Comparative benefits of particle embolization versus liquid agents in preoperative management of meningiomas: A Systematic Review and Meta-analysis

First proposed in the 1970s, preoperative embolization of meningiomas has become an accepted adjunct to surgery. However, despite its widespread utilization, there is no strong evidence to support its effectiveness. With increasing experience, the true benefits of presurgical embolization have been questioned by some since the procedure is not devoid of potentially serious complications. Over the years, I have witnessed a wide variability among different surgeons in their utilization of preoperative embolization of meningiomas, an observation that underscores the lack of consensus about its benefits. Shah and coworkers provide a systematic review on the role of preoperative embolization of meningiomas. As they acknowledge, the quality of the information contained in their review is dependent upon the quality of the studies analyzed.1 Unfortunately, the majority of studies on this topic are single-center, retrospective series with their intrinsic biases. This, of course, limits the conclusions that we can draw from the authors’ study. Moreover, since Shah et al. strictly considered articles on presurgical embolization, some of the largest series (probably more representative of the actual complication rates) were excluded from analysis, although summarized in one of the accompanying tables. In the Discussion section, Shah and coworkers provide a thoughtful analysis of the pros and cons of preoperative meningioma embolization. I agree with the authors that preoperative embolization is safe and probably useful in the occlusion of distal meningeal feeders to selected very large or giant lesions. In these cases, preoperative embolization may “soften” the tumor and facilitate its exposure. Short of this indication, the role of presurgical embolization of meningiomas is questionable given the risk of complications and the lack of well-conducted studies to convince us about its advantages. Many of the studies analyzed by Shah et al. used polyvinyl alcohol (PVA) as the embolic agent of choice.1 At our institution, we also continue to use PVA for the very few and selected cases in which preoperative embolization is utilized. This particulate agent is not only effective in devascularizing the tumor, but also has an acceptable safety profile (as long as very small particles and “dangerous” feeders are avoided) and is much cheaper than newer agents. I don’t endorse meningioma embolization with Onyx, especially in cases like the one illustrated by Shah and coworkers in their Fig. 1. In my opinion, the risks of cranial neuropathies secondary to Onyx embolization of the ascending pharyngeal artery and proximal posterior branches of the middle meningeal artery far outweigh the potential benefits. With better understanding of the anatomy of the meningeal vessels, knowledge of “dangerous” anastomosis, and choice of right embolic agent and particle size, the overall risk of embolization is probably low but not negligible. The incidence and severity of complications are related to many factors that include the location of the lesion, its vascular supply, and the type of embolic agent utilized. Based on the data available in the literature, it is difficult to estimate the risk for the individual patient given the wide variability of these factors. Thus, the decision whether to consider preoperative meningioma embolization should be carefully pondered and the risks kept very low. (http://thejns.org/doi/abs/10.3171/2013.2.JNS121860)

<h3>Introduction</h3> Multiple embolic agents have been used for preoperative tumor embolizations. Recently, the liquid embolic agent Onyx (Medtronic), initially designed for arteriovenous malformations, have also been used to perform preoperative...

Chronic subdural hematoma (CSDH) is associated with high recurrence rates. Middle meningeal artery embolization (MMAE) has emerged as a promising treatment option. In this systematic review and meta-analysis, we aimed to assess the safety and efficacy of MMAE for CSDH using liquid embolic agents and compare them with particles. We systematically reviewed all studies describing MMAE for CSDH with liquid embolic agents, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Additionally, we included a cohort of patients from our institution using liquid and particle embolic agents. Data were analyzed using random-effects proportions and comparisons meta-analysis, and statistical heterogeneity was assessed. A total of 18 studies with 507 cases of MMAE with liquid embolic agents (including our institutional experience) were included in the analysis. The success rate was 99% (95% confidence interval [CI]: 98-⁠100%), all complications rate was 1% (95% CI: 0-⁠5%), major complications rate was 0% (95% CI: 0-⁠0%), and mortality rate was 1% (95% CI: 0-⁠6%). The rate of hematoma size reduction was 97% (95% CI: 73-⁠100%), complete resolution 64% (95% CI: 33-⁠87%), radiographic recurrence 3% (95% CI: 1-⁠7%), and reoperation 3% (95% CI: 1-⁠7%). No significant differences in outcomes were found between liquid and particle embolic agents. Sensitivity analyses revealed that liquid embolic agents were associated with lower reoperation rates in upfront MMAE (risk ratio 0.13, 95% CI: 0.02-⁠0.95). MMAE with liquid embolic agents is safe and effective for the treatment of CSDH. Outcomes are comparable to particles, but liquids were associated with a decreased risk of reoperation in upfront MMAE. However, further studies are needed to support our findings.

