Enhancing Outcomes in Subdural Hematoma: The Role of Middle Meningeal Artery Embolization.

Abstract

Chronic subdural hematoma (cSDH) is a prevalent neurosurgical condition with increasing incidence, especially among the elderly. The pathophysiology of cSDH is multifactorial, involving inflammation, fibrinolysis, and angiogenesis, with fragile neovascularization contributing to recurrent microbleeding and hematoma persistence. While burr-hole evacuation remains a standard surgical approach, recurrence rates remain high, necessitating adjunctive strategies such as subdural drain placement, subdural-peritoneal shunting, and pharmacologic interventions. Middle meningeal artery embolization (MMAE) has emerged as a promising adjunctive therapy for cSDH by targeting the abnormal neovascularization of the dura and within the hematoma's outer membrane. In this meta-analysis, we pooled data from 4 recent clinical trials (EMBOLISE, STEM, MAGIC-MT, and MEMBRANE) to evaluate MMAE's efficacy and safety. Our results demonstrate that MMAE plus usual care significantly reduces recurrence or residual cSDH compared with standard care alone (RR = 0.56, P = 0.001), and is associated with lower mortality (RR = 0.54, P = 0.03). No significant differences were observed in functional outcomes, serious adverse events, or major disabling stroke. These findings highlight MMAE as an effective adjunct in cSDH management. Future studies should aim to further assess long-term outcomes and cost-effectiveness, as well as refine the optimal patient selection criteria for MMAE.