Preoperative embolization of meningiomas fed by ophthalmic branch arteries

ELSEVIER

PREOPERATIVE EMBOLIZATION OF MENINGIOMAS FED BY OPHTHALMIC BRANCH ARTERIES Tomoaki Terada, M.D., Yasunobu Kinoshita, M.D., Hideyuki Yokote, M.D., Mitsuharu Tsuura, M.D., Toru Itakura, M.D., Norihiko Komai, M.D., Yoshinari Nakamura, M.D., Satoshi Tanaka, M.D., and Tsuyoshi Kuriyama, M.D. Department of Neurological Surgery, Wakayama Medical College, and the Department Neurosurgery, Wakayama Red Cross Hospital, Wakayama City, Japan

Terada T, Kinoshita Y, Yokote H, Tsuura M, Itakura T, Komai N, Nakamura Y, Tanaka S, Kuriyama T. Preoperative embolization of meningiomas fed by ophthalmic branch arteries. Surg Neurol 1996;45:161-6. BACKGROUND

The efficacy of preoperative embolization for hypervascular meningiomas mainly fed by the branches of the ophthalmic arteries was examined. CASES

AND

METHODS

Five hypervascular meningiomas mainly fed by the branches of the ophthalmic arteries, four posterior ethmoidal arteries, one anterior falx artery, and one recurrent middle meningeal artery were embolized with Gelfoam powder, polyvinyl alcohol (PVA) particles, and/or microcoils as a preoperative treatment using a microcatheter. RESULTS

Catheterization of the ophthalmic and tumor feeding artery was possible and feeding arteries and lesion embolization were effective to reduce the bleeding during surgery in all cases. In three cases, visual acuity and visual field were preserved. However, in one case, visual acuity and visual field defect appeared due to the migration of Gelfoam powder (Upjohn, Kalamazoo, MI) into the retinal artery. In another case, the retinal artery was embolized with the feeding arteries since the patient was already blind. CONCLUSION

Embolization of hypervascular meningioma feeding vessels arising from the ophthalmic artery is possible and

effective with preservation of vision, if embolic agents are injected gently enough not to reflux into the central retinal artery. KEY WORDS

Embolization, therapeutic, Gelfoam powder, meningioma, ophthalmic artery, polyvinyl alcohol particles.

Address reprint requests to: Tomoaki Terada M.D., Department of Neurological Surgery, Wakayama Medical College, 7 Bancho 27, Wakayama City, 640 Japan. Received February 1, 1995; accepted May 24, 1995. 0 1996 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010

of

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mbolization for hypervascular brain tumors is known to be an effective method [2,7] to reduce intraoperative bleeding as well as operative difficulty. The most commonly embolized tumors are meningiomas, which are usually supplied by branches of the external carotid artery. However, some meningiomas are fed by the branches from the internal carotid artery, such as the ophthalmic artery, tentorial artery, or cortical branches. Usually these tumors are hypervascular [ 1,9]. The development of interventional neuroradiology made embolization possible within the ophthalmic artery territory as well as cortical branches [4,10,12]. We report our experience with preoperative embolization in five cases of meningiomas fed mainly by the ophthalmic artery. In addition, we discuss our embolization technique and pitfalls associated with such procedures.

CASES

AND METHODS

Five cases of meningiomas fed primarily by the branches of the ophthalmic artery were embolized using interventional neuroradiologic techniques. Two of the five patients had had previous unsuccessful attempts at tumor resection accompanied by excessive intraoperative bleeding. The age range of patients was 23 to 76 years (average, 45.6 years). Four were male and one was female. All tumors were adjacent to the frontal lobe (olfactory groove, 2; frontal convexity, 2; sphenoidal ridge, 1). Main feeding arteries to tumors included: the posterior ethmoidal artery (4), anterior falx artery (l), recurrent middle meningeal artery (l), anterior choroidal artery (l), and cortical branches from the anterior cerebral artery (2). 0090-3019/96/$15.00 SSDI0090-3019(95)00240-5

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0 No. 1

Five Cases of Menineiomas

AGE/SEX 52/F

LOCATION Olfactory groove

2 3

50/M 28/M

Olfactory groove Sphenoidal ridge

4

23/M

5

76/M

Frontal convexity Frontal convexity

FEEDINGARTERIES

Post eth.a., ACA, MMA, IMA Post eth.a., MMA Post eth.a., Ach ICA Post eth.a., ACA, ant falx a. Recurrent MMA

VISION

OPERATION

Lost before emb.

