Comparing Techniques for Treating Chronic Subdural Hematoma in a Single-Center Study

Introduction Surgical treatment of chronic subdural hematoma is associated with high recurrence rates (5% to 35%). As a result, embolization of the middle meningeal artery (MMA) has emerged and gained acceptance as an adjunct treatment modality. We aimed to evaluate functional neurological outcomes of patients undergoing minimally invasive procedures. We compared patients treated with subdural evacuating port system (SEPS), MMA embolization (MMAE) or a combined technique. Methods We conducted a single‐center retrospective cohort study of adults with chronic subdural hematoma treated between January 2015 and December 2022 by bedside SEPS placement and/or MMAE. Demographics, comorbidities, imaging findings (pre‑ and post‑intervention NCCT), and clinical outcomes were recorded. Embolization was performed with either PVA/Embosphere particles or NBCA liquid. The primary endpoint was functional status at follow‑up (mRS); secondary endpoints were length of stay, 90‑day mortality, and change in hematoma size. In SAS 9.4, continuous variables were assessed for normality (Shapiro‐Wilk) and compared by ANOVA (with Bonferroni) or Kruskal‐Wallis; categorical variables by chi‑square or Fisher's exact; and mRS by ordinal logistic regression, with p < 0.05 as significant. Results Seventy‑two patients (24 per group) were included. Baseline demographics and comorbidities were balanced, except for initial hematoma volume (greater in SEPS+MMAE group). Absolute hematoma reduction was greater with SEPS+MMAE (13.9 ± 6.4 cm³) and SEPS (12.2 ± 6.7 cm³) versus MMAE alone (8.7 ± 4.8 cm³; p = 0.011). 15 patients were lost to follow‑up and 4 died during the index admission, yielding 76 follow‑up CT measurements and 70 mRS assessments. Favorable mRS (0‐2) rates were 58% (SEPS), 70% (MMAE), and 87% (SEPS+MMAE) (χ 2 p = 0.029). Ordinal regression demonstrated better functional status with SEPS+MMAE versus SEPS (OR 0.18; 95% CI 0.06‐0.56; p = 0.003), while MMAE versus SEPS trended toward improvement (OR 0.39; 95% CI 0.14‐1.13; p = 0.083). These findings are further illustrated in Figure 1, which displays a greater proportion of favorable outcomes (mRS 0‐2) in the SEPS+MMAE group relative to the others. Conclusions Our findings suggest that combining SEPS with MMA embolization may result in better neurological outcomes than SEPS alone in patients with chronic subdural hematomas. Despite larger initial hematoma volumes, combined SEPS+MMAE achieved greater hematoma reduction. These results complement recent randomized trials and support the growing role of MMA embolization in the management of SDH, particularly as part of a multimodal, minimally invasive treatment strategy with SEPS placement.