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Embolization of Middle Meningeal Artery in Patients with Chronic Subdural Hematoma: A Systematic Review and
Nikolaos M Papageorgiou1, Lina Palaiodimou1, Konstantinos Melanis1
1Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National & Kapodistrian University of Athens, 12462 Athens, Greece.
Background: Chronic subdural hematoma (cSDH) is a common neurosurgical condition, particularly among elderly patients. Middle meningeal artery (MMA) embolization has emerged as a minimally invasive adjunctive treatment aimed at reducing recurrence. However, its comparative efficacy and safety remain under investigation. Methods: In this systematic review and meta-analysis, randomized-controlled clinical trial (RCT) data evaluating MMA embolization combined with best medical therapy (BMT) versus BMT alone in adult patients with symptomatic cSDH were pooled. The primary efficacy outcome was recurrence or progression of hematoma at follow-up. Secondary efficacy outcomes included good functional outcome [modified Rankin Scale (mRS) score ≤ 2], independent ambulation (mRS score ≤ 3), and hematoma thickness at follow-up. The primary safety outcome was all-cause mortality. Procedure-related complications were assessed as a secondary safety outcome. Results: Six RCTs were included, comprising 760 patients treated with MMA embolization and 788 patients treated with BMT alone. MMA embolization significantly reduced recurrence compared to BMT alone (RR: 0.50; 95% CI: 0.37-0.69; six studies; I2 = 0%; number-needed-to-treat = 13). No significant differences were observed in good functional outcome (RR: 1.01; 95% CI: 0.97-1.05; three studies; I2 = 0%), independent ambulation (RR: 1.01; 95% CI: 0.99-1.04; three studies; I2 = 0%), or hematoma thickness at follow-up (SMD: -0.1; 95% CI: -0.3 to 0; four studies; I2 = 42%). All-cause mortality was similar between the two groups (RR: 1.01; 95% CI: 0.42-2.40; five studies; I2 = 44%). The pooled rate of procedure-related adverse events in the MMA embolization-group was 1% (95% CI: 0-3%; two studies; I2 = 35%). Conclusions: MMA embolization significantly reduced cSDH recurrence when used as an adjunct to BMT. However, it did not demonstrate a significant impact on functional outcomes or mortality in this meta-analysis. Further research is needed to identify patient subgroups that benefit most from MMA embolization and to evaluate its impact on cognitive function and quality of life using longer follow-up periods.
Background: Chronic subdural hematoma (cSDH) is a common neurosurgical condition, particularly among elderly patients. Middle meningeal artery (MMA) embolization has emerged as a minimally invasive adjunctive treatment aimed at reducing recurrence. However, its comparative efficacy and safety remain under investigation. Methods: In this systematic review and meta-analysis, randomized-controlled clinical trial (RCT) data evaluating MMA embolization combined with best medical therapy (BMT) versus BMT alone in adult patients with symptomatic cSDH were pooled. The primary efficacy outcome was recurrence or progression of hematoma at follow-up. Secondary efficacy outcomes included good functional outcome [modified Rankin Scale (mRS) score ≤ 2], independent ambulation (mRS score ≤ 3), and hematoma thickness at follow-up. The primary safety outcome was all-cause mortality. Procedure-related complications were assessed as a secondary safety outcome. Results: Six RCTs were included, comprising 760 patients treated with MMA embolization and 788 patients treated with BMT alone. MMA embolization significantly reduced recurrence compared to BMT alone (RR: 0.50; 95% CI: 0.37-0.69; six studies; I2 = 0%; number-needed-to-treat = 13). No significant differences were observed in good functional outcome (RR: 1.01; 95% CI: 0.97-1.05; three studies; I2 = 0%), independent ambulation (RR: 1.01; 95% CI: 0.99-1.04; three studies; I2 = 0%), or hematoma thickness at follow-up (SMD: -0.1; 95% CI: -0.3 to 0; four studies; I2 = 42%). All-cause mortality was similar between the two groups (RR: 1.01; 95% CI: 0.42-2.40; five studies; I2 = 44%). The pooled rate of procedure-related adverse events in the MMA embolization-group was 1% (95% CI: 0-3%; two studies; I2 = 35%). Conclusions: MMA embolization significantly reduced cSDH recurrence when used as an adjunct to BMT. However, it did not demonstrate a significant impact on functional outcomes or mortality in this meta-analysis. Further research is needed to identify patient subgroups that benefit most from MMA embolization and to evaluate its impact on cognitive function and quality of life using longer follow-up periods.
Frequently Asked Questions
Based on this study's findings, MMA embolization serves as an adjunctive treatment that significantly reduces recurrence risk. The meta-analysis revealed a risk ratio of 0.50, effectively halving the likelihood of hematoma progression compared to patients receiving only best medical therapy (BMT).
The researchers identified a number-needed-to-treat (NNT) of 13 for the intervention. This value indicates that for every thirteen patients who undergo MMA embolization in addition to best medical therapy (BMT), one instance of hematoma recurrence or progression is successfully prevented.
The mRS was employed to evaluate functional recovery and independent ambulation following treatment. Specifically, the study assessed the proportion of patients achieving an mRS score of 2 or less for good functional outcomes and 3 or less for independent mobility.
The study found that the intervention did not significantly improve good functional outcomes (RR: 1.01) or independent ambulation. All-cause mortality remained similar between the embolization and medical therapy groups, suggesting the procedure primarily impacts recurrence rather than survival or short-term disability.
The study's authors propose that future research should identify specific patient subgroups that benefit most from the procedure. They also recommend evaluating long-term impacts on cognitive function and quality of life, as these parameters were not fully captured in the current randomized-controlled trials.
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