dr. Samuel Tandionugroho Sp.Rad (K) Interventional radiologist at Presidential Hospital RSPAD Gatot Soebroto, Jakarta

1. Transarterial Embolization of
Meningiomas
Samuel Tandionugroho
Central Army Hospital Gatot Soebroto
Jakarta

2. Samuel Tandionugroho
Mobile : +628158853373
Email : samueltn@gmail.com
Birth : 27 September 1973
Education
 Atma Jaya Catholic University, Jakarta.
Major:Medical
 Padjajaran University, Bandung. Major Magister
Management in Hospital Management
 University of Indonesia, Jakarta. Major : Radiology
 Indonesian Society of Interventional Radiology.
Major :Interventional Radiology Fellowship
Program

3. MENINGIOMA
• Most common benign intracranial neoplasm in
adults and in hospital series account for 13 to 26%
of primary intracranial tumors.
• 90% of meningiomas are benign, 6% are atypical,
and 2% are anaplastic; only 0.2% of meningiomas
metastasize
• No clinical symptoms until the tumor compresses
adjacent structures
• Recent treatments are surgery, radiotherapy
• High blood suppy  High Bleeding Risk

4. • They arise from the arachnoid cap cells imbedded in the
arachnoid villi, and they can occur in any location but arise
most commonly at the skull vault and skull base.
• Less common sites include the optic nerve sheath, choroid
plexus, and spinal cord.

6. Clinical presentation
• Regardless of the grade, will generally be dependent on the location
of the mass.
• Since most meningiomas are slow growing, the majority of patients
will have a relatively insidious onset of symptoms including headache,
pain, subtle personality change (often confused with dementia or
depression), and less commonly seizure.
• Rarely, meningiomas may present with hemorrhage that may be
intratumoral, intraparanchymal, intraventricular, or subarachnoid

12. • Manelfe et al and Richter and Schachenmayr suggested that
meningiomas be divided based on their predominant blood
supply:
• (1) those with sole ECA supply,
• (2) those with mixed ECA/ICA supply but dominant ECA
feeders,
• (3) mixed ICA/ECA but dominant ICA supply, and
• (4) those with exclusive ICA supply.
• Patients most likely to benefit from embolization fall into groups
1 or 2

15. RECENT TREATMENTS
• SURGERY
• Small tumor
• Accesible
• Low risk
patients
• RADIOTHERAPY
• Incomplete
Resection
• Recurrent
• Anaplastic
and atypical
• HIGH RISK
PATIENTS
• LOCATION
• RISK OF
NEUROLOGICAL
DEFICITS
EMBOLIZATION

16. MENINGIOMA EMBOLIZATION
DEFINITIFE ADJUVANT PALIATIF

17. •Can reveal need for embolization
•Can reveal vascular relationships
•Can reveal unexpected vascular relationships. Realization
of these can reduce potential complications
Why do preoperative angiography
for meningiomas?

18. Angiographic Findings :
• Sunburst appearance
• Prolonged vascular stain
• Venous phase vital to
evaluate sinus involvement

20. Pre-operative

21. Post-operative

22. 4 years after operative

23. Why Do We Embolize These Tumors?
•Meningiomas Typically Vascular Tumors
•Goal of the Embolization is to devascularize the tumors so
that surgical resection can easily be achieved

24. Meningioma Vascularization
• External Carotid Artery branches often supplying meningioma
include the middle meningeal artery (MMA), accessory meningeal
artery (AccMA), superficial temporal artery, ascending pharyngeal
artery (APA), and perforating transosseous occipital artery (OccA)
branches
• Dural Internal Carotid Artery branches commonly supplying
meningiomas include those arising from the meningohypophyseal
trunk (MHT), the inferolateral trunk (ILT), and the ophthalmic artery
(OPA)
• The Vertebral Artery often supplies the dura via its posterior
meningeal artery (PMA) branch.

26. • Determine the location by MRI/ CT scan
• Make angiography
• Determine location by angiography
• Determine the vascularization
• Check collateral/communication artery
• Embolant agent
• Check stasis/refluks
How does the Procedure :

27. Embolize
Embolant Agents:
• Temporary :
• Gellfoam, thrombin,collagen
• Permanen :
•Particel : PVA, Embosphere
•Coils : Pushable,
Injectable,Detachable
•Liquid : Glue, Onix,Alcohol
•Other : Balloons

29. DSA (A, B, and C) showing a left convexity meningioma. A, preembolization left
external carotid artery injection showing tumor blush from anterior MMA branch
(frontal view). B, glue injection anterior branch of MMA (frontal view). C,
postembolization left external carotid artery injection.

30. and MRI (D and E) D, preembolization T1-weighted MRI scan with gadolinium. E, MRI scan day 4
postembolization demonstrating central nonenhancement (presumed to be necrosis). DSA, digital
subtraction angiography; MMA, middle meningeal artery; MRI, magnetic resonance imaging.

31. Embolisasi Meningioma
Pro Operasi

32. Surgery Timing
• The timing of the surgery following embolization varies in the
literature from 1 day to more than a week.
• In most cases, the surgery is performed during the same hospital stay
and within 72 hours of the embolization.
• Djindjian recommended an interval of 3 days.

35. Complications :
• 2 patients with monocular
blindness
• Facial paralysis
• Dissection of MMA
• CN X, XI, XII Palsy
• MMA perforation and sacrafice
• Left Frontal Lobe
Hematoma/Intratumor
Hemorrhage
111 PATIENTS , 10 years Observation
6%
Anastomosis with branches of internal carotid a. or
vertebral a
Embolization of cranial nerve vascular supply
Size of embolant agents

36. Complications at Our Center
• Only use 300-500 micron
particles
• Only embolize tumor which
only has branches from
external internal carotid
0%
9 PATIENTS , 2 years
Observation

37. Conclusion :
• Meningioma embolization has been performed successfully for 45
years.
• Current evidence suggests that preoperative embolization can
reduce intraoperative blood loss, reduce transfusion requirements,
and make surgery easier in appropriately selected cases.
• In some cases, where the risk of surgery is prohibitive or there is
symptom relief following embolization, embolization has served as a
primary treatment.
• There is important to know variations of meningeal artery, location
of the tumor and probably supply artery involved.

38. • Embolization can be used in all type of meningioma when
another treatment were all not possible for various reasons.
• Small particles are good for embolizing, but it can increase
risk of embolization another area and increase risk of
intratumoral haemorrhage, abcess.

39. THANK YOU

43. Middle Meningiomal Artery Variations :

44. RR

45. MMA Supply to MCA with M1 MissingMMA Supply to MCA at Pterion
L L

46. ??
1973
2015
A. Pedicelli, L. Danieli, M.
Iacobucci, E. Visconti, F. D'
Argento, C. Colosimo; Rome/IT
POE is effective in
reducing surgical time
when >75% of
devascularization is
achieved after an
accurate assessment of
tumor vascularization
A. Pedicelli, L. Danieli, M. Iacobucci, E. Visconti, F.
D' Argento, C. Colosimo; Rome/IT
Fresh or recent ischemic and/or hemorrhagic
necrosis consistent with technically successful
embolization was demonstrated in 40%-60% of
cases
2005 2014
embolization did not
alter the operative
duration, complications,
or degree of resection,
but the degree of
embolization was an
independent predictor of
decreased operative
blood loss.
2017
On MRI marked
tumour shrinkage
occurred after
embolisation in
six patients, and
was most
pronounced
during the first
6 months
History