Chronic Subdural Hematoma: Pathophysiology, Diagnosis, and the Emerging Role of Middle Meningeal Artery Embolization

Chronic subdural hematoma (CSDH) is a common neurological condition, particularly in the elderly, characterized by a complex pathophysiology involving inflammation, angiogenesis, and recurrent microhemorrhages rather than a purely mechanical process. Although surgical evacuation remains the standard treatment, recurrence rates remain considerable, prompting the search for alternative and adjunctive therapies. This narrative review summarizes current evidence on the pathophysiology, diagnostic approaches, and management of CSDH, with particular emphasis on middle meningeal artery embolization (MMAE). A comprehensive literature search of major medical databases, including PubMed, Scopus, and Web of Science, was performed to identify relevant randomized controlled trials (RCTs), observational studies, and meta-analyses. Available evidence suggests that MMAE may reduce recurrence rates and the need for reoperation, particularly when used as an adjunct to surgery. However, results from RCTs remain mixed, and not all studies have demonstrated significant benefit on primary clinical endpoints. While MMAE has emerged as a promising minimally invasive approach targeting the vascular supply of hematoma membranes, further high-quality studies are required to establish standardized indications, optimize procedural techniques, and clarify long-term outcomes and comparative effectiveness.