Pre-surgical embolization of intracranial meningioma with Onyx: A safety and efficacy study.

BACKGROUND AND PURPOSE: Pre-surgical embolization of large intracranial meningioma has been demonstrated to decrease blood loss and to improve the resectability of the tumor. Few reports have evaluated the risk and benefits of using Onyx in this indication. The objective of our study was to assess the efficiency and safety of pre-surgical embolization in a consecutive series of intracranial meningioma using Onyx. MATERIALS AND METHODS: We conducted a retrospective study of consecutive patients treated from 2010 to 2018 with pre-surgical embolization with Onyx for intracranial histologically-proven meningioma. Safety was evaluated by a report of the complications related to the procedure while efficacy was assessed on angiographic and histopathologic criteria. RESULTS: Forty-four meningioma in 44 patients treated with pre-surgical embolization were included in this study. Proximal artery occlusion was obtained in 97.6% (41/42) of the cases and good intra-tumoral penetration was achieved in 75.6% (31/41). Embolic agent inside blood vessels was identified in 63.5% (28/44) of cases. Embolization-induced necrosis was present in 79.6% (35/44) of cases. Six complications have been encountered (13.6%); 3 were stated as minor complications (6.8%) and 3 as major occurring in case of trans-ophthalmic route (6.8%). CONCLUSIONS: The present work is to date the largest study to evaluate intracranial meningioma embolization using Onyx. Onyx's allowed good intra-tumoral penetration and proximal artery occlusion in most cases but carries a higher risk of complication in case of ophthalmic supply.

Preoperative embolization of intracranial meningiomas using n-butyl cyanoacrylate.

INTRODUCTION: Preoperative embolization for intracranial meningioma has been controversial for several decades. This study retrospectively reviewed our experience using n-butyl cyanoacrylate (n-BCA) to identify the factors for effective devascularization and procedure-related complications. METHODS: Fifty-seven patients who underwent preoperative embolization with n-BCA were analyzed to collect the following data: age, sex, tumor size, location, pathology, and presence or absence of pial arterial supply. The predictive factors for total devascularization and complications were examined using univariate and multivariate analyses. RESULTS: Injected n-BCA penetrated into the tumor vessels in 51 cases (89%) but resulted in feeder occlusion in 6 (11%). Angiographic total devascularization was achieved in 29 cases (51%) and partial devascularization in 28 (49%). Small size, superficial location, and absence of pial supply were independent factors for total devascularization. No major complication was encountered, but asymptomatic or transient adverse events occurred in nine patients and were significantly associated with elderly patients and large tumors. CONCLUSION: Preoperative embolization for intracranial meningiomas using n-BCA can attain effective devascularization without major complications. The effect of preoperative embolization on surgical resection or patient outcome is still unknown.

Spinal metastasis from malignant meningeal intracranial hemangiopericytoma: one-staged percutaneous Onyx™ embolization and resection - a technical innovation.

BACKGROUND: We are the first to report one-staged resection of a spinal metastasis from malignant cranial hemangiopericytoma after preoperative Onyx™-20 embolization by direct percutaneous puncture.Spinal metastases from cranial hemangiopericytoma are extremely rare. Surgical morbidity of these highly vascularized tumours results mainly from excessive blood loss. Preoperative embolization of hyper vascular tumours has been used to reduce intraoperative blood loss for a long time. To avoid complications from arterial catheter intervention, direct percutaneous puncture has been advocated as a safe and effective alternative. METHODS: A 46-year-old man with a history of malignant cranial hemangiopericytoma deriving from the left frontal skull base presented with a short history of lower back pain. A magnetic resonance imaging scan revealed an intra- and extra spinal mass lesion of the thoracic spine at Th 12. Indication for tumour resection was made and the patient's written consent was obtained. Preoperatively, arterial catheter angiography was performed to reveal the tumour's angioarchitecture, revealing high-flow arteriovenous shunts. In order to impede the expected perioperative blood loss, tumour embolization by direct percutaneous puncture and application of Onyx™-20 was performed prior to surgery. RESULTS: After percutaneous Onyx™-20 embolization, complete and safe resection of the lesion could be achieved. There was only minimal blood loss perioperatively. A pathohistological report confirmed malignant, anaplastic hemangiopericytoma. CONCLUSIONS: In our case Onyx™-20 embolization via direct percutaneous puncture of a highly vascularized tumour was shown to be a safe and efficient tool prior to surgery. Despite high-flow arteriovenous shunts, direct percutaneous administration of non-adhesive ethanol liquid was an efficient alternative to transarterial catheter embolization. The perioperative blood loss could be substantially diminished.