2nd

500 mL

Quadrant anopsia Preserved Hemianopsia by Ach emb. Preserved

1st 2nd

570 mL 2000 mL

1st

1450 mL

Preserved

1st

1980 mL

Abbreviations: M, male; F, female; post eth.a., posterior ethmoidal artery; ACA, anterior cerebral artery; Ach, anterior choroidal meningeal artery; IMA, internal maxillary artery; ICA, internal carotid artery; ant. falx a., anterior falx artery; emb., embolization.

Embolization procedures were performed using digital subtraction angiography. Tracher-18 microcatheters (Target Therapeutics, Fremont, CA) were

used for superselective catheterization of the ophthalmic artery under fluoroscopic control. Catheters were navigated beyond the central retinal artery, except one case in which visual recovery was felt to be impossible. Gelfoam powder was used as the main embolic agent in all cases. Microcoils were used after Gelfoam embolization in one case. Polyvinyl alcohol (PVA) particles (> 250-micron diameter) were used in another case. However, because of the high injection pressure required for the PVA, this embolization had to be completed using Gelfoam powder. The embolic agents were injected very gently to prevent reflux. Embolization was terminated when antegrade flow stasis was seen using digital road map imaging. Contrast enhanced computed tomography (CT) and/or magnetic resonance imaging (MRl) was performed in all cases within 1 week post procedure to evaluate the effects of embolization.

RESULTS Selective feeding artery catheterization was achieved successfully beyond the central retinal artery in all cases except one (vision in that case had already been lost prior to embolization). The average bleeding during subsequent total resection was 1300 mL. Four tumors were successfully removed without difficulty. One tumor was completely removed, but with some difficulty in its nonembolized portion (see below). We encountered complications in two patients as a result of embolization. In one case, a branch of the retinal artery was embolized by Gelfoam powder and the patient had partial visual field defect (partial right lower visual field defect in the right eye). In the other

BLEEDING

artery: MMA, middle

case, anterior choroidal embolization resulted in hemiparesis and homonymous hemianopsia. Marked reduction of the contrast-enhanced area was demonstrated in all cases after embolization on CT or MRI.

CASEREPORTS CASE

1

A 52-year-old woman was admitted to our hospital because of a recurrent meningioma. During her first surgery, the tumor, located in the olfactory groove, was subtotally removed with 10,000 mL of blood loss. Following recurrence, surgical resection was tried again but had to be abandoned due to uncontrollable bleeding from the tumor. Radiation therapy was performed for the tumor, but it continued to grow. The patient’s condition deteriorated. She became more apathetic, and her left eye vision was lost because of a long-standing choked disc. Feeding arteries of the tumor were mainly the left ophthalmic artery and callosomarginal arteries (Figure 1 A, B, C, D).Superselective embolization was attempted to reduce subsequent intraoperative bleeding. A Tracker-18 catheter was navigated into the above feeding arteries, which were then embolized with Gelfoam powder. All feeding arteries except the right ophthalmic artery were totally embolized (Figure 1 E, F'). Without difficulty the tumor was totally resected surgically 2 days following embolization with 500 mL of blood loss. CASE

2

A 50-year-old man was admitted to our hospital because of a large hypervascular meningioma discovered incidentally in the frontal base. The tumor was supplied mainly from the right middle meningeal and ophthalmic arteries (Figure 2 A).Preoperative ophthalmic branch embolization was per-

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(A) Lateral view of the left internal carotid angiogram, arterial phase. (B) Lateral view of the left internal carotid angiogram, late arterial phase. (C) A-P view of the left internal carotid angiogram, arterial phase. (D) A-P view of the left internal carotid angiogram, late arterial phase. The tumor was fed mainly by the left ophthalmic artery and callosomarginal arteries. Prominent tumor stain was demonstrated, and dilated draining vein was revealed in the late arterial film. Q A-P view of the left internal carotid angiogram with right common carotid arterial compression, arterial phase. (Q A-P view of the left internal carotid angiogram, capillary phase. The tumor stain was markedly reduced. The tu-

mor was faintly supplied from the right ophthalmic artery.

formed using a Tracker-18 catheter introduced into the posterior ethmoidal artery. Gelfoam powder mixed with contrast was gently injected until the stasis of antegrade flow was achieved (Figure 2 B, C). Once the catheter had been cleared with contrast and saline, it was withdrawn to the orifice of the ophthalmic artery for postembolization angiography. After the patient returned to his room, he complained of the partial visual field defect in his right eye. The fluorescence retinal angiogram showed the occlusion of the right upper branch of the retinal artery (Figure 3). The tumor was later resected without difficulty.

