Comparative outcomes of middle meningeal artery embolization for chronic subdural hematoma: A comprehensive systematic review, meta-analysis, meta-regression and network meta-analysis

Background Middle meningeal artery embolization (MMAE) has emerged as a promising minimally invasive approach for chronic subdural hematoma (cSDH). We aimed to compare the effectiveness of middle meningeal artery embolization (MMAE) as a standalone therapy, MMAE combined with surgery, and surgery alone, while also compare embolic agents (Onyx, NBCA, particles), and access approaches (femoral vs. radial). Methods We systematically searched PubMed, Scopus, and Web of Science through January 2025 for comparative studies focusing on MMAE and surgery in cSDH. Primary outcomes were recurrence and rescue surgery. Results A total of 44 studies (39 observational and 5 randomized controlled trials) met inclusion criteria. MMAE alone (OR: 0.39; CI: 0.25 to 0.64) and adjunctive MMAE (OR: 0.40; CI: 0.29 to 0.55) had lower recurrence rates compared to surgery alone. However, there were no significant differences in complication rates or functional outcome (mRS 0–2) at the last follow-up. Onyx was associated with the lowest surgical rescue needs and radial access trended toward fewer access site complications compared to femoral access. Conclusion MMAE, whether used alone or as an adjunct, is associated with significantly lower recurrence and fewer complications than surgery alone. Choice of embolic agent and radial access may also confer additional benefits. These findings emphasize the need for a comprehensive and tailored approach when utilizing MMAE to treat cSDH. Further studies are needed.