Particle embolic agents for embolization of middle meningeal artery in the treatment of chronic subdural hematoma: A systematic review and meta-analysis

Abstract

Objective: In this systematic review and meta-analysis, we investigated the efficacy and safety of middle meningeal artery embolization (MMAE) using particle embolic agents to treat cSDH.

Methods: To retrieve articles investigating outcomes of patients following MMAE with particle agents and to compare their outcome with conventional treatment, Scopus, PubMed, Embase, and Web of Science were searched using relevant keywords. Original articles with more than 10 cases were included. The meta-analysis was carried out using the R studio and the random-effects model. Publication bias was assessed using Peter's test and quality assessment using NIH tools.

Results: Eleven studies with 359 patients were included. The analysis revealed a pooled recurrence rate of 5% (CI: 3-8%), a need for reoperation rate of 5% (3-9%), and a peri-procedural complication rate of 4% (CI:2-9%) following MMAE with particle embolic agents. The pooled rates of decrease in size or resolution of the hematoma were 85% (CI:66-94%) and 66% (39-86%), respectively. Comparing MMAE using particulate embolysate with conventional treatments, risk ratio (RR) of 0.10 (CI:0.04-0.27) was achieved for recurrence, 0.25(CI:0.13-0.49) for reoperation, and 0.34 (CI:0.16-0.27) for peri-procedural complications. 91% of cSDH cases responded to MMAE with particles in the way they showed either down-sizing or complete resolution of the hematoma on follow-up imaging. In comparison, this rate was found to be 63% following conventional treatment.

Conclusion: Middle meningeal artery embolization using particle embolysates is a safe and effective technique for the treatment of cSDH, whether as a standalone intervention or in combination with conventional treatments.

Keywords: Middle meningeal artery embolization; chronic subdural hematoma; particle embolization agents.

Fig. 1.

PRISMA flowchart of included studies illustrating the screening process.

Fig. 2.

Meta-analysis of outcomes as a single proportion. A: Mortality rate (1%, CI:0–3%), B: Recurrence rate(5%, CI:3–8%), C: Reoperation rate(5%, CI:3–9%), D: Success rate(100%(CI:19–100).

Fig. 3.

Meta-analysis of outcomes as a single proportion. A: Improve in the size of hematoma (85%, CI:66–94%), B: Resolution of hematoma (66%, CI:39–86%%), C: Complication rate (4%, CI:2–9%).

Fig. 4.

Meta-analysis of outcomes comparing MMAE to conventional treatment. A: Mortality(0.17, CI:0.01–2.01), B: Recurrence(0.10, CI:0.04–0.27), C: Reoperation(0.25,CI:0.13–0.49), D: Complication(0.34, CI:0.16–0.72), E: Decrease in size or resolution of hematoma following MMAE in studies comparing MMAE and Conventional treatment(91%, CI:40–99%), F: Decrease in size or resolution of hematoma following Conventional treatment in studies comparing MMAE and Conventional treatment(63%,CI:39–81%).