Single-session versus staged approaches for chronic subdural hematoma treatment with middle meningeal artery embolization and evacuation surgery: a propensity score–matched analysis

OBJECTIVE Surgical evacuation is the mainstay of treatment for patients with chronic subdural hematoma (cSDH) who have symptomatic mass effect, yet it carries a recurrence risk of up to 20%. Recent randomized trials have shown that adding middle meningeal artery embolization (MMAE) can significantly reduce both reoperations and overall treatment failures. However, whether performing MMAE and surgical evacuation in a single session impacts treatment efficacy remains an open question. METHODS The authors retrospectively identified 429 patients across 14 institutions who underwent MMAE plus surgical evacuation of cSDH. Patients were stratified into single-session (MMAE and evacuation under the same anesthesia session) or staged (separate sessions) cohorts. Baseline demographic, procedural, and imaging data were collected. Propensity score matching was performed to balance key baseline variables. Primary outcomes included hematoma recurrence, hospital length of stay (LOS), and functional independence (modified Rankin Scale score ≤ 2). RESULTS Of 429 patients, 205 (47.8%) received single-session treatment. In the unmatched analysis, single-session patients showed a lower rate of cSDH reaccumulation and repeat surgery (4.7% vs 10.7%, p = 0.010) and a shorter median LOS (6 vs 7 days, p < 0.005). After matching, reaccumulation rates were not significantly different, but LOS remained significantly shorter (5 vs 7 days, p = 0.002). Functional outcomes and overall mortality were similar in both groups. Complication rates did not differ, and MMAE-related adverse events were rare. CONCLUSIONS Single-session MMAE plus surgical evacuation appears to be safe and shortens LOS compared with a staged approach. The rates of functional outcomes, re-evacuation, and mortality did not differ significantly from those observed in patients who underwent staged procedures.