Middle meningeal artery embolization versus standard of care for chronic subdural hematoma: Meta-analysis of randomized controlled trials

Background The safety and efficacy of the middle meningeal artery embolization (MMAE) in patients with non-acute or chronic subdural hematoma (cSDH) has significant reporting within recent literature, however, mainly in the form of observational data. Methods We conducted a systematic review and meta-analysis including all available randomized clinical trials (RCTs) that compared MMAE in addition to standard of care (SOC) versus SOC alone for cSDH. The primary outcome was the rate of recurrence and reoperation. Secondary outcomes included serious adverse events (SAEs), mortality rate, independent ambulation (modified Rankin Scale (mRS) score 0 – 3), and changes in hematoma characteristics at 90 days. The fixed-effect or random-effects model was used based on the significancy of the heterogenicity (I 2 > 50%, P < .1). Results Findings showed significant superiority of MMAE over SOC in 90-day recurrence (RR = 0.55, 95% CI = 0.36 – 0.83, P = .0047, I 2 = 43.3%), reoperation within 180 days (RR = 0.38, 95% CI = 0.26–0.56, P < .001, I 2 = 0.0%), ambulatory functional outcome (RR = 1.034, 95% CI = 1.0–1.07, P = .0296, I 2 = 53.9%), SAE at any time (RR = 0.59, 95% CI = 0.38–0.94, P = .025, , I 2 = 0.0%), and 90-day any-cause mortality (RR = 0.29, 95% CI = 0.14–0.6, P = .0008, I 2 = 0.0%). Successful embolization and 30-day embolization-related complications occurred in 99.2% (95% CI = 94.54% – 100%) and 1.18% (95% CI = 0.39% – 2.31%) of patients, respectively. Additionally, subgroup analyses on major and pilot RCTs, comparison of embolic agents, and MMAE adjuvant to surgery versus surgery alone confirmed these findings. Conclusion MMAE appears to be safe and effective in the management of cSDH with low recurrence and SAE rate.