ORCID

Abstract

Background: Middle Meningeal Artery Embolization (MMAE) has been proposed as adjunct and stand-alone treatment for Chronic Subdural Hematoma (CSDH). We aimed to meta-analyze three recently published randomized controlled trials, to reliably estimate the effect of MMAE. We also carried out a systematic review of ongoing trials and their key outcomes. Methods: A PRISMA-compliant meta-analysis was conducted (PROSPERO ID CRD42024618816). Three published RCTs (MAGIC-MT, EMBOLISE, and STEM) assessing MMAE in CSDH were included. Trial primary outcomes were pooled for analysis using random effects models. Primary and secondary outcomes (recurrence/surgical rescue, functional outcome) were obtained, stratified by treatment group (undergoing surgery, and nonsurgical management). A descriptive review of trials in public registries was also conducted (search date 30th November 2024). Results: In total, 1432 patients were included from three trials in meta-analysis. Overall, MMAE reduced symptomatic progression or recurrence, but was not statistically significant (RR 0.50, 95% CI 0.23–1.06, P = 0.058). For the group undergoing surgery, MMAE was not associated with reduced recurrence (RR 0.60, 95% CI 0.19–1.88, P = 0.194). For nonsurgical management, MMAE reduced progression (RR 0.36, 95% CI 0.22–0.60, P < 0.001). MMAE did not influence functional outcome (RR 1.01, 95% CI 0.97–1.04, P = 0.790). From the literature search, there are twenty-one registered trials. Nineteen studies include arms assessing MMAE as an adjunct to surgery, eleven compare MMAE to observation, and four with surgery. The most common primary outcome is recurrence (47.8%, N = 11), either radiologically, or requiring a second surgery. Inclusion criteria, embolization agents, primary and secondary outcomes differed significantly between studies. Conclusions: In this meta-analysis of three randomized controlled trials, the use of MMAE in patients undergoing surgery did not appear to significantly reduce recurrence or improve functional outcomes, but did reduce progression in nonsurgical cohorts. Further studies assessing these cohorts are ongoing.

Publication Date

2025-06-10

Publication Title

Acta Neurochirurgica

Volume

167

Issue

1

ISSN

0001-6268

Acceptance Date

2025-06-02

Deposit Date

2025-12-02

Funding

CSG is supported by an NIHR Academic Clinical Fellowship. WHC is supported by a Woolf Fisher Scholarship from the Woolf Fisher Trust of New Zealand and Cambridge Commonwealth, European & International Trust and by Christ’s College, Cambridge. PJH is supported by the NIHR (Senior Investigator Award, NIHR Global Health Research Group on Acquired Brain and Spine Injury, NIHR Health Tech Research Centre for Brain Injury, Cambridge Biomedical Research Centre). AGK is supported by the NIHR (Cambridge BRC, Health Technology Assessment program, NIHR Global Health Research Group on Acquired Brain and Spine Injury (ref: NIHR132455)), the Royal College of Surgeons of England and the Wellcome Trust (ISSF Fund).

Keywords

Chronic subdural hematoma, MMAE, Middle meningeal artery embolization, Recurrence, Hematoma, Subdural, Chronic/therapy, Meningeal Arteries, Humans, Treatment Outcome, Embolization, Therapeutic/methods, Randomized Controlled Trials as Topic

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