Which arteries are safe to embolize for a meningioma?

Safe Arteries for Meningioma Embolization

For meningioma embolization, deep arterial feeding vessels that are surgically inaccessible are safe to embolize, while arteries with dangerous anastomoses to the ophthalmic artery or other intracranial vessels must be avoided.

Arterial Anatomy and Safety Considerations

Safe Arteries to Embolize

• Deep, surgically inaccessible feeding vessels:
  • Anterior/posterior perforating vessels
  • Choroidal vessels
  • Posterior cerebral vessels
  • Main feeding branches of the meningioma 1

Dangerous Arteries to Avoid

• Middle meningeal artery when it has anastomoses with:
  • Ophthalmic artery (particularly dangerous)
  • Other intracranial arteries 2
• Any vessel with extracranial-to-intracranial anastomoses

Pre-Embolization Assessment

Required Imaging

• Selective angiography of:
  • External carotid artery branches
  • Internal carotid artery
  • Vertebral artery (if applicable)
• Super-selective angiography of target vessels to identify dangerous anastomoses 2

Critical Safety Steps

1. Perform detailed angiographic assessment even when conventional angiograms don't show obvious anastomoses
2. Consider selective intra-arterial MR perfusion imaging to assess vascular territories before embolization 3
3. Use superselective Amytal testing for vessels with uncertain territory 1

Goals of Meningioma Embolization

1. Decrease nidus size of the tumor
2. Occlude deep, surgically inaccessible feeding vessels
3. Occlude intranidal aneurysms (if present)
4. Occlude high-flow fistulas 1

Technical Considerations

Embolic Materials

• Most centers recommend permanent agents:
  • Polymers of cyanoacrylate (NBCA)
  • Onyx (ethylene vinyl alcohol copolymer)
• Particles and coils may also be used in specific situations 4

Procedural Approach

• Direct arterial pressure monitoring during procedure
• Either general endotracheal anesthesia or deep sedation
• Post-procedure monitoring for at least 24 hours 5

Complication Risks and Prevention

• Hemorrhagic complications: 2-4.7% of cases
• Neurological morbidity: 2-5% of cases
• Mortality: ≤1.08% 1

Potential Complications

• Arterial perforation
• Intranidal aneurysm rupture
• Unintended venous occlusion
• Thromboembolic events
• Post-procedure edema 1, 5

Special Considerations

For middle cranial fossa meningiomas, be particularly vigilant about middle meningeal artery to ophthalmic artery anastomoses, which may not be visible on conventional angiograms but can be detected with selective angiography 2.

When flow-related aneurysms are associated with meningiomas, endovascular embolization with liquid glue can safely and effectively eliminate the risk of rupture 6.

Remember that proximal occlusion of arterial feeding vessels without occluding the tumor nidus may have deleterious effects due to development of collateral circulation 1.