A comparison of the prevalence and risk factors of complications in intracranial tumor embolization between the Japanese Registry of NeuroEndovascular Therapy 2 (JR-NET2) and JR-NET3

Evaluating the effectiveness of preoperative embolization for meningioma with pial feeders: Analysis of perfusion magnetic resonance imaging

Background and purposeMeningiomas often contain a pial supply, and devascularization through preoperative transarterial embolization (TAE) is useful. However, the efficacy indicators of TAE for meningiomas with pial feeders remain unclear owing to their challenging quantification. Therefore, we propose a practical and quantitative intratumoral cerebral blood volume (CBV) from the pial supply, called pial-nCBV. This study aimed to identify the efficacy indicators of TAE against meningiomas in pial feeders using pial-nCBV.Materials and methodsBetween 2015 and 2021, 25 patients who underwent preoperative TAE and perfusion magnetic resonance imaging (MRI) for meningiomas with pial feeders were included in the study. We set 5 mm diameter round Region Of Interests as many as possible within the tumor at the border with the brain parenchyma, and calculated the intratumoral CBV from pial supply. The reduction rate was defined as primary outcome, termed Δ pial-nCBV. Additionally, we collected data on the injection behavior of the n-Butyl-Cyanoacrylate (n-BCA), including intratumoral embolization (IE) and feeder occlusion. We then analyzed the association between each variable and Δ pial-nCBV.ResultsThe median Δ pial-nCBV was 25%. The n-BCA was applied in 22 (88%) cases, of which nine (36%) cases were injected into pial feeders. The use of n-BCA (p = .037), treatment with pial feeders (p = .002), and IE in meningeal feeders (p = .049) were associated with an increase in Δ pial-nCBV.ConclusionWe proposed a practical indicator, pial-nCBV, and increasing Δ pial-nCBV was associated with treating pial feeder using n-BCA.

Volume Reduction Effect of Preoperative Embolization of Only the Feeding Arteries from the External Carotid Artery on Vestibular Schwannomas

BACKGROUND

Although there are many reports on the efficacy of preoperative embolization for meningioma, such as a reduction in intraoperative blood loss, its efficacy for vestibular schwannoma remains unclear. Feeding arteries of vestibular schwannomas include branches from the anterior inferior cerebellar artery and internal carotid artery, in addition to the branches from the external carotid artery (ECA). However, it has been reported that the embolization of feeding arteries from the anterior inferior cerebellar artery and the internal carotid artery has a high risk of complications. Therefore, we retrospectively analyzed the effects of preoperative embolization of only the feeding arteries from the ECA for vestibular schwannomas, particularly regarding its volume reduction effect.

METHODS

Of the 805 patients with vestibular schwannoma who underwent tumor removal at our department between September 2013 and March 2022, a total of 15 patients who underwent preoperative embolization of only the feeding arteries from the ECA were analyzed. Tumor volume was measured based on contrast-enhanced T1-weighted imaging, and the effects of preoperative embolization on tumor volume reduction were analyzed.

RESULTS

Tumor volumes before and after embolization were 16.4 ± 9.2 mL and 14.1 ± 9.6 mL, respectively, indicating a volume reduction effect of 15.3 ± 10.3% (P < 0.001). The mean time from embolization to contrast-enhanced T1-weighted imaging was 5.1 ± 3.0 days.

CONCLUSIONS

Preoperative embolization of only the feeding arteries from the ECA may be an effective adjunctive treatment for vestibular schwannomas, given the significant volume reduction effect achieved within several days after embolization, in addition to reducing intraoperative blood loss.

Cone-Beam Computed Tomography Fusion Technique for Vascular Assessment of Skull Base Meningiomas

OBJECTIVE

Cone-beam computed tomography (CBCT) images for skull base tumors provide detailed vascular information and localization in regard to surrounding bony structures. We report use of the CBCT fusion technique for skull base meningiomas.

METHODS

Six patients with petroclival or petrotentorial meningiomas supplied by multiple arterial systems were preoperatively evaluated using CBCT fusion imaging. Fusion images were reconstructed from three-dimensional rotational angiography with contrast agent injections from the internal carotid artery (ICA) and external carotid artery in 4 cases, vertebral artery and external carotid artery in 1 case, and ICA and vertebral artery in 1 case.

RESULTS

The feeding pedicles and tumor stains from 2 arterial systems were differentiated by separate colors. The courses and territories of the ICA dural feeders or ICA/vertebral artery pial feeders were easily distinguished from the external carotid artery dural feeders. Anastomoses between thin feeders from different arterial systems could be detected. Mixed stain (stain with both colors) was observed in some tumor compartments, suggesting dual supply from 2 arterial systems and the presence of peritumoral anastomoses. All patients underwent preoperative embolization without complications.

CONCLUSIONS

CBCT fusion images clearly visualized the feeders from each arterial system, the vascular compartments within the tumor, and possible peritumoral anastomoses. This technique provides a substantial contribution to both preoperative embolization and surgical resection of skull base meningiomas.

Transarterial Embolization of a Parasellar Hypervascular Tumor

Embolization of hypervascular tumors has been widely performed for over four decades, particularly for preoperative meningioma. Several benefits of preoperative embolization have been reported, including reduced blood loss, surgical time and surgical complications, and improved outcomes. However, the technical details of both embolization and surgical procedures, and lesions widely vary. Thus, the actual benefits of preoperative embolization have not been clarified by prospective randomized studies. Procedure-related complications due to embolization developed in 3%-12% in previous studies. For parasellar lesions, both surgical resection and embolization have a higher risk of complication than for lesions at other locations because of the complicated neurovascular anatomy in the parasellar area. Therefore, close attention should be paid to the detailed vascular anatomy, embolic material, and related information for embolization and resection in individual cases to improve patient outcomes.

Onyx embolization of skull base paragangliomas: a single-center experience

BACKGROUND

Skull base paragangliomas are highly vascular tumors that are often embolized before surgical resection; however, the safety and efficacy of preoperative embolization using an ethylene vinyl alcohol copolymer (Onyx; Medtronic, Dublin, Republic of Ireland) in these tumors is unknown. This retrospective cohort study evaluated patient outcomes after preoperative embolization of skull base paragangliomas using Onyx.

METHODS

We retrospectively analyzed data from all patients with skull base paragangliomas who underwent preoperative Onyx embolization at our institution (January 01, 2005-December 31, 2017). Patient, tumor, embolization, and outcomes data were extracted by reviewing inpatient and outpatient clinical and imaging records.

RESULTS

Seven patients were studied (5/7 [71%] female), 6 with glomus jugulares and 1 with a glomus vagale. The median age was 52 years, and the most common presenting symptom was cranial neuropathy (6/7 [86%]). The tumor vascular supply was from the ascending pharyngeal artery in all 7 cases (100%) with additional feeders including the occipital artery in 5 (71%); internal carotid artery in 3 (43%); middle meningeal, vertebral, and internal maxillary artery each in 2 (29%); and posterior auricular artery in 1 (14%). The median postembolization tumor devascularization was 80% (range, 64-95%). The only postembolization complication was a facial palsy in 1 patient.

CONCLUSION

Preoperative embolization with Onyx affords excellent devascularization for the majority of skull base paragangliomas, and it may facilitate resection of these hypervascular lesions. The advantages provided by Onyx with respect to penetration of intratumoral vessels must be weighed against the risk of cranial neuropathy.