Comparison of Middle Meningeal Artery Embolization Alone, in Combination With Surgery, and Surgery Alone for Chronic Subdural Hematoma: A Network Meta-Analysis of 143,590 Patients Publisher Pubmed



A Soltani Khaboushan ALIREZA ; Ps Pichardorojas Pavelsalvador SALVADOR ; Ah Zare Amir HOSSEIN ; A Kamroo AMIRHOSSEIN ; A Moeinafshar AYSAN ; Ct Hooper Camila TERAN ; Yl Esquenazi Yoshua L ; Ah Siddiqui Adnan HUSSAIN ; Ln Rangelcastilla Leonardo N
Source: Neurosurgical Review Published:2025

Abstract

Chronic subdural hematoma (cSDH) is associated with high recurrence following surgical evacuation. Middle meningeal artery embolization (MMAE) has emerged as a minimally invasive alternative or adjunct to surgery. This study aimed to compare the clinical effectiveness of standalone MMAE, adjunct MMAE, and surgical drainage alone for managing cSDH. A systematic review was conducted across major databases. Outcomes of interest included recurrence, rescue surgery, hematoma resolution, complications, functional outcome (mRS > 2), hospital stay, and mortality. Following screening, thirty-four studies (6 randomized trials) comprising 143,590 patients were included. A Bayesian network meta-analysis (NMA) was conducted on extracted data. Both standalone and adjunct MMAE reduced recurrence (OR = 0.12, 0.28, respectively) and need for rescue surgery (OR = 0.36, 0.37, respectively) compared to surgery alone in Bayesian NMA. Baseline characteristics were largely comparable across groups. While pairwise analysis showed standalone MMAE associated with greater hematoma reduction (OR = 1.46) and fewer complications (OR = 0.79), Bayesian NMA showed no significant difference. No significant differences were found in functional outcome, resolution, hospital stay, or mortality. Subgroup analysis on randomized trials confirmed adjunct MMAE reduced rescue surgery (P < 0.001) but not recurrence (P = 0.53). Both standalone and adjunctive MMAE reduce recurrence risk in cSDH compared to surgery alone. Standalone MMAE reduces complications and hematoma volume, making it suitable for nonsurgical candidates or smaller hematomas. Adjunct MMAE is effective in reducing reintervention risk and may be preferred when immediate surgical evacuation is necessary. MMAE, as a standalone or combined approach, represents a valuable strategy in cSDH management that helps minimize recurrence. © 2025 Elsevier B.V., All rights reserved.