
case. Interestingly the 3 cases where edema and intra-
tumoral bleeding occurred showed prominent tumor
staining with early filling of vein angiography. The
authors suggested that a slow injection speed and
an embolic agent with higher viscosity be used so
as not to cause occlusion of the draining veins. Fur-
thermore, the JR-NET3 study (Sugiu et al., 2019)
demonstrated that use of liquid embolic material were
significantly associated with the development of
complications, including a surprisingly high 12.3%
hemorrhagic complication rate.
Lastly, although not common in clinical practice,
embolization has been described as a sole modality
in patients who are not candidates for surgical resec-
tion (Nakajima et al., 2017). In particular, one study
demonstrated reductions in meningioma tumor vol-
ume varying from 10% to 30%, as well as a 30% to
70% decrease in peritumoral edema following embo-
lization with n-BCA (Nakajima et al., 2017).
CONCLUSIONS
Embolization of intracranial meningiomas has been
historically used as a preoperative strategy resulting
in improved surgical outcomes for larger tumors.
However, the risks, including stroke, hemorrhage,
edema, cranial nerve deficits, and blindness, are not
negligible, and a thorough discussion of the benefits
versus risks of this procedure should be had in a
multidisciplinary approach. The operator performing
 ANGIOGRAPHY AND EMBOLIZATION OF MENINGIOMAS
the embolization procedure should be well versed on
the presence of dangerous anastomoses and cranial
nerve arterial supply as well as the anatomy of impor-
tant dural structures. In addition, it is of paramount
importance that the physician performing the endo-
vascular embolization understands the risks and
benefits of each specific embolic agent available.
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