Neurosurgery 98:303–317, 2026
This meta-analysis evaluates whether adding middle meningeal artery embolization (MMAE) to surgical evacuation improves outcomes in patients with chronic subdural hematoma (CSDH).
Key Insights and Themes
Chronic subdural hematoma (CSDH) is a common neurological disorder with high recurrence rates after surgical evacuation, ranging from 2% to 37%.
Middle meningeal artery embolization (MMAE) has emerged as an adjunct or alternative to surgery, aiming to reduce CSDH recurrence by targeting the vascular supply of the hematoma membranes.
Systematic review and meta-analysis included 17 studies (1814 patients; 939 MMAE+S, 1440 S), comprising randomized trials, matched, and unmatched cohorts, with a mean follow-up of 3 months.
Baseline comparability between MMAE+S and surgery-alone groups was achieved except for higher antithrombotic use in the MMAE+S group (34.9% vs 22.4%).
Recurrence rates were significantly lower in the MMAE+S group compared to surgery alone (4.7% vs 17.7%; relative risk [RR] 0.31, P < .01), a benefit confirmed in randomized and matched studies.
Radiological outcomes (postoperative hematoma thickness, volume, and midline shift) were all significantly reduced in the MMAE+S group.
Functional outcomes, complications, mortality, and hospital stay were similar between groups, indicating no increased risk with adjunctive MMAE.
Timing of embolization affected outcomes: postoperative MMAE was associated with lower recurrence, while preoperative MMAE did not show significant benefit.
Embolic agent selection mattered: liquid embolic agents (e.g., Onyx, Squid) led to better outcomes than particles, with recurrence reduction seen only with liquid agents.
Antithrombotic use, a known risk factor for recurrence, was higher in the MMAE+S group, yet recurrence rates remained lower, suggesting a robust effect of adjunctive MMAE.
Surgical technique variability (burr-hole craniostomy, craniotomy, twist-drill) existed across studies, potentially influencing heterogeneity in outcomes.
Complication rates were low and comparable between groups; most complications were minor, and serious adverse events were rare.
Length of hospital stay did not differ significantly between groups, though some previous studies suggested longer stays with MMAE+S, possibly due to worse initial clinical status.
Cost-effectiveness may favor MMAE+S in the long term, as reduced recurrence and reoperation rates can offset higher initial costs.
Ongoing clinical trials (e.g., CHESS, MEMBRANE, EMPROTECT) are expected to clarify optimal timing, patient selection, and cost-effectiveness of adjunctive MMAE.
Limitations include heterogeneity in surgical and embolization techniques, retrospective study designs, and reliance on aggregate rather than individual patient data.
Areas for future research include optimal timing and materials for MMAE, patient selection, and cost-benefit analyses.
Conclusion
Adjunctive MMAE with surgical evacuation significantly reduces CSDH recurrence and improves radiological outcomes without increasing complications or mortality, supporting its use in high-risk patients.
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