Comparison of embolic agents in preoperative embolization for intracranial meningiomas: multicenter adjusted analysis of 275 cases.

in Journal of neurointerventional surgery by Julio Isidor, Rahim Abo Kasem, Mohammad-Mahdi Sowlat, Conor Cunningham, Michael Levitt, Margaret McGrath, Christopher S Ogilvy, Omar Alwakaa, Alexandra R Paul, Matthew Cullen, Isaac Josh Abecassis, Ahmad Alhourani, Isabel Fragata, Mariana Baptista, Ali Alaraj, Mpuekela Tshibangu, Fazeel Siddiqui, Elyza Larson, Marios-Nikos Psychogios, Aikaterini Anastasiou, Ramesh Grandhi, Santiago Gomez-Paz, Clemens Schirmer, Prateeka Koul, Syed Uzair Ahmed, Jack Su, Mohamad Ezzeldin, Alejandro M Spiotta, Ben A Strickland

TLDR

  • A study comparing three embolic materials for preoperative embolization of meningiomas found that Onyx reduced estimated blood loss, surgery duration, and increased gross total resection rates, suggesting its potential as a more effective embolic material.
  • The study's findings have implications for the treatment of meningiomas and highlight the need for further investigation and validation of embolic materials and patient selection factors.

Abstract

Preoperative embolization has been used for intracranial meningiomas for nearly 40 years with varying preferences for embolic materials and limited comparative data on their efficacy. Consecutively treated patients from 2013 until 2023 who underwent preoperative embolization for meningioma from 12 centers across North America and Europe were included and classified by embolic material: (1) particles, (2) Onyx, and (3) coils. Primary outcomes included estimated blood loss (EBL), procedural complications, surgery duration, gross total resection (GTR), unplanned rescue surgery, modified Rankin Scale (mRS), and mortality. After unmatched analysis. Propensity score matching (PSM) subgroup analyses compared each pair of embolic materials, controlling for age, sex, body mass index, smoking, comorbidities, prior surgery, pre-treatment antithrombotics, WHO grade, tumor location, maximal diameter, and baseline mRS. A total of 275 patients (median age 47 years, 62.9% female) underwent preoperative embolization for meningioma. The mean maximum tumor diameter was 32.9±10.1 mm, with 61.1% classified as WHO I. Onyx was most frequently used 117 (42.5%), followed by particles 107 (38.9%), and coils (18.5%). Unmatched analysis revealed that Onyx was significantly associated with reduced EBL, surgery duration, and increased GTR, while decreasing unplanned rescue surgeries compared to particles and coils. PSM produced 89, 48, and 44 matched pairs for Onyx vs. Particles, Particles vs. Coils, and Onyx vs. Coils, respectively. Onyx demonstrated significant reductions against Particles in EBL (250 mL vs. 350 mL, P = 0.011) and surgical time (291 min vs. 403 min, P < 0.001), and against Coils in EBL (250 mL vs. 400 mL, P = 0.012) and surgical time (255 min vs. 347 min, P = 0.002). Onyx also showed higher rates of gross total resection compared to Particles (80.9% vs. 56.2%, P = 0.021) and Coils (88.6% vs. 56.8%, P = 0.002). No significant differences were observed in blood transfusion requirements, embolization-related complications mRS, or mortality rates across all comparisons. Onyx, a liquid embolic agent, reduces EBL which may explain the shorter surgery duration, higher GTR rates, and lower retreatment rates. Procedural risks and patient selection require further investigation.

Overview

  • The study aimed to compare the efficacy of three embolic materials used for preoperative embolization of intracranial meningiomas: particles, Onyx, and coils.
  • The study's primary objective was to evaluate the effect of these embolic materials on estimated blood loss, procedural complications, surgery duration, and gross total resection rates.
  • The study included 275 patients who underwent preoperative embolization from 12 centers across North America and Europe between 2013 and 2023.

Comparative Analysis & Findings

  • Onyx was significantly associated with reduced estimated blood loss, surgery duration, and increased gross total resection rates compared to particles and coils.
  • Onyx demonstrated significant reductions in estimated blood loss and surgery duration compared to both particles and coils.
  • Onyx also showed higher rates of gross total resection compared to both particles and coils.

Implications and Future Directions

  • The study's findings suggest that Onyx may be a more effective embolic material for preoperative embolization of meningiomas, leading to reduced blood loss and surgery duration.
  • However, the study's limitations, including the small sample size and lack of control over patient selection, require further investigation and validation.
  • Future studies should explore the procedural risks and patient selection factors to determine the optimal use of Onyx and other embolic materials in meningioma treatment.
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