Date Published: April 9, 2019
Publisher: Public Library of Science
Author(s): Ulf Jensen-Kondering, Michael Helle, Thomas Lindner, Olav Jansen, Arya Nabavi, Jonathan H. Sherman.
Intracranial meningiomas may be amenable to presurgical embolization to reduce bleeding complications. Detailed information usually obtained by digital subtraction angiography (DSA) on the contribution of blood supply from internal and external carotid artery branches is required to prevent non-target embolization and is helpful for pre-surgical planning.
To investigate the contribution of the feeding vasculature to intracranial meningiomas with superselective arterial spin labelling (sASL) as an alternative to DSA.
Consecutive patients presenting for meningioma resection were prospectively included. sASL perfusion images acquired on a clinical 3T MRI scanner were independently rated by two readers. Contribution of the external carotid artery (ECA), internal carotid artery (ICA) and vertebral/basilar artery (VA/BA) was rated as none, <50% or >50%. Correlation of sASL was performed in two patients undergoing DSA.
32 patients (61 ± 13 years) harboring 42 meningiomas could be included. sASL was technically successful in all patients. 19 meningiomas had ICA dominant supply, 19 had ECA dominant supply. One meningioma had mixed supply and in three meningiomas a perfusion signal could not be detected. While exclusive unilateral ECA supply was common (n = 14) and exclusive unilateral ICA was rare (n = 4), mixed supply from multiple vessels (n = 20) was a frequent finding. Interrater agreement was substantial (κ = 0.73). Agreement with DSA was perfect within our predefined categories.
sASL is able to identify the presence and extent of the feeding vasculature in intracranial meningiomas.
Meningiomas are the most common benign tumors of the central nervous system. Although malignant meningiomas and malignant transformation are rare, space occupying or symptomatic meningiomas may require resection . Meningiomas are richly vascularized lesions and thus are amenable to presurgical embolization to reduce bleeding complications . Detailed information on the contribution of blood supply from internal and external carotid artery branches are helpful for pre-surgical planning and required to prevent non-target embolization . This is usually obtained by digital subtraction angiography (DSA). However, DSA utilizes ionizing radiation and iodinized contrast agent. Further, DSA is an invasive procedure and bears the risk of stroke, hemorrhage and vessel perforation .
32 patients (29 females, 3 males, age 61 ± 13 years) were prospectively included. One patient was excluded due to histological diagnosis of metastatic disease. The remaining patients were harboring a total of 42 (median 1, range 1–7) intracranial tumors. 31 meningiomas could be histologically confirmed. In cases histology was not obtained (n = 11) image appearance of the tumors was consistent with meningioma (dural based well defined mass, isointense to gray matter on T1w and T2w images, intense homogenous enhancement, hyperostosis or calcifications on CT). Mean tumor volume was 43 ± 53 cm3 (range 0.35 to 231 cm3). For tumor location and size see Table 1.
We could demonstrate the feasibility of superselective ASL in patients with intracranial meningiomas to identify the feeding vasculature. Although one previous study already used this approach  our study was the first to incorporate a semiquantitative approach to quantify the extent of supply of different feeding vessels.
Superselective ASL allows semiquantitative depiction of blood supply to intracranial meningiomas. It may serve as a screening method for patients who may benefit from DSA and embolization. It may also be of special interest in future MR guided invasive embolization procedures . More validation against DSA in larger cohorts of patients is necessary.