CASE

3

A 2%year-old man presented to our institution for the treatment of an incidentally-found sphenoidal ridge meningioma. This tumor was first operated on at an another hospital but only a partial resection was achieved due to uncontrollable intraoperative blood loss. Preoperative embolization was performed at our department. Main tumor feeding vessels were from the ophthalmic artery, anterior choroidal artery, and perforators from the internal carotid artery and posterior communicating artery (Figure 4 A, B). A Tracker-18 catheter was navigated

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(A) Lateral view of the right internal carotid artery. The prominent tumor stain was demonstrated from the right ophthalmic artery. The anterior portion of the tumor was supplied from the right middle meningeal artery (not shown). (B) Superselective right ophthalmic angiography before embolization. (C) Superselective right ophthalmic angiography after embolization. The tumor stain from the ophthalmic artery markedly reduced after embolization.

Q

into the ophthalmic artery and advanced into the posterior ethmoidal artery (Figure 5 A). At first, injection of 250-500 microns PVA particles was attempted but was stopped because of resistance during injection (which threatened reflux and nontarget embolization). Gelfoam powder was then gently injected until the feeding arterial flow became slow (Figure 5 B). His vision remained normal following embolization. The angiographic tumor stain was absent within the embolized area (Figure 4 C, D). Embolization was performed within the anterior choroidal artery and perforators arising from the internal carotid artery. Hemiparesis and homonymous hemianopsia appeared after embolization for the anterior choroidal artery. The tumor was totally removed. The embolized area was easily resected. However, bleeding was difficult to control

Q

Fluorescence ocular angiography (case 2). The left upper portion of the retinal artery was obliterated.

in the proved original anopsia

nonembolized area. His hemiparesis imafter the surgery and he returned to his job, although his left homonymous hemiremained unchanged.

DISCUSSION Surgery for hypervascular brain tumors is still difficult, frequently requiring extensive blood transfusions despite advances in microsurgical technique [5,6,9]. Radiation therapy is effective for some, but not all, types of meningiomas (as illustrated in case 1). In some tumors, such as hemangiopericytomas and certain types of hypervascular meningiomas [3,8,11,13,14], vessels have thin walls and are difficult to coagulate using a bipolar device. For these types of tumors, preoperative embolization therapy is effective and can markedly decrease operative technical difficulty. Recent advances in interventional neuroradiology have made catheterization of the ophthalmic artery and its branches possible [4]. Neurointerventional techniques have been used for both embolization and thrombolytic therapy within the central retinal artery [10,12]. Catheterization of the ophthalmic artery was not difficult in cases in which this vessel was enlarged as a result of increased blood flow supplying a tumor. In our series, we could navigate the catheter into the ophthalmic artery in all cases, although we encountered some difficulty in two cases due to a sharp bend in the proximal ophthalmic artery. We used mainly Gelfoam powder as an embolization agent. The major reason was that Gelfoam pow-

Embolization

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01

(A) Lateral view of the right internal carotid angiogram before embolization, early arterial phase. (B) Lateral view of the right internal carotid angiogram before embolization, late arterial phase. The tumor was fed from the right ophthalmic artery, anterior choroidal artery, and perforators from the right internal carotid artery. The internal carotid artery became narrow because of the encasement by the tumor. (C) Lateral view of the right internal carotid angiogram after embolization, early arterial phase. (D) Lateral view of the right internal carotid angiogram after embolization, late arterial phase. The tumor stain reduced in the area emboli. zatron was pertormea.

