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

Abstract

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 ...

Controversies in the role of preoperative embolization in meningioma management

“…The use of Onyx as the embolizing agent has been reported only in small case series or case reports, and it is difficult to draw any significant conclusions. 9,28 Fibrin glue has also been reported in only a single large case series, and the authors concluded that the use of this material is safe and technically easy.…”

Transarterial Onyx Embolization of an Orbital Solitary Fibrous Tumor

“…Transarterial embolization was used in this case due to the identification of posteriorly located main feeding vessels. Onyx liquid embolic agent is an ideal substance for embolizing orbital lesions of this type, because the slow precipitation properties of Onyx allows deep penetration into smaller vessels within the tumor, producing a diffuse infiltration and minimizing the need for repeated catheterizations [3,4]. The timing of the resection after embolization may be immediately after the radiologic interventional procedure or a few days following the embolization.…”

“…Recently, vision-sparing preoperative Onyx embolization of orbital meningiomas fed by the ophthalmic artery has been described [4]. Onyx embolization of lesions may be performed transarterially or via direct percutaneous tumor puncture [3].…”

Pre-operative Embolization as Resection Strategy in Brain Tumor with No Neurological Deficit

“…effective strategy to prevent intraoperative complications and facilitate better outcomes. 1,3,5,10 This case has an important challenge because the patient was a young productive female with no neurological deficits, so the complication after surgery should be avoided for the survival of patients in her daily life. The good strategy and good experience is the best way to solve this problem.…”