Tag: Surgical evacuation

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Added Value of Adjunctive Middle Meningeal Embolization to Surgical Evacuation for Chronic Subdural Hematoma: Comprehensive Meta-Analysis Based on Controlling Confounders

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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Middle Meningeal Artery Embolization in Adjunction to Surgical Evacuation for Treatment of Subdural Hematomas

Neurosurgery 93:1082–1089, 2023

Surgical evacuation is the standard treatment for chronic subdural hematomas (CSDHs) but is associated with a high risk of recurrence and readmission. Middle meningeal artery embolization (MMAE) is a novel treatment approach which could be performed upfront or in adjunction to surgical evacuation. MMAE studies are limited by small sample sizes. This study aimed to describe and compare outcomes of MMAE in adjunction to surgery with those of surgery alone on a national level.

METHODS: The national Vizient Clinical Database was queried by use of a specific validated set of International Classification of Diseases, Tenth Revision codes (October 2018-June 2022). Patients with the diagnosis of nontraumatic CSDH who received MMAE and surgical drainage in the same hospitalization were identified, and their outcomes were compared with isolated surgical drainage.

RESULTS: A total of 606 subjects from 156 institutes and 6340 subjects from 369 institutes were included in the MMAE plus surgery (M&S) and surgery groups, respectively. Average length of stay was significantly longer in the M&S group (9.87 vs 7.53 days; P < .01). There was no significant difference in the in-hospital mortality rate (2.8% vs 2.9%), but the complication rate was significantly higher in the M&S group (8.7% vs 5.5%; P < .01). Complications that were significantly more common in the M&S group included aspiration pneumonia, postoperative sepsis, and anesthesia-related. Mean direct costs were significantly higher in the M&S group (28 834 vs 16 292 US dollars; P < .01). The 30-day readmission rate was significantly lower in the M&S group compared with the surgery group (4.2% vs 8.0%; P < .01).

CONCLUSION: This analysis of large-scale national data indicates that MMAE performed in adjunction to surgery for treatment of CSDH is associated with higher direct costs, higher complication rates, and longer length of stay but lower readmission rates compared with surgical evacuation alone.

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Surgical management of spontaneous intracerebral hemorrhage: insights from randomized controlled trials

Neurosurgical Review (2020) 43:999–1006

Spontaneous intracerebral hemorrhages (ICH) are a major cause of neurologic morbidity and mortality. The optimal management strategy of ICH remains controversial.

We examine the available randomized controlled trial (RCT) data regarding neurosurgical evacuation of ICHs. A systematic literature review on surgical evacuation of spontaneous ICHs was performed to identify pertinent RCT data published between 1980 and 2019.

We identified five RCTs that assessed the clinical impact of evacuation of spontaneous ICHs. Data from two high-quality RCTs randomizing 1033 and 601 patients with spontaneous ICHs (Surgical Trial in Intracerebral Hemorrhage (STICH) I and II) (1) failed to demonstrate a significant clinical benefit of routine open surgical evacuation of spontaneous cortical ICHs and (2) reinforced the high morbidity and mortality associated with ICH. These trials were nonetheless limited by high (> 20%) crossover from the medical to surgical arms. Data from three smaller RCTs on minimally invasive (stereotactic and endoscopic) surgical approaches randomizing 377, 242, and 100 patients with spontaneous ICHs suggest potential benefits relating to mortality and functional outcomes in patients with subcortical ICHs.

While these RCTs do not clearly define the role of surgical resection for ICHs, they provide insights into opportunities for patient advocacy, clinical trial design, and future research studies. Ongoing studies building upon the potential for minimally invasive approaches for ICH evacuation may expand the surgical indications for ICH.

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