Chronic subdural haematoma (cSDH) is an increasingly prevalent condition in older, anticoagulated, and medically frail patients, in whom recurrence and perioperative risk remain substantial despite standard surgical evacuation. Growing recognition of cSDH as an angiogenic, inflammatory disorder has prompted interest in minimally invasive strategies that combine mechanical decompression with targeted modulation of the underlying vascular pathology. This study aimed to evaluate the safety, effectiveness, and health-economic profile of combined middle meningeal artery embolisation and subdural evacuation port system (MMAE-SEPS) drainage for cSDH, compared with conventional burr-hole evacuation. MEDLINE, Embase, and CENTRAL were searched from inception to 24th August 2025. Prospective and retrospective studies reporting outcomes of adult cSDH patients treated with combined MMAE-SEPS were included. Primary outcomes were functional outcome at discharge, recurrence and overall complications. Secondary outcomes included functional outcome at last follow-up, length of hospital stay (LOS), repeat SEPS, craniotomy escalation, readmission, seizures, and mortality. Risk of bias was assessed using ROBINS-I and certainty of evidence using GRADE. Random-effects meta-analysis generated pooled estimates. UK NHS tariffs were used for episode cost modelling. Four observational cohorts were included. Recurrence occurred in 10.9% (95% CI 6.40–16.24%). Good functional outcome was achieved in 86.0% (95% CI 77.55–93.45%). Repeat SEPS was required in 7.3% and craniotomy escalation in 7.0%. Mean LOS was 6.9 days. Overall complications were infrequent (9.7%), with procedural morbidity rare, and mortality was low (0.4%). Certainty of evidence was low to moderate due to retrospective designs and small sample sizes. Cost modelling demonstrated higher episode costs for MMAE-SEPS (£ 11058.87) than burr-hole evacuation (£ 7695.30), without cost neutrality. Combined MMAE-SEPS is a mechanistically rational, minimally invasive strategy that achieves favorable functional outcomes and low morbidity in carefully selected, high-risk cSDH patients. However, current evidence does not support routine use over burr-hole evacuation. MMAE-SEPS should be considered selectively, pending prospective comparative and cost-effectiveness studies. • Chronic subdural haematoma is increasingly managed with minimally invasive strategies. • Combined artery embolisation and port drainage shows low recurrence and mortality. • Functional recovery is high in older and medically frail patient populations. • Higher procedural costs limit routine use compared with burr-hole evacuation.
Nischal et al. (2026) studied this question.