der mixed with contrast created little resistance during injection. Thus, we could inject Gelfoam powder in a form nearly like a liquid embolic agent, thereby preventing reflux of the embolic agent from a feeding artery and into the central retinal artery. We used PVA as an embolic agent in one case, but much more pressure was necessary to inject PVA compared to Celfoam powder. We felt it was difficult to inject PVA without reflux. Horton [4] reported the size of the central retinal artery is smaller than 300 microns, therefore, the use of PVA particles larger than 300 microns might be a safe embolization agent. However, PVA particles might fragment into smaller sizes during mixture, thus contaminating the PVA mixture with particles capable of occluding the central retinal artery. We encountered embolic complications in two patients. In one of these patients (case 1) the complication may have been caused by adhesion of a small residual amount of Gelfoam powder within the microcatheter, which was released into the central retinal artery during postembolization superselective angiography. For this reason, perhaps one

should not use this catheter for postembolization superselective angiography. In conclusion, we believe the use of Gelfoam powder as an ophthalmic branch embolic agent is safe, if the catheter tip is introduced well into the feeding branch beyond the central retinal artery and injected very gently without any reflux. REFERENCES Angervall L, Kindblom LG, Nielsen JM, Svendsen P. Hemangiopericytoma: a clinicopathological, angiographic and microangiographic study. Cancer 1978; 42~2412-27. Debrun G, Lacour P, Caron JP, Hurth M, Comoy J, Keravel Y. Detachable balloon and calibrated leak balloon technique in the treatment of cerebral vascular lesions. J Neurosurg 1978;49:635-49. Fukui M, Kitamura K, Ohgami T, Takaki T, Kinoshita K, Watanabe K, Mihara K. Radiosensitivity of meningioma analysis of five cases of highly vascular meningioma treated by preoperative irradiation. Acta Neurochir (Wien) 1977;36:47-60. Horton JA, Kerber CW. Lidocaine injection into external carotid branches: provocative test to preserve

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7. Mira JG, Chu FCH, Fortner JG. The role of radiotherapy in the management of malignant hemangiopericytoma. Cancer 1977;39:1254-9. 8. Pithkethly DT, Hardman JM, Kempe LG, Kenneth ME. Angioblastic meningiomas: clinicopathologic study of 81 cases. J Neurosurg 1970;32:539-44. 9. Takase M, Watanabe 0. Radiosensitive hemangiopericytoma of the falx: case report. J Neurosurg 1988;68: 640-l. 10. Yamakawa Y, Kinoshita K, Fukui M, Mihara K, Koga K, Kitamura K. Radiosensitive meningioma. Surg Neurol 1980;13:471-5. 11. Wara WM, Sheline GE, Newman H, Townsend JJ, Boldrey EB. Radiation therapy of meningiomas. Am J Roentgen01 Radium Ther Nucl Med 1975;123:453-8.

COMMENTARY The presentation

(A) Right ophthalmic angiogram before embolizaIa tion, early arterial phase. @) Right ophthalmic an-

by Terada et al focuses on a major problem for the neurosurgeon treating these lesions: uncontrolled blood loss. When the principal blood supply is by ophthalmic as well as other internal carotid branches, the reported technique may be quite worthwhile, particularly if the definitive surgical procedure follows soon after the embolization. A delay of several days tends to decrease the effectiveness of embolization, at least in our experience. Harry 0. Cole, M.D. Chesterfield, Missouri

giogram after embolization, early arterial phase. The tumor stain from the ophthalmic artery markedly reduced after the embolization.

cranial nerve function in therapeutic embolization. AJNR 1986;7:105-8. 5. Jaaskelainen J, Servo A, Haltia M, Wahlstrom T, Valtonen S. Intracranial hemangiopericytoma: radiology, surgery, radiotherapy, and outcome in 21 patients. Surg Neurol 1985;23:227-36. 6. Jellinger K, Slowik F. Histological subtypes and prognostic problems in meningiomas. J Neurol 1975;208: 279-98.

E

VERYONE

PUSHES

It is a challenge to superselectively catheterize the ophthalmic artery and to advance into the feeder beyond the origin of the central artery to the retina. In this scenario, the choice of embolic agent was correct. They used Gelfoam powder, particles of PVA, and microcoils. Liquid embolic agents would have been more dangerous to use.

A FALLlNG

Gerard Debrun, M.D. Chicago, Illinois

FENCE. CHINESE

PROVERB