Embolization of Skull Base Meningiomas with Embosphere Microspheres: Factors Predicting Treatment Response and Evaluation of Complications.

OBJECTIVE: Preoperative embolization for intracranial meningiomas can cause tumor necrosis, reduce intraoperative blood loss, and facilitate surgery. This study aimed to evaluate the efficacy of tumor embolization using Embosphere microspheres for skull base meningiomas and analyze postembolization plain computed tomography (CT) and magnetic resonance imaging (MRI) scans to identify findings that could potentially predict treatment response. METHODS: Between April 2014 and April 2020, 80 patients with skull base meningiomas presenting at our medical center underwent embolization with Embosphere microspheres. The effects of tumor embolization were evaluated through a comparison of postembolization plain CT and contrast-enhanced MRI. RESULTS: A total of 143 vessels (102 of 108 external carotid artery branches and 41 of 65 internal carotid artery branches) from 80 skull base meningiomas were embolized with Embosphere microspheres. Microspheres 100-300 µm in size were used in 2 cases, microspheres 300-500 µm in size were used in 12 cases, and microspheres 500-700 µm in size were used in 66 cases. Postembolization contrast-enhanced MRI showed reductions in enhancing lesions within the tumor in 55 of 80 cases. Postembolization plain CT scans showed high-density lesions within the tumor in 41 of 55 cases. Thus, reductions in enhancing lesions on postembolization contrast-enhanced MRI were statistically significantly associated with the presence of high-density lesions on postembolization plain CT (P < 0.001). Embolization-related neurological complications occurred in 3 cases. CONCLUSIONS: Embosphere microspheres are user friendly and effective embolic materials for the embolization of skull base meningiomas. Postembolization contrast-enhanced MRI and plain CT findings may be useful for evaluating the effects of tumor embolization.

Therapeutic embolization of meningiomas with Onyx for delayed surgical resection.

BACKGROUND: Liquid embolic agents can achieve penetration of capillaries in tumors and thus may be even more effective at creating tumor necrosis than small particles. This study assesses the safety and efficacy of preoperative embolization of meningiomas with Onyx liquid embolic agent (Micro Therapeutics, Inc, Irvine, Calif) for delayed surgical resection. METHODS: Three cases of hypervascular intracranial meningiomas were treated by preoperative embolization with Onyx embolic agent using superselective catheterization of the feeding arteries from the ECA and the reflux-hold-reinjection technique. RESULTS: Meningiomas were devascularized successfully, and these patients did not present the symptoms of postembolization tumor swelling or hemorrhage before complete resection of the tumors 10 days later. Massive tumor necrosis was observed in all 3 cases of pathologic specimens, and shrinkage of tumor was seen by MRI as early as 8 days in 1 case. All patients had no recurrence of tumor at 12-month follow-up. CONCLUSION: Preoperative embolization with Onyx may be a useful tool for treatment of meningiomas. Palliative embolization treatment of nonresectable hypervascular intracranial tumors with Onyx warrants future clinical investigation.

Preoperative Embolization of Meningiomas: Differences in Surgical Operability and Histopathologic Changes Between Embosphere and N-butyl 2-cyanoacrylate.

