Preoperative embolization of intracranial meningiomas

Since the first pre-operative embolization of a meningioma, performed over forty years ago, significant progress has been made in the techniques and clinical decision-making surrounding meningioma embolization prior to surgical resection. Aided by modern endovascular techniques, refined embolic agents, and ongoing clinical studies, preoperative embolization may significantly diminish surgical blood loss, hasten operative time, and ultimately lead to safe and total removal of large, vascular intracranial meningiomas. This chapter provides an updated review of the current practice of meningioma embolization in the 21st century, as it pertains to practicing clinicians. First, the pertinent intracranial vascular anatomy is presented with attention paid to the most common vessels that supply meningiomas, located through the extraaxial, intracranial space. Subsequently, the most recent literature reporting outcomes and complications with the latest techniques is discussed. Next is a review of particle and liquid embolic agents that are used in current practice, followed by a discussion of the optimal timing of surgery after embolization and the use of advanced imaging to verify complete tumor devascularization. Lastly, the key points in this chapter are summarized, including clinical recommendations based on the authors’ experiences.