J Cerebrovasc Endovasc Neurosurg.  2016 Mar;18(1):12-18. 10.7461/jcen.2016.18.1.12.

Preoperative Embolization of Extra-axial Hypervascular Tumors with Onyx

• Fusco MR
• Salem MM
• Gross BA
• Reddy AS
• Ogilvy CS
• Kasper EM
• Thomas AJ

• KMID: 2161697
• DOI: http://doi.org/10.7461/jcen.2016.18.1.12

Abstract

OBJECTIVE
Preoperative endovascular embolization of intracranial tumors is performed to mitigate anticipated intraoperative blood loss. Although the usage of a wide array of embolic agents, particularly polyvinyl alcohol (PVA), has been described for a variety of tumors, literature detailing the efficacy, safety and complication rates for the usage of Onyx is relatively sparse.
MATERIALS AND METHODS
We reviewed our single institutional experience with pre-surgical Onyx embolization of extra-axial tumors to evaluate its efficacy and safety and highlight nuances of individualized cases.
RESULTS
Five patients underwent pre-surgical Onyx embolization of large or giant extra-axial tumors within 24 hours of surgical resection. Four patients harbored falcine or convexity meningiomas (grade I in 2 patients, grade II in 1 patient and grade III in one patient), and one patient had a grade II hemangiopericytoma. Embolization proceeded uneventfully in all cases and there were no complications.
CONCLUSION
This series augments the expanding literature confirming the safety and efficacy of Onyx in the preoperative embolization of extra-axial tumors, underscoring its advantage of being able to attain extensive devascularization via only one supplying pedicle.

Keyword

Embolization; Endovascular; Meningioma; Onyx; Tumor

MeSH Terms

Hemangiopericytoma
Humans
Meningioma
Polyvinyl Alcohol
Polyvinyl Alcohol

Figure

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  Fig. 1 Case 1. Preoperative T1-weighted post contrast coronal magnetic resonance imaging showing an extra-axial mass with significant mass effect and edema on the adjacent brain parenchyma (A). Anteroposterior view of left external carotid artery arteriogram demonstrating filling of the tumor through branches of the left superficial temporal artery and the left middle meningeal artery draining into a venous fistula and also supplying the tumor through multiple collaterals (B). Anteroposterior skull film demonstrating Onyx cast (C).

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  Fig. 2 Case 2. Preoperative T1-weighted post contrast coronal magnetic resonance imaging demonstrates an extra-axial, falcine lesion over the frontoparietal vertex with mass effect and an associated inferolateral peritumoral cyst (A). Anteroposterior view of a distal left external carotid artery arteriogram illustrates the classic "spoke wheel" filling of the falcine meningioma supplied by distal branch of the middle meningeal artery (C). Lateral view of post-embolization angiogram of left external carotid artery shows occlusion of the distal middle meningeal artery.

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  Fig. 3 Case 3. Preoperative T1-weighted post contrast sagittal magnetic resonance imaging shows an extra-axial enhancing mass centered in the falx cerebri (A). This lesion extended bilaterally with invasion of the anterior and mid superior sagittal sinus. Anteroposterior view of left external carotid artery arteriogram showing multiple arterial feeders to the tumor, mainly from the left middle meningeal artery (B). Anteroposterior view of post-embolization left common carotid artery arteriogram (C).

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  Fig. 4 Case 4. Preoperative T1-weighted post contrast axial magnetic resonance imaging shows a right frontal extra-axial mass with intraosseous extension and adjacent dural thickening (A). Lateral view of right external carotid artery angiogram shows a hypervascular tumor blush, supplied by the middle meningeal artery and accessory middle meningeal artery (B). Anteroposterior, unsubtracted view of post-embolization of right external carotid artery angiogram demonstrates Onyx casting within the distal middle meningeal artery, with markedly diminished supply to the tumor but little flow from the accessory middle meningeal artery (C).

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  Fig. 5 Case 5. Preoperative T1-weighted post contrast coronal magnetic resonance imaging shows a right temporal occipital extra-axial mass, with midline shift and mass effect noted on the right lateral ventricle and extensive edema (A). Anteroposterior view of right external carotid artery angiogram shows arterial supply to the tumor from branches of right occipital artery and the middle meningeal artery (B). Lateral view of post-embolization of right common carotid artery angiogram demonstrates little residual supply to the tumor (C).

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