Umbrella review of middle meningeal artery embolization and surgery outcomes in chronic subdural hematoma

Middle meningeal artery embolization has been investigated as a minimally invasive alternative or adjunct to conventional surgery for chronic subdural hematoma. This umbrella review aimed to synthesize and critically appraise published systematic reviews and meta-analyses comparing embolization with surgery, with emphasis on methodological quality, consistency of findings, overlap of primary studies, and umbrella-level GRADE-informed certainty judgments. Following PRISMA 2020 and Joanna Briggs Institute guidance for umbrella reviews, we searched PubMed, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews for English-language eligible reviews published between January 1, 2015, and July 15, 2025, and screened the reference lists of included reviews. Methodological quality was assessed using AMSTAR 2, umbrella-level GRADE-informed certainty judgments were applied and overlap of primary studies was quantified using the corrected covered area method. Twenty-three systematic reviews comprising 108 unique primary studies were included. Across reviews, middle meningeal artery embolization was generally associated with lower recurrence and reoperation rates than surgery or conventional management, although these findings were constrained by review overlap, heterogeneity, mixed primary study designs, and variable methodological quality. Functional outcomes and complication rates were broadly similar across treatment strategies, whereas evidence for mortality and hospital length of stay remained less certain. Overall, the most consistent review-level evidence suggested an association between embolization and lower recurrence and reoperation. These findings suggest that middle meningeal artery embolization may be associated with favorable outcomes for selected endpoints, but the evidence remains insufficient to establish definitive superiority across clinical domains. Further high-quality prospective studies are needed.