OBJECTIVE: This study aimed to examine whether there is a difference in the difficulty of extirpation after use of Embosphere versus n-butyl 2-cyanoacrylate (NBCA) for the embolization of meningiomas. METHODS: Study subjects were 20 patients with meningioma who underwent embolization using either NBCA or Embosphere from April 2012 to December 2016. The difficulty of extirpation was compared and assessed in terms of objective indices, such as operative duration, perioperative bleeding, and Simpson grade, and in terms of subjective indices such as "impression on operative field" and "hardness of tumors" that the surgeon assessed using 3-point scales (dry, moderate, bloody, and soft, moderate, hard, respectively). Pathologic findings, including ischemia, necrosis, and inflammatory changes, were assessed. RESULTS: No significant differences were found between the 2 groups regarding the mean values of operative duration (P = 0.27), perioperative bleeding (P = 0.23), and Simpson grade (P = 0.39). On the other hand, there was a significant difference with respect to the "impression on operative field" and "hardness of tumors," with reports of dry (54%; P = 0.034) and soft (81%; P = 0.0001), respectively, in the Embosphere group exceeding those of the NBCA group. The pathologic findings showed that although ischemic change (P = 0.43) and necrosis (P = 0.79) were observed in both groups, perivascular inflammation was observed only in the NBCA group (P = 0.006). CONCLUSIONS: No relative merits were found regarding objective indices, whereas the Embosphere group had superior "ease of extirpation" as reported by the surgeon.

Preoperative Embolization of Skull Base Meningiomas: Outcomes in the Onyx Era.

OBJECTIVE: Preoperative embolization may facilitate skull base meningioma resection, but its safety and efficacy in the Onyx era have not been investigated. In this retrospective cohort study, we evaluated the outcomes of preoperative embolization of skull base meningiomas using Onyx as the primary embolysate. METHODS: We queried an endovascular database for patients with skull base meningiomas who underwent preoperative embolization at our institution in 2007-2017. Patient, tumor, procedure, and outcome data were analyzed. RESULTS: Twenty-eight patients (28 meningiomas) underwent successful preoperative meningioma embolization. The mean patient age ± SD was 56 ± 13 years, and 18 patients (64%) were women. The mean tumor size was 49 cm3. There were 1, 2, or 3 arterial pedicles embolized in 21 cases (75%), 6 cases (21%), and 1 case (4%), respectively. The embolized pedicles included branches of the middle meningeal artery in 19 cases (68%), the internal maxillary artery in 8 cases (29%), the ascending pharyngeal artery in 2 cases (7%), and the posterior auricular, ophthalmic, occipital, and anterior cerebral arteries in 1 case each (4%). The embolysates used were Onyx alone in 20 cases (71%), n-butyl cyanoacrylate alone in 3 cases (11%), coils/particles and Onyx/n-butyl cyanoacrylate in 2 cases each (7%), and Onyx and coils in 1 case (4%). The median degree of tumor devascularization was 60%. Significant neurologic morbidity occurred in 1 patient (4%) who developed symptomatic peritumoral edema after Onyx embolization. CONCLUSIONS: For appropriately selected skull base meningiomas supplied by dura mater-based arterial pedicles without distal cranial nerve supply, preoperative embolization with current embolysate technology affords substantial tumor devascularization with a low complication rate.

Meningioma embolization with the pressure cooker technique using Squid 12.

Background Preoperative meningioma embolization may be performed with microparticles or liquid embolic agents. The pressure cooker technique (PCT) has recently been described for the embolization of brain arteriovenous malformations (AVMs). Case We present the case of a 73-year-old woman with a large frontal interhemispheric meningioma that was successfully preoperatively embolized with the PCT using Squid 12, a new ethyl-vinyl alcohol copolymer embolic agent. The PCT presents considerable advantages relative to conventional embolization techniques such as deeper and faster tumor penetration and embolization of tumors with difficult vascular access, and retrograde feeling of pial afferents may be achieved. Conclusions The use of the PCT with Squid 12 may potentially increase the effectiveness of meningioma embolization, increase tumor devascularization and improve outcomes of surgical resection.

