Pre-operative embolization of skull base meningiomas

Skull base meningiomas are challenging tumors to resect and confer a high risk of surgical morbidity due to their location in deep-seated regions of the cranium. These tumors can have robust and variable blood supply from branches of the internal and external carotid artery, as well as from posterior circulation vasculature, and may have anastomotic connections that supply cranial nerves. If tumoral blood supply cannot be readily accessed early during surgery, pre-operative embolization may be considered in select cases to facilitate subsequent surgical resection. However, the indications and purported utility of pre-operative embolization are wide-ranging and are influenced by individual surgeon preference. Furthermore, the reported risks of pre-operative embolization are varied. In this review, we provide an overview of the indications and outcomes from pre-operative embolization of skull base meningiomas, discuss the various embolic materials available for use and their associated risks and benefits, and review relevant vascular anatomy as it pertains to the blood supply of skull base meningiomas. Based on the literature, we recommend selective use of pre-operative embolization for skull base meningiomas identified as hypervascular on imaging or when the chosen surgical approach limits the possibility of early devascularization.