Chronic Subdural Hematomas in the Era of Middle Meningeal Artery Embolization

Area of Science:

• Neurology
• Interventional Neuroradiology
• Neurosurgery

Background:

• Chronic subdural hematoma (cSDH) is an age-associated condition frequently linked to falls and antithrombotic use.
• The incidence of cSDH is increasing due to the aging population.
• Current understanding views cSDH as a vascular-inflammatory disorder involving microhemorrhage from neovessels supplied by the middle meningeal artery.

Purpose of the Study:

• To evaluate the efficacy of middle meningeal artery embolization (MMAE) as an adjunct or alternative to standard care for cSDH.
• To assess the impact of MMAE on reducing recurrence and reoperation rates in cSDH patients.

Main Methods:

• Review of recent randomized controlled trials (EMBOLISE, STEM, MEMBRANE) evaluating MMAE in cSDH.
• Analysis of clinical outcomes, including treatment failure and reoperation rates.
• Consideration of real-world adoption and clinical practice trends.

Main Results:

• Three major trials demonstrated that adjunctive MMAE significantly reduced treatment failure and the need for reoperation in cSDH patients.
• Real-world data supports the effectiveness of MMAE in lowering recurrence rates, especially when used in conjunction with surgical evacuation.
• MMAE is emerging as a valuable strategy for managing cSDH, particularly in high-risk patient cohorts.

Conclusions:

• Middle meningeal artery embolization is an effective strategy for reducing recurrence and reoperation in chronic subdural hematoma.
• Further research is needed to optimize patient selection, embolic agent choice, and procedural techniques for MMAE.
• Addressing evidence gaps and improving health system planning are crucial for managing the growing burden of cSDH.