Infiltrated Embolization of Meningioma with Dilute Cyanoacrylate Glue.

We describe the efficacy and technical aspects of infiltrated preoperative embolization of meningioma by penetration of very dilute glue. In this method, a 13% n-butyl-cyanoacrylate (NBCA)-lipiodol mixture is injected extremely slowly from the middle meningeal artery (MMA) in a similar manner to plug and push injection of ethylene vinyl alcohol copolymer mixed with tantalum and dimethyl sulfoxide (Onyx®) after the tortuous side feeders are proximally embolized. The glue is infiltrated into small tumor arteries and extends to inaccessible feeders from deep meningeal arteries. Since 2011, we have used this technique in the embolization of 32 cases preoperatively diagnosed with meningioma. Intratumoral embolization was possible in 30 cases (94%), and a greater than 50% reduction in contrast area of contrast-enhanced T1-weighted MR imaging (T1-WI) was achieved in 18 cases (56%). Two cases achieved complete devascularization, showing a remarkable shrinkage in tumor size after embolization. If excessive reflux of embolization and the resulting migration of glue into normal arteries is achieved, this method provides extremely effective devascularization on surgical extirpation. It might also be applicable to surgically untreatable meningiomas as a semi-radical treatment option.

The safety and efficacy of preoperative embolization of meningioma with N-butyl cyanoacrylate.

OBJECTIVE: Preoperative embolization of meningioma is commonly performed; however, there is no consensus on the best embolic material to reduce intraoperative blood loss and surgery time. METHOD: We retrospectively assessed the safety and efficacy of 56 cases of preoperative embolization of the middle meningeal artery with N-butyl cyanoacrylate (NBCA) in 105 cases of surgery for meningioma. We also defined a blood loss to tumor volume ratio to compensate for bias caused by tumor volume, and analyzed limited cases (the embolized group n = 52, the non-embolized group n = 21) of the convexity, the parasagittal region, the falx, and the sphenoidal ridge. RESULT: The blood loss to tumor volume ratio was significantly less in the embolized group (p < 0.007). Preoperative embolization could be useful for cases with the external carotid artery as the dominant feeder vessel (p < 0.02); however, the efficacy decreased for cases with an internal carotid artery feeder. Transient complications occurred in four cases (hemiparesis secondary to edema: two cases; intratumoral bleeding: one case; trigeminal nerve disorder: one case). The cases that showed a postoperative increase in edema or intratumoral bleeding were large tumors with the early filling of veins. For such cases, surgeons should pay close attention to slow injection speed and higher NBCA viscosity, not to cause the occlusion of draining vessels. CONCLUSION: Tumor embolization with NBCA can be safely performed, and the procedure significantly reduces intraoperative blood loss.

Hydroxyapatite ceramics as a particulate embolic material: report of the clinical experience.

BACKGROUND AND PURPOSE: Our newly developed biocompatible embolic materials, hydroxyapatite ceramic microparticles, have good visibility during injection control and were shown to be capable of producing effective occlusion of the distal arteriocapillary bed in an experimental animal study. The purpose of this present study was to evaluate hydroxyapatite ceramic microparticles for use in human meningioma embolization. METHODS: Thirteen patients with meningiomas underwent preoperative superselective embolization with the use of hydroxyapatite microparticles. Radiologic and histopathologic studies of the surgical specimens were performed. RESULTS: During embolization, no microcatheter clogging was observed and angiographic devascularization was consistently obtained without unexpected proximal occlusions. Histopathologic findings showed that there was mild inflammatory response in the thrombosed lumen. CONCLUSION: Hydroxyapatite microparticles are excellent embolic materials for the treatment of human meningioma. They have excellent biocompatibility and good injection control, which produces occlusion of the distal arteriocapillary bed.

