Middle meningeal artery embolization for chronic subdural hematoma: meta-analysis of three randomized controlled trials and review of ongoing trials

Abstract

Background: Middle Meningeal Artery Embolization (MMAE) has been proposed as adjunct and stand-alone treatment for Chronic Subdural Hematoma (CSDH). We aimed to meta-analyze three recently published randomized controlled trials, to reliably estimate the effect of MMAE. We also carried out a systematic review of ongoing trials and their key outcomes.

Methods: A PRISMA-compliant meta-analysis was conducted (PROSPERO ID CRD42024618816). Three published RCTs (MAGIC-MT, EMBOLISE, and STEM) assessing MMAE in CSDH were included. Trial primary outcomes were pooled for analysis using random effects models. Primary and secondary outcomes (recurrence/surgical rescue, functional outcome) were obtained, stratified by treatment group (undergoing surgery, and nonsurgical management). A descriptive review of trials in public registries was also conducted (search date 30th November 2024).

Results: In total, 1432 patients were included from three trials in meta-analysis. Overall, MMAE reduced symptomatic progression or recurrence, but was not statistically significant (RR 0.50, 95% CI 0.23-1.06, P = 0.058). For the group undergoing surgery, MMAE was not associated with reduced recurrence (RR 0.60, 95% CI 0.19-1.88, P = 0.194). For nonsurgical management, MMAE reduced progression (RR 0.36, 95% CI 0.22-0.60, P < 0.001). MMAE did not influence functional outcome (RR 1.01, 95% CI 0.97-1.04, P = 0.790). From the literature search, there are twenty-one registered trials. Nineteen studies include arms assessing MMAE as an adjunct to surgery, eleven compare MMAE to observation, and four with surgery. The most common primary outcome is recurrence (47.8%, N = 11), either radiologically, or requiring a second surgery. Inclusion criteria, embolization agents, primary and secondary outcomes differed significantly between studies.

Conclusions: In this meta-analysis of three randomized controlled trials, the use of MMAE in patients undergoing surgery did not appear to significantly reduce recurrence or improve functional outcomes, but did reduce progression in nonsurgical cohorts. Further studies assessing these cohorts are ongoing.

Keywords: Chronic subdural hematoma; MMAE; Middle meningeal artery embolization.

Fig. 1

Forest plot of A) Meta-analysis from three studies for primary outcome (progression/recurrence), comparing MMAE and usual care (i.e. surgery or non-surgical); B) Primary outcome in patients undergoing MMAE + surgery and surgery only; C) Primary outcome of repeat surgery at 90 days in patients undergoing MMAE + surgery and surgery only D) Primary outcome in patients undergoing nonsurgical management only; E) Modified Rankin Scale 0–2 comparing MMAE and usual care F) Modified Rankin Scale 0–3 (at follow-up comparing MMAE and usual care

Fig. 2

PRISMA flow-chart

Fig. 3

Bubble plot of ongoing and recently published MMA trials, grouped by trial design/arms. Bubble size = reflective of total population size of trial. *MMA vs Obs = Trial of MMAE Vs nonsurgical management only; MMA vs Surg = Trial of MMAE alone vs surgery; Surg + MMA = Trial of MMAE + Surgery vs Surgery; Surg + MMA and MMA vs Obs = Trial including both arms

Fig. 4

Stacked bar chart demonstrating differences in primary outcome MMAE groups (red) compared to non-MMAE groups as controls (blue), stratified by cohort (overall, surgical, and nonsurgical)