Yttrium-90 Radioembolization for Recurrent Meningioma: Rationale and Roadmap for Neurointerventional Translation

Background: Meningiomas are typically managed with surgery or radiotherapy, but recurrent or surgically inaccessible tumors present a persistent therapeutic gap, particularly for progressive higher grade disease. Intra-arterial yttrium-90 (90Y) transarterial radioembolization (TARE) is well established for hepatocellular carcinoma to deliver high dose, short range β-brachytherapy in the form of 20-60µm radioactive microspheres. This technology could plausibly be adapted to meningiomas, exploiting their dominant dural arterial supply. Methods: We performed systematic searches of PubMed and Google Scholar for literature directly addressing intracranial TARE planning or delivery, supplemented by a scoping review of adjacent fields: meningioma radionuclide therapy, peptide receptor radionuclide therapy (PRRT), hepatic TARE, bland meningioma embolization, and the radiobiology relevant to meningioma vascular behavior, dosimetry, hypoxia, and imaging. Results: Five studies and one ongoing clinical trial directly addressed intracranial TARE or its planning. Seventy-four supporting studies informed synthesis across meningioma embolization, vascular anatomy, hepatic TARE dosimetry and device characteristics, and foundational radiobiology. Currently two TARE platforms exist (glass and resin), with differences in dose-per sphere and physical density which may impact deliverability. The compartmentalized dural arterial supply of most meningiomas supports catheter-based access and may permit single-compartment dosimetry modeling, with generally low-to-moderate arterial shunting risk. The established but incomplete efficacy of radioligand therapies provides a biologic rationale for TARE, while underscoring the need for higher tumor radiation delivery, which early dosimetry work suggests may be achievable with TARE. Conclusions: TARE is a plausible treatment for recurrent and inoperable meningiomas due to their compartmentalized vascular supply. Four considerations should anchor early phase trial design: (1) microsphere platform selection between glass and resin spheres, with their differing embolic burden and dosimetric profiles; (2) whether to limit treatment to external carotid artery territories or include internal carotid artery supplied tumor; (3) compartmental dosimetric planning calibrated to meningioma angiosomes; and (4) a structured safety framework non-target deposition, peri-procedural risks, and delayed radiation necrosis.