Embolization with cellulose porous beads, II: Clinical trial.

PURPOSE: To evaluate the clinical applicability of cellulose porous beads (CPBs) as an embolic material for permanent vascular occlusion. METHODS: Embolization with CPBs was performed in 16 patients, six with meningioma of the sphenoid wing, two with meningioma of the falx, three with meningioma of the tentorium, two with dural arteriovenous fistula, one with paraganglioma, and two with spinal arteriovenous malformation. Surgical specimens were examined histologically. RESULTS: No complications were encountered in any of the 16 patients. Angiograms obtained after embolization showed satisfactory vascular stasis in all cases. Histologic examination of surgical specimens disclosed that vessels having approximately the same caliber as the CPB particles were occluded without stretching of the vessel wall. Larger vessels were occluded by aggregates of many particles, which left no open spaces. Although a few inflammatory cells were seen in the thrombosed vessels, inflammation evoked by CPB was mild and did not extend to either the vessel wall or to surrounding tissues. CONCLUSION: CPBs were easy to inject through microcatheters, traveled to distal sites, and produced homogeneous and peripheral embolization without inflammatory changes different from other embolic materials. CPBs are a good embolic material for permanent occlusion in the clinical setting.

Ischemic necrosis of the scalp after preoperative embolization of meningeal tumors.

The authors report two patients who suffered ischemic necrosis of their scalps after preoperative therapeutic embolic occlusion of the external carotid artery and its terminal branches for highly vascular meningeal tumors. Local anesthesia, selective catheterization of the external carotid artery, and radiopaque polyvinyl alcohol and Gelfoam as embolic agents were used. The various complications of external carotid artery embolization are reviewed. The importance of preserving normal branches of the external carotid artery (especially the superficial temporal artery) during embolization and of careful design of the scalp flap to avoid ischemic necrosis is emphasized.

Embolization of neurosurgical lesions involving the ophthalmic artery.

OBJECTIVE: A number of anteriorly located cranial base and extracranial lesions receive their vascular supply wholly or in part from the ophthalmic artery, and embolization of the ophthalmic artery can be helpful in the management of these lesions, either as the primary treatment or as an adjunct to surgery. We present situations in which the embolization of lesions involving the ophthalmic artery was performed to effect a partial or total cure of the lesion. METHODS: Twelve patients underwent a total of 15 embolization attempts on lesions involving the ophthalmic artery. Four patients had arteriovenous malformations of the orbit, four had dural arteriovenous fistulae, two had orbital meningiomas, one had a planum sphenoidale meningioma, and one had a juvenile nasal angiofibroma. In each case, a Tracker No. 18 microcatheter (Target Therapeutics, Inc., Fremont, CA) was navigated into the ophthalmic artery using a steerable guidewire and digital road mapping. Embolic agents included polyvinyl alcohol particles ranging from 350 to 1500 microm in diameter, 2-mm platinum microcoils, and n-butyl-cyanoacrylate. In 12 of 15 cases, lidocaine and amytal provocation tests were conducted before any attempt at embolization to assess the role of the ophthalmic artery in vision. RESULTS: Embolization was successfully performed in the 14 situations in which it was attempted. Positive results of two lidocaine/amytal tests were noted. In one case, embolization was not attempted. In the other case, a larger caliber embolic agent (2-mm platinum coils) was used. A single transient decrease in visual acuity lasting 4 days was the only embolization-related complication. CONCLUSION: Proper case selection, judicious use of embolic agents, and use of provocative testing can result in safe embolization of lesions supplied by the ophthalmic artery.

Cobb's syndrome and its treatment with embolization. Case report.

A case of Cobb's syndrome, which is characterized by spinal and vertebral angiomas and a skin nevus at the same metameric level, is reported. The spinal angiomas were treated with liquid embolization using ethylene vinyl alcohol.

