Efficacy and safety of middle meningeal artery embolisation for chronic subdural haematoma: a systematic review and meta-analysis of randomised controlled trials

Chronic subdural haematoma (cSDH) frequently recurs following standard treatment. Middle meningeal artery embolisation (MMAE) may reduce recurrence by decreasing perfusion of the vascularised subdural membranes. This systematic review and meta-analysis evaluated the efficacy and safety of MMAE versus standard management. This PRISMA-compliant systematic review and meta-analysis (PROSPERO: CRD420261325584) searched PubMed, Ovid (MEDLINE and Embase), Web of Science, and the Cochrane Library from inception to 28 September 2026. Randomised controlled trials comparing MMAE-based treatment with standard management in adults with radiologically confirmed cSDH were included. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using random-effects models. The primary outcome was study-defined treatment failure. Twelve randomised controlled trials ( n = 2,429; 1,202 MMAE; 1,227 control) were included in the primary analysis. Treatment failure occurred in 9.1% versus 18.3%, respectively. MMAE reduced treatment failure (RR 0.52, 95% CI 0.39–0.69), corresponding to an absolute risk reduction of approximately 8.8% and an NNT of approximately 12. In subgroup analyses, benefit was observed in both surgery-only comparator trials (RR 0.41, 95% CI 0.23–0.76) and mixed surgical/conservative comparator trials (RR 0.55, 95% CI 0.37–0.81), with no significant subgroup difference ( p = 0.317). MMAE also reduced reoperation/surgical rescue (RR 0.40, 95% CI 0.31–0.52). All-cause mortality (RR 0.72, 95% CI 0.37–1.43) and severe adverse events (RR 0.83, 95% CI 0.60–1.16) did not differ significantly between groups. Certainty was moderate for treatment failure and reoperation/surgical rescue and low for mortality and severe adverse events. MMAE-based treatment reduces treatment failure in cSDH, with no statistically significant difference in mortality or severe adverse events. Further well-powered randomised trials using standardised efficacy and safety outcomes are needed to define the optimal role of MMAE in cSDH management.