Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: Predictors of Clinical and Radiographic Failure from 636 Embolizations

Mohamed M. Salem, Okkes Kuybu, Alex Nguyen Hoang, Ammad A. Baig, Mirhojjat Khorasanizadeh, Cordell Baker, Joshua C. Hunsaker, Aldo A. Mendez, Gustavo Cortez, Jason M. Davies, Sandra Narayanan, C. Michael Cawley, Howard A. Riina, Justin M. Moore, Alejandro M. Spiotta, Alexander A. Khalessi, Brian M. Howard, Ricardo Hanel, Omar Tanweer, Elad I. LevyRamesh Grandhi, Michael J. Lang, Adnan H. Siddiqui, Peter Kan, Christopher S. Ogilvy, Bradley A. Gross, Ajith J. Thomas, Brian T. Jankowitz, Jan Karl Burkhardt

Research output: Contribution to journalArticlepeer-review

20 Scopus citations


Background: Knowledge regarding predictors of clinical and radiographic failures of middle meningeal artery (MMA) embolization (MMAE) treatment for chronic subdural hematoma (CSDH) is limited. Purpose: To identify predictors of MMAE treatment failure for CSDH. Materials and Methods: In this retrospective study, consecutive patients who underwent MMAE for CSDH from February 2018 to April 2022 at 13 U.S. centers were included. Clinical failure was defined as hematoma reaccumulation and/or neurologic deterioration requiring rescue surgery. Radiographic failure was defined as a maximal hematoma thickness reduction less than 50% at last imaging (minimum 2 weeks of head CT follow-up). Multivariable logistic regression models were constructed to identify independent failure predictors, controlling for age, sex, concurrent surgical evacuation, midline shift, hematoma thickness, and pretreatment baseline antiplatelet and anticoagulation therapy. Results: Overall, 530 patients (mean age, 71.9 years ± 12.8 [SD]; 386 men; 106 with bilateral lesions) underwent 636 MMAE procedures. At presentation, the median CSDH thickness was 15 mm and 31.3% (166 of 530) and 21.7% (115 of 530) of patients were receiving antiplatelet and anticoagulation medications, respectively. Clinical failure occurred in 36 of 530 patients (6.8%, over a median follow-up of 4.1 months) and radiographic failure occurred in 26.3% (137 of 522) of procedures. At multivariable analysis, independent predictors of clinical failure were pretreatment anticoagulation therapy (odds ratio [OR], 3.23; P =.007) and an MMA diameter less than 1.5 mm (OR, 2.52; P =.027), while liquid embolic agents were associated with nonfailure (OR, 0.32; P =.011). For radiographic failure, female sex (OR, 0.36; P =.001), concurrent surgical evacuation (OR, 0.43; P =.009), and a longer imaging follow-up time were associated with nonfailure. Conversely, MMA diameter less than 1.5 mm (OR, 1.7; P =.044), midline shift (OR, 1.1; P =.02), and superselective MMA catheterization (without targeting the main MMA trunk) (OR, 2; P =.029) were associated with radiographic failure. Sensitivity analyses retained these associations. Conclusion: Multiple independent predictors of failure of MMAE treatment for chronic subdural hematomas were identified, with small diameter (<1.5 mm) being the only factor independently associated with both clinical and radiographic failures.

Original languageEnglish (US)
Article numbere222045
Issue number4
StatePublished - May 2023
Externally publishedYes

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging


Dive into the research topics of 'Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: Predictors of Clinical and Radiographic Failure from 636 Embolizations'. Together they form a unique fingerprint.

Cite this