[Embolization of meningiomas using liquid embolizing agents]. / Meningeomembolisationen mit flüssigen Embolisaten.

In 25 patients with meningiomas, the tumours were embolised with liquid embolising materials following angiography. Nine subselective flow-guided Ethibloc embolisations were performed, four selective Ethibloc embolisations and 16 selective Histoacryl embolisations. The physical properties and pathophysiological behaviour make liquid embolising materials superior to particles. The use of micro-catheter systems introduced as far as possible into the feeding vessels makes Histoacryl embolisation an uncomplicated, effective and painless method for obliterating the vascular bed of the tumour.

Disappearance of a tumor shadow fed by the tentorial artery after embolization of the external carotid artery.

The tentorial artery is a branch of the meningohypophyseal trunk originating from the internal carotid artery; this artery sometimes becomes an enlarged feeding artery in patients with tentorial lesions, especially tentorial meningiomas. We experienced a case of a cerebellopontile angle meningioma whose angiogram revealed the disappearance of a feeding artery arising from the tentorial artery after embolization of the external carotid artery. We report this case and discuss the mechanism of this phenomenon.

Preoperative embolization of meningiomas fed by ophthalmic branch arteries.

BACKGROUND: The efficacy of preoperative embolization for hypervascular meningiomas mainly fed by the branches of the ophthalmic arteries was examined. CASES AND METHODS: Five hypervascular meningiomas mainly fed by the branches of the ophthalmic arteries, four posterior ethmoidal arteries, one anterior falx artery, and one recurrent middle meningeal artery were embolized with Gel-foam powder, polyvinyl alcohol (PVA) particles, and/or microcoils as a preoperative treatment using a microcatheter. RESULTS: Catheterization of the ophthalmic and tumor feeding artery was possible and feeding arteries and lesion embolization were effective to reduce the bleeding during surgery in all cases. In three cases, visual acuity and visual field were preserved. However, in one case, visual acuity and visual field defect appeared due to the migration of Gelfoam powder (Upjohn, Kalamazoo, MI) into the retinal artery. In another case, the retinal artery was embolized with the feeding arteries since the patient was already blind. CONCLUSION: Embolization of hypervascular meningioma feeding vessels arising from the ophthalmic artery is possible and effective with preservation of vision, if embolic agents are injected gently enough not to reflux into the central retinal artery.

[Preoperative embolization for meningiomas using PVA particles].

Preoperative embolization for highly vascularized and large meningiomas is an indispensable technique for facilitating their surgical removal by decreasing blood loss during the operation. This is a report of 4 large and highly vascularized meningiomas in the skull base, on which embolization of feeders was performed preoperatively by PVA (Polyvinyl alcohol foam) particles (150-250 micron produced by INGENOR CO, Paris) and small strips of gelfoam (0.5 x 0.5 x 3-5mm). Under EEG monitoring, Isosorbide dinitrate was used for prevention and relief of vascular spasm. Lidocaine injection tests (Xylocaine 2%: 50mg mixed in equal volumes with Iopamiron 300) were performed for checking before embolization. In the intracranial portion, standard taper steerable guide wire was changed to seeker flexible soft-tip guide wire. In two cases, the meningioma was located in the medial part of the sphenoidal ridge. In the other two cases, one meningioma was in the lateral part of the sphenoidal ridge and the other was in the olfactory groove. In all 4 cases, we successfully performed embolization without complication. In one case, we had to perform embolization twice, because of revascularization detected by angiography 3 weeks after the first embolization. In this latter case, we had performed central embolization only, by using PVA particles, having left feeder without occlusion (peripheral embolization) using gelfoam. The result suggested that it was also necessary to perform peripheral embolization especially if the tumor is fed by large tortuous and irregular abnormal vessels. Peripheral embolization may prevent PVA particles from washing out and causing progressive thrombosis by PVA particles.(ABSTRACT TRUNCATED AT 250 WORDS)