Figure 1
Contrast-enhanced CT scan at the level of the lateral ventricles
Inhomogeneous left convexity meningioma.
Embolisation of a left convexity meningioma
SectionInterventional radiology
Case TypeClinical Cases
AuthorsH. Gunselmann, D. Vorwerk, K. Rummel, E. Clar
Connected authors
56 years, female
Clinical History
The patient presented with sudden incomplete motoric aphasia. Clinical examination revealed a slight right-sided hemiparesis.
Imaging Findings
The patient presented with sudden incomplete motoric aphasia. Clinical examination revealed a slight right-sided hemiparesis.
Contrast-enhanced CT (Fig. 1) and T1-weighted MRI (Fig. 2) scans showed the typical appearances of a partially cystic convexity meningioma in a left fronto-temporo-parietal location. The neurological deficits were slightly improved with intravenous corticosteroid therapy (12 mg dexamethasone/24 hours). Since the patient was willing to undergo surgical treatment, preoperative embolisation was recommended.
Discussion
After retrograde puncture, a 5F sheath was introduced into the right common femoral artery, followed by administration of 5000 IU heparin i.a. Selective catheterisation of the left external carotid artery was performed using a 5F guiding catheter (Envoy/Cordis, 0.050in) and a coated guidewire (Terumo, 0.035in). The guiding catheter was continuously flushed with a solution of 5000 IU heparin/500ml sodium chloride through the haemostatic valve. Selective contrast injection showed a large tumour blush in the expected location, proving typical hypervascularisation of the meningioma. Superselective angiography of the middle meningeal artery (MMA) (Fig. 3) through a coaxially advanced 1.9F microcatheter (Prowler/Cordis) demonstrated exclusive tumour supply via the frontal and parietal branches of the MMA. As both branches participated in feeding the tumour, there was no need - in this case - for more distal catheterisation. So, the catheter tip was a placed a few millimeters proximal to the meningial bifurcation. The embolisation was performed using polyvinyl-alcohol (PVA) particles (150-250µm) and a 1ml insulin-syringe, which is easy and safe to handle and offers good injection control, thus reducing the risk of retrograde embolisation into other vascular territories, especially the petrosal branch of the MMA, whose occlusion may cause the severe complication of facial nerve paresis.
After embolisation, the tumour blush disappeared completely (Fig. 4) and during surgery the typical yellow-coloured surface of a devascularised meningioma could be seen (Fig. 5). The tumour was completely removed without related haemorrhage.
Although there are conflicting opinions concerning the value of preoperative embolisation of meningiomas among neurosurgeons, it is now a standard procedure for reducing blood loss during surgery. At histological examination, the first manifestations of necrosis are apparent the day after embolisation, so surgical removal should not be performed before.
It is most important to achieve a distal embolisation of the tumour's vascular bed, which is provided by the use of small particles (150-250µm) and superselective catheterisation, and furthermore, to avoid any complications due to vasospasm, rupture, external-internal anastomoses or retrograde embolisation.
In our opinion devascularisation of supplying vessels within the internal carotid artery territory should not be performed, because its risk-to-benefit ratio is too high for a benign disease like a meningioma.
Differential Diagnosis List
Embolisation of a convexity meningioma
Final Diagnosis
Embolisation of a convexity meningioma
References
[1] Black PM. Meningiomas. Neurosurgery. 1993 Apr;32(4):643-57. (PMID: 8474655)
[2] Wakhloo AK, Juengling FD, Van Velthoven V, Schumacher M, Hennig J, Schwechheimer K. Extended preoperative polyvinyl alcohol microembolization of intracranial meningiomas: assessment of two embolization techniques. AJNR Am J Neuroradiol. 1993 May-Jun;14(3):571-82. (PMID: 8517342)
[3] Ginsberg LE. Radiology of meningiomas. J Neurooncol. 1996 Sep;29(3):229-38. (PMID: 8858529)
[4] Neumaier-Probst E, Grzyska U, Westphal M, Zeumer H. Preoperative embolization of intracranial meningiomas with a fibrin glue preparation. AJNR Am J Neuroradiol. 1999;20:1695-1702. (PMID: 10543643)
Case information
| URL: | https://www.eurorad.org/case/1111 |
| DOI: | 10.1594/EURORAD/CASE.1111 |
| ISSN: | 1563-4086 |
Figure 2
T1-weighted gadolinium-enhanced MRI scan at the same level as Fig. 1
Partially cystic meningioma of the left convexity.
Figure 3
Selective angiograpy of the middle meningeal artery before embolisation
Typical tumour blush of a convexity meningioma.
Figure 4
Selective angiography of the left middle meningeal artery after embolisation
Devascularisation of the meningioma after embolisation. Note that the tumour blush (see Fig. 3) is gone.
Figure 5
Meningioma after removal of the skull
Typical yellow-coloured surface of an embolised meningioma after partial removal of the dura mater.
Contrast-enhanced CT scan at the level of the lateral ventricles
Inhomogeneous left convexity meningioma.
T1-weighted gadolinium-enhanced MRI scan at the same level as Fig. 1
Partially cystic meningioma of the left convexity.
Selective angiograpy of the middle meningeal artery before embolisation
Typical tumour blush of a convexity meningioma.
Selective angiography of the left middle meningeal artery after embolisation
Devascularisation of the meningioma after embolisation. Note that the tumour blush (see Fig. 3) is gone.
Meningioma after removal of the skull
Typical yellow-coloured surface of an embolised meningioma after partial removal of the dura mater.