Middle meningeal artery embolization alone versus combined with conventional surgery in the management of chronic subdural hematoma: A systematic review and meta-analysis

Objective: To compare outcomes of middle meningeal artery embolization (MMAE) alone versus combined with conventional surgery in the management of chronic subdural hematoma (cSDH). Methods: A systematic literature search was performed on PubMed, Google Scholar, Scopus, and CINAHL, followed by a meta-analysis comparing recurrence rates, surgical rescue, mortality, in-hospital complications, and length of hospital stay was conducted. Mean differences and risk ratios were pooled using a random effects model, with subgroup analysis performed using Cochrane RevMan 5.4.1 software. Results: A total of 23 studies including 302,168 patients (62.5 % male, 37.5 % female) were analyzed, with most studies published between 2017 and 2024. Among these patients, 299,195 (99.0 %) were treated with conventional surgery, whereas 3113 underwent MMAE. MMAE patients showed a significantly lower recurrence rate compared to conventional surgery, with a 0.35 times lower risk of recurrence (95 % CI: 0.24–0.51, p<0.01). However, adjunctive MMAE was associated with a longer hospital stay (SMD: 2.61 [95 % CI: 2.46–2.76], p<0.01), though MMAE alone had a shorter stay compared to adjunctive MMAE. Additionally, MMAE demonstrated a lower risk of surgical rescue (0.29 times, p<0.01). While no significant difference was found in-hospital complications (RR: 1.01, 95 % CI 0.90–1.14, p=0.84) and mortality rates (RR: 0.88, 95 % CI 0.69–1.14, p=0.34). Conclusion: MMAE stand-alone or adjunctive with conventional surgery presents a promising alternative to conventional surgery alone for chronic subdural hematomas due to lower recurrence and surgical rescue risk. Further prospective studies are needed to study the efficacy of this new approach.