Adjunct Middle Meningeal Artery Embolization Chronic Subdural Hematoma: a Meta-analysis to Guide Surgical Decision Making
Adeena Musheer1, Ali Israr Ahmed2, Sana said3, Usman Arshad4, Aqsa Amjad5, Huzaifa Nawaz6, Muhammad Hassan Abbas Khan7, Muneeb Ur Rehman8, Syed Tehseen Haider9, Hafiz Sohail Ashraf10
1Dow Medical College, Dow University of Health Sciences, 2Bahria University medical and dental college, 3saidu medical college, swat, Pakistan, 4Ziauddin University, 5Aga Khan University, 6Services Institute of Medical Sciences (SIMS), Ghaus-ul-Azam Jail Road, Lahore, Pakistan 54000, 7Khawaja Muhammad safdar medical college,Sialkot, 8Khawaja Muhammad Safdar Medical College, Sialkot, 9Shifa International Hospital Islamabad, 10Carle foundation Hospital Urbana Illinois
Objective:
To compare the efficacy and safety of middle meningeal artery embolization (MMAE) as a standalone therapy or adjunct to surgery versus conventional surgery for chronic subdural hematoma (cSDH).
Background:
Chronic subdural hematoma (cSDH) is a common neurosurgical condition in older adults. Burr-hole drainage remains standard, but recurrence rates of 9–33% highlight the need for better strategies. Middle meningeal artery embolization (MMAE) has emerged to reduce recurrence. This study evaluates safety, feasibility, and efficacy of MMAE as standalone or adjunctive treatment to guide practice and guidelines.
Design/Methods:
We searched PubMed, MEDLINE, and EMBASE through June 2025. Randomized and observational studies in adults with cSDH reporting outcomes were eligible. Random-effects meta-analyses pooled RR or MD with 95% CIs; heterogeneity used I². Subgroups examined intervention type, design, hematoma thickness; sensitivity and meta-regression were performed.
Results:
Eighteen studies (n=25,663; 2,468 MMAE; 23,195 surgery) met criteria. Primary outcome was recurrence of cSDH. MMAE significantly reduced recurrence compared to surgery (RR 0.37, 95% CI 0.27–0.51; I² 50.5%; p<0.001). Benefit was seen with adjunct MMAE (RR 0.29, 95% CI 0.22-0.39; I² 0%) and standalone MMAE (RR 0.33, 95% CI 0.12-0.91; I² 60.7%); no subgroup difference (p=0.74). Across hematoma thickness <20 mm and ≥20 mm, effects were directionally consistent without significant interaction (p=0.147). Secondary outcome was mortality which did not differ between groups (RR 0.76, 95% CI 0.36-1.60). Complications were similar (RR 1.15, 95% CI 0.70-1.88). Length of stay showed a nonsignificant increase with MMAE (MD +2.88 days, 95% CI -1.68 to +7.44). Overall certainty ranged from low to moderate.
Conclusions:
This meta-analysis of 25,000+ patients, including recent randomized trials through 2025, provides strong evidence that MMAE, adjunctive or standalone, significantly reduces cSDH recurrence without increasing mortality or complications. Comparing both strategies and stratifying by hematoma thickness shows consistent benefit, establishing MMAE as a paradigm-shifting, minimally invasive therapy.
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