Purpose: Preoperative embolization of meningiomas decreases intraoperative bleeding and shortens operation time. However, in meningiomas predominantly vascularized by the internal carotid artery (ICA) or vertebral artery (VA) branches, embolization of external carotid artery feeder branches may lead to a hemodynamic increase in blood supply from the ICA or VA, whereas embolization of ICA or VA feeder branches with particle embolic agents may be associated with complications. This study investigated the safety and efficacy of Glubran, a liquid embolic agent, for the embolization of this type of meningioma compared with polyvinyl-alcohol (PVA) particles. Materials and methods: From January 2006 to June 2015, 157 consecutive patients (98 females; mean age = 48.3 years) who suffered from meningiomas and were preoperatively referred for embolization were retrospectively analyzed. Glubran (n = 40) and PVA (n = 55) were used to devascularize tumors. Sixty-two patients were not embolized because of dangerous anastomosis or other tumor characteristics. Intraoperative blood loss, intraoperative time, degree of angiographic devascularization and embolization-related complications were analyzed. Results: The intraoperative blood loss and operative time were significantly lower in the Glubran-embolized versus non-embolized group. Furthermore, Glubran embolization significantly reduced intraoperative blood loss and operative time for meningiomas that received their primary blood supply from the ICA and/or VA compared with PVA embolization. Conclusions: Preoperative meningioma embolization with Glubran decreases intraoperative blood loss and operative time. Furthermore, embolization with Glubran produces more effective devascularization compared with PVA for meningiomas supplied by the ICA and/or VA. Thus, Glubran may represent a better embolic agent for this meningioma subtype.

Intracranial hemangioblastomas are highly vascular tumors that account for 1% to 2% of all central nervous system tumors. Preoperative embolization has been proposed to limit the often significant intraoperative blood loss associated with resection and potentially make the tumor more soft/necrotic and thus more amenable to gross total resection. The safety and efficacy of preoperative embolization of intracranial hemangioblastomas, however, are not well characterized. To evaluate the safety and efficacy of preoperative endovascular embolization of intracranial hemangioblastomas using a variety of embolic agents. A retrospective review of all surgically resected intracranial hemangioblastomas treated with preoperative embolization between 1999 and 2014 at 2 high-volume centers was performed. Clinical and radiographic criteria, including von Hippel-Lindau status, magnetic resonance imaging tumor characteristics, embolization-related complications, degree of angiographic devascularization, intraoperative blood loss, ability to obtain gross total resection, transfusion requirements, and operative time, were analyzed. A total of 54 patients underwent surgery, with 24 undergoing preoperative embolization followed by surgical resection, and 30 patients undergoing surgical resection alone. Embolization-related neurological complications were seen in 6 patients (25%), including 3 hemorrhages when polyvinyl alcohol particles (P = .04) were used and 3 infarctions when liquid embolic agents were used (P = .27). Permanent neurological deficits were seen in 15%. Preoperative embolization of intracranial hemangioblastomas should be performed with caution, given the potential for neurological morbidity. Further studies are needed to help guide patient and embolic agent selection.

BackgroundLiquid embolic agents are the preferred embolic material in endovascular treatment of pial and brain arteriovenous malformations and dural arteriovenous fistulas (DAVFs). There is little choice available in interventional neuroradiology...

IntroductionPre-operative embolization of hypervascular head and neck tumors can be achieved using particulate agents or liquid embolic agents. Particulate agents are preferable due to the lower cost. However, the presence...

Safety Profile of Preoperative Meningioma Embolization: A Meta-Analysis Comparing Embolic Agents and Carotid Systems Embolized.

Preoperative embolization of meningiomas with polyvinyl alcohol particles: The benefits are not outweighed by risks.

IntroductionThe incidence of chronic subdural hematoma (cSDH) has been increasing, while recurrence after surgery reaches up to 30%. Middle meningeal artery embolization (MMAE) is an increasingly popular treatment option for...

Our purpose is to clarify the optimal timing of surgery after transarterial embolization (TAE) for renal cell carcinoma (RCC) bone metastases. This retrospective study included 41 patients with RCC bone metastases embolized between 2013 and 2019. Different-sized particulate and/or liquid embolic agents were used for TAE. Embolizations were categorized into groups 1-3 according to the interval between TAE and surgery (group 1: <1 day, group 2: 1-3 days, group 3: >3 days). Degree of embolization after TAE was graded visually based on angiographic images (<50%, 50%-75%, 75%-90%, >90%). The relationship between the TAE-surgery interval and intraoperative blood loss (IBL) and the correlation between IBL and embolization grade were examined. Lesion sizes and the relationships among lesion localizations and contrast media usage, intervention time, and IBL were also analyzed. Forty-six pre-operative TAEs (single lesion at each session) were performed in this study (26 in group 1, 13 in group 2, 7 in group 3). Lesion sizes and distributions were similar between groups (p = 0.897); >75% devascularization was achieved in 40 (TAEs 86.96%), but the IBL showed no correlation with the embolization rate (r=0.032, p = 0.831). The TAE-surgery interval was 1-7 days. The median IBL in group 1 (750 mL; range, 150-3000 mL) was significantly lower than those in the other groups (p = 0.002). Contrast media usage (p = 0.482) and intervention times (p = 0.261) were similar for metastases at different localizations. IBL values after TAE were lower for extremity metastases (p = 0.003). Bone metastases of RCC are well-vascularized, and to achieve lowest IBL values, surgery should preferably be performed <1 day after TAE.

