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Adjunct middle meningeal artery embolization versus surgery alone for chronic subdural hematoma: A meta-analysis and
João Pedro Fernandes Gonçalves1, Gabriel Souza Medrado-Nunes1, Gabriel Teles de Oliveira Piñeiro1
1Federal University of Bahia, Av. Reitor Miguel Calmon, S/N - Vale do Canela, Zip code: 40110-100, Salvador, Bahia State, Brazil.
Introduction:
Middle meningeal artery embolization (MMAE) has been studied as an adjunct to surgical evacuation for chronic subdural hematoma (cSDH). Previous meta-analyses comparing MMAE with conventional treatment for cSDH included both observational and randomized studies. To provide a more robust assessment, we performed a meta-analysis of randomized controlled trials to evaluate the outcomes of adjunct MMAE compared to surgical treatment alone.
Methods:
We searched PubMed, EMBASE, and Cochrane CENTRAL databases for studies comparing adjunct middle meningeal artery embolization to surgical treatment alone until December 2024. The outcomes assessed were treatment failure, reoperation, complications, mortality, functional outcome, and length of hospital stay. Statistical analysis was performed via R software (version 4.3.2). Heterogeneity was assessed with I2 statistics. The risk of bias was assessed using the Cochrane Risk of Bias Tool for Randomized Trials.
Results:
We included 6 studies with 1,422 patients, of whom 700 (49.2 %) received adjunct middle meningeal artery embolization. The mean age ranged from 64.2 to 77.4 years in the embolization group and from 70 to 74.4 years in the surgery-only group. Among the patients, 435 (54.5 %) had previous known head trauma, and 315 (22.1 %) were on antiplatelets or anticoagulants. The follow-up ranged from 90 to 180 days. Adjunct middle meningeal artery embolization reduced the occurrence of treatment failure compared to surgical treatment alone (RR 0.482; 95 % CI 0.328 to 0.708; p < 0.001; I2 = 0 %) and reoperation (RR 0.333; 95 % CI 0.212 to 0.521; p < 0.001; I2 = 0 %), however, didńt reduce the occurrence of any cause mortality (RR 0.970; 95 % CI 0.400 to 2.353; p = 0.946; I2 = 39.6 %), functional dependence at the last follow-up (RR 1.000; 95 % CI 0.726 to 1.377; p = 0.705; I2 = 0 %), or the length of stay (MD 0.576; 95 % CI -0.085 to 1.238; p = 0.088; I2 = 0 %). Furthermore, no differences were found regarding complications secondary to the surgical procedure (RR 0.902; 95 % CI 0.688 to 1.182; p = 0.455; I2 = 0 %), and the occurrence of embolization-related complication was low (RR 0.013; 95 % CI 0.006 to 0.027; I2 = 0 %). Trial sequential analysis judged the sample size sufficient for treatment failure and reoperation but suggested that further trials are needed to prove differences in surgical-related complications.
Conclusion:
Our results confirm that middle meningeal artery embolization significantly reduces recurrence and reoperation rates compared to surgery alone, with low adverse event rates. However, the impact on functional outcomes and mortality remains uncertain, warranting further studies to clarify its long-term benefits.
