Middle meningeal artery embolisation reduces chronic subdural haematoma recurrence: A meta-analysis of EMBOLISE, STEM, MAGIC-MT and EMPROTECT trials and cost analysis

Objective

To assess the effectiveness and cost implications of middle meningeal artery embolisation (MMAE) in reducing recurrence of chronic subdural haematoma (CSDH) requiring surgery, through a meta-analysis of the four largest randomized controlled trials (RCTs) published to date.

Methods

A systematic review and meta-analysis were conducted on four RCTs (EMBOLISE, STEM, MAGIC-MT, EMPROTECT) comparing MMAE to standard treatment in adult patients with CSDH. The primary outcome was recurrence requiring surgery. Secondary outcomes included modified Rankin Scale (mRS) at follow-up, mortality, adverse events, and hospital stay. A United Kingdom-based cost analysis was performed using National Health Service (NHS) payment tariffs and institutional estimates to evaluate economic viability.

Results

MMAE significantly reduced recurrence requiring surgery (pooled risk ratio [RR]=0.40, 95 % CI: 0.28–0.58; p < 0.00001). No significant differences were found in mortality (RR 0.94, p = 0.85), serious adverse events (RR 0.92, p = 0.47), or functional independence at follow-up (OR 0.97, p = 0.88). The estimated number needed to treat was 15. Cost analysis showed that while MMAE could prevent 53 surgical recurrences in a historical cohort of CSDH patients from the United Kingdom, it could incur a net loss of £ 1.6–1.9 million under current NHS tariffs.

Conclusion

MMAE is effective and safe in reducing CSDH recurrence but is not currently cost-effective for universal use in the NHS. Selective use in high-risk patients and cost-reduction strategies may enhance its economic viability.