Preoperative embolization in intracranial meningioma surgery: An updated systematic review and meta-analysis

Background: Intracranial meningiomas are vascular tumors often causing significant intraoperative blood loss. Preoperative embolization (POE) aims to reduce vascularity and improve outcomes, though its efficacy is debated. This systematic review and meta-analysis evaluate the impact of POE on operative and postoperative outcomes in intracranial meningioma surgery. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a literature search from 2017 to 2025 identified 13 English-language, non-randomized studies comparing POE to no embolization. Outcomes included intraoperative blood loss, operative time, extent of resection, complications, and tumor recurrence. Due to heterogeneity, a meta-analysis was performed where possible, supplemented by a narrative synthesis. Risk of bias assessment was performed. Results: Meta-analysis revealed that POE significantly reduced complications (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.53-0.88) and increased the likelihood of achieving gross total resection (GTR) (pooled OR 0.61, 95% CI 0.46-0.80). In contrast, findings on intraoperative blood loss and operative time were highly inconsistent with extreme heterogeneity. Tumor recurrence data were extremely limited, reported in only on study, precluding synthesis on long-term outcomes. Significant methodological variability was identified. Conclusion: POE consistently improves the likelihood of achieving GTR in intracranial meningiomas. However, its benefits in reducing intraoperative blood loss and operative time remain inconsistent. Neurosurgeons should consider POE when maximal resection is the primary surgical goal, especially for highly vascular tumors. Future research requires robust designs, such as matched-cohort studies or randomized controlled trials, to definitively establish its precise role.