Middle Meningeal Artery Embolization in Chronic Subdural Hematomas: A Literature Review

Abstract

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions and is associated with considerable morbidity, mortality, and recurrence despite standard surgical treatment. Although burr-hole evacuation with postoperative drainage remains the main treatment for symptomatic CSDH, recurrence continues to occur even after optimization of surgical technique. Contemporary evidence suggests that CSDH is not merely a passive accumulation of blood, but a dynamic pathological process driven by inflammation, angiogenesis, hyperfibrinolysis, and the formation of vascularized neomembranes. These mechanisms provide the rationale for middle meningeal artery embolization (MMAE), which aims to reduce the arterial supply to the pathological outer membrane and interrupt the self-perpetuating cycle of microbleeding and hematoma persistence.

This review summarizes the pathophysiology of CSDH, current standard surgical treatment, the technical principles of MMAE, and the clinical evidence supporting its use. Early observational studies and retrospective series suggested reduced recurrence and favorable hematoma resolution after MMAE. More recently, randomized controlled trials including EMBOLISE, STEM, and MAGIC-MT have provided higher-level evidence, generally supporting the potential safety and efficacy of MMAE in selected patients, although results vary according to treatment setting and outcome definition. Meta-analytic evidence suggests a possible reduction in symptomatic recurrence or progression, particularly in nonsurgically managed patients, but heterogeneity between trials limits definitive conclusions.