Standalone middle meningeal artery embolization vs. surgical evacuation in chronic subdural hematoma: A comprehensive systematic review and meta-analysis

Authors

• Ibrahim Mohammadzadeh, Skull Base Research Center, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Iran.
• Bardia Hajikarimloo, Department of Neurological Surgery, University of Virginia, USA.
• Sai Sanikommu, Department of Neurological Surgery, Radiology, Neurosciences, Pharmacology, University of Miami School of Medicine, USA.
• Amirhossein Zare, Neurology Department, Tehran University of Medical Sciences, Iran.
• Ali Mortezaei, Student Research Committee, Gonabad University of Medical Sciences, Iran.
• Saba Aghajani, Department of Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Iran.
• Ahmad Alagha, Skull Base Research Center, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Iran.
• Misagh Iranpour, Skull Base Research Center, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Iran.
• Mohammad Amin Habibi, Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Iran.
• Kivanc Yangi, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, USA.
• Seyed Ali Mousavinejad, Skull Base Research Center, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Iran.
• Farzan Fahim, Skull Base Research Center, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Iran.
• Adam A. Dmytriw, Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, USA.
• Redi Rahmani, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, USA.
• Vratko Himic, Department of Neurological Surgery, University of Miami Miller School of Medicine, USA.
• Ricardo J. Komotar, Department of Neurological Surgery, University of Miami Miller School of Medicine, USA.
• Khaled M. Taghlabi, Department of Neurological Surgery, Houston Methodist Hospital, USA.
• Amir H. Faraji, Department of Neurological Surgery, Houston Methodist Hospital, USA.
• Emade Jaman, Department of Neurological Surgery, Radiology, Neurosciences, Pharmacology, University of Miami School of Medicine, USA.
• Ahmed Abdelsalam, Department of Neurological Surgery, Radiology, Neurosciences, Pharmacology, University of Miami School of Medicine, USA.
• Ahmet Günkan, Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, University of Arizona, USA.
• Peter Kan, Department of Neurosurgery, University of Texas Medical Branch, USA.
• Jason P. Sheehan, Department of Neurological Surgery, University of Virginia, USA.
• Robert M. Starke, Department of Neurological Surgery, Radiology, Neurosciences, Pharmacology, University of Miami School of Medicine, USA.
• Pascal Jabbour, Neurological Surgery, Thomas Jefferson University, USA.

Document Type

Article

Abstract

BackgroundChronic subdural hematoma (cSDH) remains a prevalent neurosurgical condition in elderly patients, traditionally managed via surgical evacuation when symptomatic. Middle meningeal artery embolization (MMAE) has recently emerged as a minimally invasive alternative. However, the comparative efficacy and safety of standalone MMAE versus standalone surgical evacuation remain inadequately defined.MethodsA comprehensive search of PubMed, Scopus, Embase, and Web of Science, was performed on March 20, 2025. Studies comparing standalone MMAE and standalone surgical evacuation in patients with cSDH were included. The primary outcome was recurrence; secondary outcomes included complication and mortality rates. A random-effects pairwise meta-analysis model using restricted maximum likelihood (REML) was applied to account for between-study variability.ResultsTen studies encompassing 50,138 patients were included. Recurrence was significantly lower with MMAE (RR = 0.51, 95% CI: 0.33-0.80, p = .00), with no statistically detected heterogeneity (I = 0%), although clinical variability across studies cannot be excluded. Mortality (RR = 0.70, 95% CI: 0.44-1.12, p = .14) and complications (RR = 1.04, 95% CI: 0.67-1.64, p = .85) did not differ significantly between both groups. The GRADE assessment rated the certainty of evidence for recurrence as moderate, while the certainty for both mortality and complications were rated as very low, underscoring the need for further high-quality studies.ConclusionStandalone MMAE significantly reduces recurrence risk compared to surgical evacuation in cSDH patients, while showing no significant difference in mortality or complication rates. These findings highlight MMAE as a promising first-line treatment option, particularly for patients at high surgical risk. Prospective randomized trials are warranted to further validate these outcomes.

Publication Date

3-11-2026

Publication Title

The neuroradiology journal

E-ISSN

2385-1996

First Page

1.9714009261432e+16

PubMed ID

41811919

Digital Object Identifier (DOI)

10.1177/19714009261432000

Recommended Citation

Mohammadzadeh, Ibrahim; Hajikarimloo, Bardia; Sanikommu, Sai; Zare, Amirhossein; Mortezaei, Ali; Aghajani, Saba; Alagha, Ahmad; Iranpour, Misagh; Habibi, Mohammad Amin; Yangi, Kivanc; Mousavinejad, Seyed Ali; Fahim, Farzan; Dmytriw, Adam A.; Rahmani, Redi; Himic, Vratko; Komotar, Ricardo J.; Taghlabi, Khaled M.; Faraji, Amir H.; Jaman, Emade; Abdelsalam, Ahmed; Günkan, Ahmet; Kan, Peter; Sheehan, Jason P.; Starke, Robert M.; and Jabbour, Pascal, "Standalone middle meningeal artery embolization vs. surgical evacuation in chronic subdural hematoma: A comprehensive systematic review and meta-analysis" (2026). Neurosurgery. 2366.
https://scholar.barrowneuro.org/neurosurgery/2366