Standalone middle meningeal artery embolization vs. surgical evacuation in chronic subdural hematoma: A comprehensive systematic review and meta-analysis

Background: Chronic subdural hematoma (cSDH) remains a prevalent neurosurgical condition in elderly patients, traditionally managed via surgical evacuation when symptomatic. Middle meningeal artery embolization (MMAE) has recently emerged as a minimally invasive alternative. However, the comparative efficacy and safety of standalone MMAE versus standalone surgical evacuation remain inadequately defined. Methods: A comprehensive search of PubMed, Scopus, Embase, and Web of Science, was performed on March 20, 2025. Studies comparing standalone MMAE and standalone surgical evacuation in patients with cSDH were included. The primary outcome was recurrence; secondary outcomes included complication and mortality rates. A random-effects pairwise meta-analysis model using restricted maximum likelihood (REML) was applied to account for between-study variability. Results: Ten studies encompassing 50,138 patients were included. Recurrence was significantly lower with MMAE (RR = 0.51, 95% CI: 0.33–0.80, p = .00), with no statistically detected heterogeneity (I² = 0%), although clinical variability across studies cannot be excluded. Mortality (RR = 0.70, 95% CI: 0.44–1.12, p = .14) and complications (RR = 1.04, 95% CI: 0.67–1.64, p = .85) did not differ significantly between both groups. The GRADE assessment rated the certainty of evidence for recurrence as moderate, while the certainty for both mortality and complications were rated as very low, underscoring the need for further high-quality studies. Conclusion: Standalone MMAE significantly reduces recurrence risk compared to surgical evacuation in cSDH patients, while showing no significant difference in mortality or complication rates. These findings highlight MMAE as a promising first-line treatment option, particularly for patients at high surgical risk. Prospective randomized trials are warranted to further validate these outcomes.