Current state of the field and recommendations for middle meningeal artery embolization in chronic subdural hematoma: A Report of the SNIS Standards and Guidelines Committee, Endorsed by ANZSNR and ESMINT.

BACKGROUND: Middle meningeal artery embolization (MMAE) is increasingly being used for adjunctive and standalone treatment of chronic subdural hematoma (cSDH). The Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee set out to provide up-to-date recommendations on the use of MMAE for the treatment of cSDH. METHODS: A structured literature review was performed pertinent to the use of MMAE. The strength and quality of evidence were graded according to established criteria. Recommendations were developed by consensus of the writing committee with input from the SNIS Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS: Highlighted recommendations are as follows. Recommendation 1: MMAE as an adjunct to surgical drainage is recommended to decrease the risk of recurrence requiring a further intervention and should be balanced against the risk of the procedure (class I, level A). Recommendation 2: standalone MMAE for cSDH in special circumstances/populations such as high-risk surgical patients, those with bleeding diathesis including thrombocytopenia or coagulopathy, or the elderly is reasonable (class IIa, level B-NR). Recommendation 3: practitioners should assess for dangerous collaterals prior to embolization (class I, level C-EO). CONCLUSIONS: The strongest recommendation currently is for MMAE as an adjunct to surgical drainage of cSDH to decrease the risk of recurrence. Ongoing studies will continue to address standalone MMAE, special populations, and technical nuances.