IntroductionJuvenile nasopharyngeal angiofibroma is a locally invasive tumor in adolescent males. Surgical resection is the treatment of choice, but the tumor's extensive vascular involvement necessitates preoperative embolization. In this retrospective...

IntroductionChronic subdural hematomas (cSDH) are increasingly recognized as a major cause of morbidity in aging populations. Procedural Innovations such as middle meningeal artery embolization (MMAE) are becoming more widely adopted for cSDH treatment. While embolization reduces hematoma recurrence, the economic cost of different embolic agents remains unclear. This study evaluates inpatient procedural costs associated with particulate versus liquid embolic materials in MMAE for cSDH.MethodsA retrospective cohort study was conducted at a Comprehensive Stroke Center, including patients who underwent MMAE for cSDH between January 2019 and January 2024. Actual hospital expenditure data was used to assess total procedural and material-specific costs. Clinical outcomes, such as modified Rankin Scale (mRS) scores and 90-day retreatment rates, were compared between embolic agent groups. The primary independent variable was the embolic agent, categorized as particulate or liquid embolics (liquid including Onyx and nBCA).Results114 patients were included, with 18 (15.8%) treated with liquid embolics and 96 (84.2%) treated with particulate embolization. Baseline demographics and procedural variables were largely similar across groups. Procedural costs trended higher for liquid embolization than particulates ($27,419.50 ± $15,851.84 vs. $24,731.24 ± $23,195.37, p = 0.639). Material-specific costs were substantially greater for liquid ($3703.17 ± $1797.85) than to particulates ($152.74 ± $75.91, p < 0.0001). Functional outcomes (mRS at discharge, 30 days, and 90 days) and 90-day retreatment rates were not significantly different between groups. Subgroup analyses of hospital costs and access site also showed no significant differences.ConclusionsParticulate embolic agents offer a cost-effective alternative to liquid embolics for MMAE in cSDH, achieving comparable clinical outcomes at a significantly reduced material cost. Cost-conscious embolic selection may help sustain procedural expansion as MMAE adoption grows.

Chronic subdural hematoma (cSDH) represents a relatively treatment-resistant pathologic process with a large impact on quality-adjusted life years. This risk is increased in the elderly, and the prevalence is expected to rise as the population ages. Expectant management and classical surgical treatment are associated with increased recurrence rate as well as complications. Middle meningeal artery (MMA) embolization is being utilized more frequently as adjunctive and primary treatment. It has demonstrated beneficial effects on recurrence and progression of cSDH. Here, we present the outcomes of this technique with different embolic agents in our patient population. IRB approval was obtained for this study. Retrospectively, all patients at a single institution who underwent endovascular MMA embolization with or without open surgical intervention for cSDH were included. Vulnerable populations were excluded. Demographic and medical data were collected at initial, 1-month, and 3-month time points if available and analyzed for differences with unpaired T-test, paired-T test, and chi-square test. Between 2020 and 2024, a total of 50 patients were treated with MMA embolization for cSDH. Mean age was 73 years. Majority were male. Most were on antithrombotic therapy. Of these, 34 had history of prior SDH, and 38 had history of head trauma. Of the 50 patients, 29 patients underwent combined open surgery and MMA embolization, while 21 underwent MMA embolization alone. The cSDH was bilateral in 23 patients and unilateral in 27 (13 right, 14 left) for a total of 73 cSDHs. Surgical evacuation was performed in 44 cSDHs. Liquid embolic agent (Onyx) was utilized for 32 patients, while particulate embolic agents (250-500 um) were utilized for 18 patients. Of the patients who had follow-up CTs at 1 month, there were 21 cSDHs treated with particles and 39 with Onyx. There was no significant difference in the proportions of patients undergoing surgery in addition to MMA embolization between the groups treated with Onyx and those treated with particle embolization. Additionally, there was no significant difference in the proportions of treated hemispheres with ≥ 50% reduction or ≥ 75% reduction between those treated with Onyx and those treated with particles. At our institution, there was no difference in reduction of cSDH with Onyx as compared to particle embolization. MMA embolization was associated with no recurrence or progression of cSDH at 3 months.

IntroductionLiquid embolic agents (LEAs) such as cryanoacrylates or ethylene vinyl alcohol (EVOH) may be advantageous for middle meningeal artery embolization (MMAE) treatment of chronic subdural hematomas (cSDH) because they are...