Fatal Hemorrhage after Particle Embolization of an Intracranial Meningioma

Bendszus, Martin; Monoranu, Camelia; Vince, Giles H.; Solymosi, L.

doi:10.1007/s00062-004-5394-2

Cited by 36 publications

(57 citation statements)

References 12 publications

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“…Risk factors that increase the chances of ischemic complications include an arterial-arterial anastomosis between dural and neuroparenchymal vessels, skull base meningiomas with feeding vessels from the internal carotid artery, and the use of smaller particles. 2,5,17 The incidence of ischemic complications can be lowered through the use of relatively large particles, anticoagulation with heparin, thorough understanding of the arterial anatomy, provocative testing, and use of neuromonitoring in high-risk cases such as large skull base meningiomas. Likewise, appreciation of the anastomosis between the proximal middle meningeal artery branches with arteries supplying cranial nerves can lower the incidence of cranial nerve palsies.…”

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confidence: 99%

Controversies in the role of preoperative embolization in meningioma management

Singla¹,

Deshaies²,

Melnyk³

et al. 2013

FOC

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The role of preoperative embolization in meningioma management remains controversial, even though 4 decades have passed since it was first described. It has been shown to offer benefits such as decreased blood loss and “softening of the tumor” during subsequent resection. However, the actual benefits remain unclear, and the potential harm of an additional procedure along with the cost of embolization have limited its use to a small proportion of the meningiomas treated. In this article the authors retrospectively reviewed their experience with preoperative embolization of meningiomas over the previous 6 years (March 2007–March 2013). In addition, they performed a MEDLINE search using a combination of the terms “meningioma,” “preoperative,” and “embolization” to analyze the indications, embolizing agents, timing, and complications reported during preoperative embolization of meningiomas. In this retrospective review, 18 cases (female/male ratio 12:6) were identified in which endovascular embolization was used prior to resection of an intracranial meningioma. Craniotomy for tumor resection was performed within 4 days after endovascular embolization in all cases, with an average time to surgery of 1.9 days. The average duration of surgery was 4 hours and 18 minutes, and the average blood loss was 574 ml, with a range of 300–1000 ml. Complications following endovascular therapy were identified in 3 (16.7%) of 18 cases, including one each of transient hemiparesis, permanent hemiparesis, and tumor swelling. The literature review returned 15 articles consisting of a study population greater than 25 patients. No randomized controlled study was found. The use of small polyvinyl alcohol particles (45–150 μm) is more effective in preoperative devascularization than larger particles (150–250 μm), but is criticized due to the higher risk of complications such as cranial nerve palsies and postprocedural hemorrhage. Time to surgery after embolization is inconsistently reported across the articles, and conclusions on the appropriate timing of surgery could not be drawn. The overall complication rate reported after treatment with preoperative meningioma embolization ranges from as high as 21% in some of the older literature to approximately 6% in recent literature describing treatment with newer embolization techniques. The evidence in the literature supporting the use of preoperative meningioma embolization is mainly from case series, and represents Level III evidence. Due to the lack of randomized controlled clinical trials, it is difficult to draw any significant conclusions on the overall usefulness of preoperative embolization during the management of meningiomas to consider it a standard practice.

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confidence: 99%

Controversies in the role of preoperative embolization in meningioma management

Singla¹,

Deshaies²,

Melnyk³

et al. 2013

FOC

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“…[2][3][4][5][12][13][14][15] In this situation, the benefits of preoperative embolization must be weighed against the risk of complications, as an inadvertent interruption of blood flow to the central retinal artery may lead to retinal ischemia and visual compromise. 1,8,[13][14][15][16] The preoperative embolization of meningiomas supplied by the OPH requires superselective catheterization and the most distal placement of the microcatheter as possible, aiming to protect the central retinal artery of any reflux. There are several embolic materials, such as PVA particles, spheres, and glue, that were widely used in the literature.…”

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confidence: 99%

Preoperative Onyx Embolization of Meningiomas Fed by the Ophthalmic Artery: A Case Series

Trivelatto¹,

Nakiri²,

Manisor³

et al. 2011

AJNR Am J Neuroradiol

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SUMMARY:Embolization of head and neck hypervascular tumors is a well-established therapeutic technique. Preoperative embolization reduces intraoperative blood loss, shortens the length of surgery, and decreases surgical morbility and mortality. This study assesses the safety and efficacy of preoperative embolization of meningiomas fed by the OPH by using Onyx liquid embolic agent.ABBREVIATIONS: ACA ϭ anterior cerebral artery; DSA ϭ digital subtraction angiography; MMA ϭ middle meningeal artery; OPH ϭ ophthalmic artery, PVA ϭ polyvinyl alcohol. Preoperative embolization of meningiomas can reduce surgical blood loss, shorten operation length, reduce the risk of damage to surrounding structures, and increase the likelihood of complete tumor resection.1-11 Embolization becomes especially important when meningiomas are located at the skull base, because of the difficulties of bleeding management in this region. 2,11,12 The blood supply of meningiomas usually arises from branches of the external carotid artery, except in cases of anterior and middle skull base tumors. In these cases, hypervascularized tumors are often fed by internal carotid artery branches, such as the OPH. [2][3][4][5][12][13][14][15] In this situation, the benefits of preoperative embolization must be weighed against the risk of complications, as an inadvertent interruption of blood flow to the central retinal artery may lead to retinal ischemia and visual compromise. 1,8,[13][14][15][16] The preoperative embolization of meningiomas supplied by the OPH requires superselective catheterization and the most distal placement of the microcatheter as possible, aiming to protect the central retinal artery of any reflux. There are several embolic materials, such as PVA particles, spheres, and glue, that were widely used in the literature. 3,4,6,[14][15][16][17][18] However, these embolic agents are usually injected by using guide-dependent microcatheters that are known to have limited distal reach.Liquid embolic agent reflux into the OPH could lead to inadvertent occlusion of the central retinal artery. 3,[14][15][16][17][18] This article reports our experiences with the preoperative embolization of meningiomas fed by OPH branches by using Onyx (ev3, Irvine, California). This endovascular approach with Onyx was proposed as an alternative strategy for a more controlled embolization, aiming to reduce the risks of visual impairment caused by central retinal artery occlusion. Materials and MethodsFrom February 2008 to January 2010, 5 patients with untreated intracranial meningiomas fed mainly by OPH branches underwent preoperative embolization with Onyx-18 at our institution. There were 2 men and 3 women, with a mean age of 56 with an SD of 11.11 years (median, 53.3 years; range, 46 -74 years).Clinical presentation included headache in 3 patients, confusion in 3, anosmia in 1 patient, decreased visual acuity in 1 patient, and epilepsy in 1 patient. No patient had appendicular deficits. All patients underwent a CT scan, MR imaging, and DSA. Hypervascular blush ...

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“…It has been postulated that necrosis as a result of deep penetration of the particles causes the tissue to be more vulnerable to bleeding. [6][7][8]11,12 Possibly, penetration of particles into the draining veins of the tumor may block the outflow, increasing the risk of hemorrhage.…”

Section: Discussionmentioning

confidence: 99%

“…Recently, several authors have reported a considerable hemorrhagic and ischemic complication rate. [6][7][8] In a previous study, we found a 5.1% hemorrhagic complication rate of embolization of meningiomas in 198 patients, leading to death or dependency in 7, despite emergency surgery. 9 In that study, the use of small PVA particles (45-150 m) proved to be a significant risk factor for this serious complication.…”

Section: Abbreviationsmentioning

confidence: 99%