Efficacy of middle meningeal artery embolization combined with surgery versus standalone surgery for chronic subdural hematoma: a comprehensive systematic review and Meta-Analysis with separate analysis of randomized controlled trials

Authors

• Ibrahim Mohammadzadeh, Skull Base Research Center, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran, Tehran, Iran, Islamic Republic of. Ibrahim.mdz7777@gmail.com.
• Bardia Hajikarimloo, Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA, Virginia, United States.
• Amirhossein Zare, Neurology Department, Tehran university of medical sciences, Tehran, Iran, Tehran, Iran, Islamic Republic of.
• Shahin Mohammadzadeh, Skull Base Research Center, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran, Tehran, Iran, Islamic Republic of.
• Pooya Eini, Cardiovascular Research Center, Rajaie Cardiovascular Institute, Tehran, Iran, Tehran, Iran, Islamic Republic of.
• Saba Aghajani, Department of Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran, Tehran, Iran, Islamic Republic of.
• Ali Mortezaei, Student Research Committee, Gonabad University of Medical Sciences, Gonabad, Iran, Gonabad, Iran, Islamic Republic of.
• Mohammad Amin Habibi, Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran, Tehran, Iran, Islamic Republic of.
• Kivanc Yangi, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States, Arizona, United States.
• Ahmet Günkan, Department of Radiology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey, Istanbul, Turkey.
• Pascal Jabbour, Thomas Jefferson University, Neurological Surgery, Philadelphia, PA, US, Philadelphia, United States. Pascal.Jabbour@jefferson.edu.

Document Type

Article

Abstract

BACKGROUND: Chronic subdural hematoma (CSDH) is a prevalent neurosurgical condition with high recurrence rates after standard surgical evacuation. Middle meningeal artery embolization (MMAE) has emerged as a potential adjunct to reduce recurrence by targeting the vascular supply of neomembranes. OBJECTIVE: To evaluate the efficacy and safety of MMAE combined with surgery versus standalone surgical evacuation in patients with CSDH, through a comprehensive systematic review and meta-analysis, including separate analysis of randomized controlled trials (RCTs). METHODS: A systematic search of PubMed, Scopus, Web of Science, Embase, and Google Scholar was performed through March 2025. Dual-arm studies comparing MMAE plus surgery with surgery alone were included. Outcomes of interest were recurrence, complications, all-cause mortality, and functional outcome (modified Rankin Scale ≤ 2; mRS ≤ 2). Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were estimated using a random-effects model. Bias and evidence certainty were assessed via RoB tools and GRADE. RESULTS: Twenty-five studies (6 RCTs, 19 observational) comprising 119,812 patients were included. MMAE plus surgery significantly reduced recurrence (RR = 0.47, 95% CI: 0.36-0.62, p < 0.001; I² = 3.0%), without increasing complications (RR = 1.02, 95% CI: 0.8-1.3) or mortality (RR = 0.98, 95% CI: 0.72-1.33) compared with surgery alone. Functional outcomes were similar between both approaches (RR = 1.07, 95% CI: 0.93-1.23). Subanalysis of RCTs, was consistent with overall analysis showing a significant reduction in recurrence (RR = 0.44, 95% CI: 0.25-0.78) with MMAE plus surgery, without an increase in complications or mortality compared to surgery alone. CONCLUSION: MMAE as an adjunct to surgery significantly lowers recurrence in CSDH. No significant differences in complications, mortality, or functional outcomes were detected compared with surgery alone; however, these outcomes are less common, and available studies may not have been adequately powered to exclude small but clinically meaningful effects.

Medical Subject Headings

Humans; Combined Modality Therapy; Embolization, Therapeutic (methods); Hematoma, Subdural, Chronic (therapy, surgery); Meningeal Arteries; Neurosurgical Procedures (methods); Randomized Controlled Trials as Topic; Recurrence; Treatment Outcome

Publication Date

10-1-2025

Publication Title

Neuroradiology

E-ISSN

1432-1920

Volume

67

Issue

10

First Page

2897

Last Page

2919

PubMed ID

41099761

Digital Object Identifier (DOI)

10.1007/s00234-025-03777-w

Recommended Citation

Mohammadzadeh, Ibrahim; Hajikarimloo, Bardia; Zare, Amirhossein; Mohammadzadeh, Shahin; Eini, Pooya; Aghajani, Saba; Mortezaei, Ali; Habibi, Mohammad Amin; Yangi, Kivanc; Günkan, Ahmet; and Jabbour, Pascal, "Efficacy of middle meningeal artery embolization combined with surgery versus standalone surgery for chronic subdural hematoma: a comprehensive systematic review and Meta-Analysis with separate analysis of randomized controlled trials" (2025). Neurosurgery. 2352.
https://scholar.barrowneuro.org/neurosurgery/2352