Preoperative Embolization for Tentorial and Subtentorial Tumors

Preoperative embolization of tentorial and subtentorial tumors represents a valuable adjunct to skull base surgery. Tentorial tumor resection can be challenging. However, brain tumors in the tentorial regions have a relatively complex angioarchitecture, and only a few studies have reported the safety and effectiveness of preoperative embolization for these tumors. This review examined the technical considerations and outcomes of 29 consecutive preoperative embolization procedures for tentorial tumors performed at our institution between September 2020 and August 2025. Tentorial tumors present unique challenges owing to their deep location, narrow surgical corridors, and complex angioarchitecture. The goal of embolization is to achieve tumor necrosis, as evidenced by the disappearance of contrast enhancement on postembolization MRI, which makes the tumor softer and less vascular during subsequent resection. We detail the technical approaches for embolization from the 3 main feeder categories: medial feeders (meningohypophyseal trunk [MHT] and inferolateral trunk [ILT]), lateral feeders (middle meningeal and occipital arteries), and inferior feeders (ascending pharyngeal artery [APA]). Technical success was achieved in 96.6% of cases (28/29), with embolization from the MHT or ILT in 53.6% of cases and APA in 21.4%. Multiple feeders were targeted in 46.6% of the cases. N-butyl cyanoacrylate was the predominant embolic agent (85.7%), followed by coils (39.3%) and particles (35.7%). Post-embolization neurological complications occurred in 2 cases (7.1%), both involving cranial nerve palsies. At least partial tumor necrosis was achieved in 60.7% of the cases, with complete disappearance of contrast enhancement in 10.7%. Our experience demonstrates that preoperative embolization of tentorial tumors can be performed effectively with acceptable risks in the context of highly complex procedures. When performed with appropriate technical expertise and detailed knowledge of functional vascular anatomy, it provides substantial benefits for subsequent surgical resection.