Abstract 103: Middle Meningeal Artery Embolization for Chronic Subdural Hematoma in Patients with Coagulopathies

Introduction/Purpose Chronic subdural hematoma (cSDH) recurs after surgical evacuation in 5%‐30% of cases. In patients with coagulopathies, recurrence is particularly problematic due to heightened bleeding risk and surgical morbidity. Middle meningeal artery embolization (MMAE) interrupts the vascular supply to the hematoma's outer membrane, aiming to reduce inflammation, angiogenesis, and rebleeding. While MMAE is effective in general cSDH populations, its role in coagulopathic patients is poorly defined. We evaluated long‐term recurrence, reintervention, and safety outcomes of MMAE compared with standard care in this high‐risk group. Materials/Methods We performed a retrospective, propensity score‐matched, multicenter cohort study using the TriNetX Analytics Network, including adults (≥18 years) with chronic subdural hematoma (cSDH) and a documented coagulopathy from database inception to May 2025. The MMAE cohort underwent transcatheter embolization of the middle meningeal artery. The comparison cohort received standard care without MMAE, including surgical evacuation or conservative management. Propensity score matching (1:1) balanced demographics, comorbidities, coagulopathy type, and antithrombotic use. Primary outcomes were all‐cause mortality, recurrence, and reintervention, assessed at 6, 12, 24, and 60 months. Secondary outcomes included hematoma resolution, hospital readmission, and complications. Results Of 25,311 eligible patients, 207 underwent MMAE and 25,104 received standard care. After matching, 180 pairs were well balanced across baseline characteristics. At 6 months, MMAE reduced recurrence (7.8% vs 17.8%; RR, 0.44; 95% CI, 0.24‐0.80; p=0.006) and reintervention (7.2% vs 16.1%; RR, 0.45; 95% CI, 0.24‐0.84; p=0.010) without affecting mortality (17.8% vs 22.2%; RR, 0.80; p=0.290). At 60 months, recurrence (13.3% vs 25.0%; RR, 0.53; p=0.006) and reintervention (11.7% vs 23.3%; RR, 0.50; p=0.005) remained lower, with no mortality difference. Secondary outcomes showed more frequent hematoma resolution after MMAE (45.0% vs 35.0%; p=0.050) and similar rates of readmission and complications, including stroke (2.2% vs 1.1%; p=0.410), major bleeding, infection, and thromboembolism. Subgroup analyses demonstrated consistent recurrence reduction in thrombocytopenia (RR, 0.45; p=0.020), age ≥75 years (RR, 0.45; p=0.040), and anticoagulated patients (RR, 0.42; p=0.050). Sensitivity analyses excluding early deaths and adjusting for thrombocytopenia confirmed these findings. Conclusion In cSDH patients with coagulopathies, MMAE significantly reduced recurrence and reintervention without increasing mortality or major complications, with benefits sustained over 5 years. The effect was consistent across high‐risk subgroups, supporting MMAE as a safe, durable option and a valuable adjunct or alternative to conventional surgery for patients with elevated bleeding risk. image