Bland embolization for meningioma treatment shows safety and symptom improvement

Introduction A 2005 review proposed that definitive endovascular embolization may serve as primary therapy for select meningiomas, yet most subsequent work has addressed preoperative use. As minimally invasive options expand, we revisited the evidence for “bland” embolization used as a stand‐alone treatment and focused on vascular targets, embolic agents, outcomes, and safety. Methods We reviewed peer‐reviewed reports in which intracranial meningiomas were treated primarily with embolization. Studies were eligible when embolization was the intended or de facto definitive therapy. Extracted variables included embolic material, target vessels, technical and imaging success, symptom change, complications, and additional therapy. Results Eleven articles encompassing twenty‐seven patients met criteria. The middle meningeal artery (MMA) was embolized in twenty‐four patients (89%): unilateral in ten, bilateral in one, selectively in distal end‐branches in two, proximal in one, and in combination with internal‐carotid feeders in two. Three cases involved non‐MMA targets, the ophthalmic and ascending pharyngeal arteries, the occipital‐mastoid branch, and the lateral posterior choroidal artery. Agents included trisacryl gelatin microspheres (100‐300 μm), polyvinyl alcohol particles (50‐300 μm), n‐butyl cyanoacrylate, Onyx, and coils in one case. Technical success was achieved in all patients (27/27). Immediate or early angiography/MRI showed near‐total devascularization in 21/27 (78%), with early tumor volume decreases of 10‐23% and edema reductions of 10‐80%. During follow‐up of three to forty‐eight months, all tumors regressed or stabilized; shrinkage ranged from 10% to 81%. Two lesions nearly involuted within twenty‐four months, and only one displayed marginal regrowth managed with radiosurgery. Among twenty‐two symptomatic patients, symptoms improved or were nearly resolved: headaches in seven, motor deficits in six of six, seizures were controlled in four, and reported cognitive, behavioral, or gait disturbances normalized. Several individuals returned to independent living or work, including one patient who was comatose from her hemorrhagic menignioma. Three asymptomatic tumors remained clinically silent. No procedure‐related neurological complications occurred (0/27). Adjunct therapy was minimal: one brief steroid course for edema and one elective delayed resection despite ongoing shrinkage. Discussion Definitive embolization produced durable radiographic control and consistent symptom relief without periprocedural morbidity. Most lesions behaved radiographically like World Health Organization grade I disease, yet benefit was also observed in a hemorrhagic presentation when the family declined craniotomy, suggesting a role in select emergencies. Collectively, the data support embolization as a pragmatic stand‐alone option when patients are poor surgical candidates because of age, comorbidity, or unfavorable location or when patients decline craniotomy. Favorable anatomy includes dominant external‐carotid supply, most commonly the MMA, with limited pial or internal‐carotid feeders. Although materials varied, overall clinical benefits were similar. Conclusion Definitive endovascular embolization appears safe and potentially effective for carefully selected meningiomas, offering durable control and symptom improvement for patients who might otherwise face high‐risk or unwanted surgery. Evidence remains limited by small, heterogeneous series, publication biases, and intrinsic selection (survivorship) bias and short follow‐up. Prospective studies should define selection criteria, compare against radiosurgery and observation, and optimize embolic strategy. Reporting standardized imaging and patient‐centered outcomes will be essential for adoption and reimbursement.