Interventional procedure overview of middle meningeal artery embolisation for chronic subdural haematomas
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Other relevant studies
Other potentially relevant studies to the IP overview that were not included in the main evidence summary (tables 2 and 3) are listed in table 5.
Article | Number of patients and follow up | Direction of conclusions | Reason study was not included in main evidence summary |
|---|---|---|---|
Al-Mufti F, Kaur G, Amuluru K et al. (2021) Middle meningeal artery embolization using combined particle embolization and n-BCA with the dextrose 5% in water push technique for chronic subdural hematomas: a prospective safety and feasibility study. AJNR. American journal of neuroradiology 42(5): 916-920 | Case series n=12 follow up: 3 months | Embolisation of the MMA using diluted n-BCA and ethiodized oil (1:6) is safe and feasible from a technical standpoint. The use of a dextrose 5% bolus improves distal penetration of the glue. | Small sample |
Badger CA, Shaikh HA and Jankowitz BT (2020) Treatment of chronic subdural hematomas utilizing middle meningeal artery embolization. Journal of Radiology Nursing 39(4): 298-301 | Case report n=1 | Current evidence suggests that embolisation of the MMA is a safe and effective method for treatment of chronic subdural haematomas. It can be utilised as an additional intervention to surgical evacuation or as a primary treatment method. After the intervention, nursing care for the patient should focus on detailed neurological assessments with special attention to the unique potential risk to this procedure. | Single case report |
Ban SP, Hwang G, Byoun HS et al. (2018) Middle meningeal artery embolization for chronic subdural hematoma. Radiology 286(3): 992-9 | Non-randomised comparative study n=541 (MMAE, n=72; historic control group, n=469) follow up: 6 months | MMAE has a positive therapeutic effect on CSDH and is more effective than conventional treatment. | This study was included in Ironside (2021) |
Bounajem MT, Campbell RA, Denorme F et al. (2021) Paradigms in chronic subdural hematoma pathophysiology: Current treatments and new directions. The journal of trauma and acute care surgery 91(6): e134-e141 | Review | Targeted approaches, such as MMAE and anti-inflammatory therapies, have become increasingly common and require further prospective analysis to aid in the determination of their efficacy. | Review article |
Carpenter A, Rock M, Dowlati E et al. (2022) Middle meningeal artery embolization with subdural evacuating port system for primary management of chronic subdural hematomas. Neurosurgical review 45(1): 439-49 | Non-randomised comparative study n=250 (surgery, n=185; SEPS, n=19; surgery plus MMAE, n=23; MMAE and SEPS placement, n=23) | Patients treated with MMA/SEPS were more likely to be older, be on anticoagulation, have significant comorbidities, have shorter length of stay, and less likely to have symptomatic recurrence compared to SEPS only cohort. Thus, MMAE/SEPS appears to be a safe and equally effective minimally invasive treatment for CSDH patients with significant comorbidities who are poor surgical candidates. | Number of patients having MMAE (plus surgery or SEPS placement) was small. |
Catapano JS, Ducruet AF, Nguyen CL et al. (2021) A propensity-adjusted comparison of middle meningeal artery embolization versus conventional therapy for chronic subdural hematomas. Journal of Neurosurgery 135(4): 1208-13 | Non-randomised comparative study n=231 (MMAE, n=35, conservative or surgical treatment, n=196) | This propensity-adjusted analysis suggests that MMAE for CSDH is associated with a greater extent of haematoma volume reduction with fewer treatment failures than conventional therapy. | Small sample (35 patients having MMAE) |
Catapano JS, Koester SW, Srinivasan VM et al. (2021) Total 1-year hospital cost of middle meningeal artery embolization compared to surgery for chronic subdural hematomas: a propensity-adjusted analysis. Journal of neurointerventional surgery | Non-randomised comparative study n=170 (MMAE, n=48; surgery, n=122) | MMAE is associated with decreased total hospital cost compared with surgery for CSDH. This lower cost is directly related to the decreased need for additional treatment interventions. | This study focused on hospital cost with limited efficacy and safety data being reported. |
Catapano JS, Nguyen CL, Wakim AA et al. (2020) Middle meningeal artery embolization for chronic subdural hematoma. Frontiers in Neurology 11: 557233 | Review | MMAE for CSDH represents an emerging treatment modality, with a rapidly increasing number of studies analysing this innovative and largely successful technique. However, many questions remain, including appropriate patient selection, efficacy as a stand-alone procedure, optimal embolisation techniques, and timing of embolisation with regard to surgical intervention in symptomatic patients. Furthermore, most literature on MMAE for CSDH reports cases studies and small case series, whereas several RCTs have shown efficacy with surgical interventions. Hence, many RCTs using MMAE as a treatment for CSDH are underway. These studies will ultimately provide insight on the safety, efficacy, and use of this novel technique in the treatment of CSDH. | Review article |
Catapano JS, Ducruet AF, Nguyen CL et al. (2021) Middle meningeal artery embolization for chronic subdural hematoma: an institutional technical analysis. Journal of neurointerventional surgery 13(7): 657-60 | Case series n=35 follow up: mean 120 days | MMAE of CSDH appears to be both safe and efficacious. Furthermore, embolization of both the anterior and posterior MMA branches may be associated with increased odds of complete resolution. | This study was included in Ironside (2021). |
Catapano JS, Scherschinski L, Rumalla K et al. (2022) Emergency department visits for chronic subdural hematomas within 30 days after surgical evacuation with and without middle meningeal artery embolization. American Journal of Neuroradiology 43(8): 1148-51 | Non-randomised comparative study n=137 (surgery and MMAE, n=28; surgery only, n=109) | Surgical evacuation combined with middle meningeal artery embolisation in patients with chronic subdural hematoma is associated with fewer 30-day emergency department visits compared with surgery alone. | Small sample (the number of patients who had surgery and MMAE was 28). |
Court J, Touchette CJ, Iorio-Morin C et al. (2019) Embolization of the middle meningeal artery in chronic subdural hematoma - A systematic review. Clinical neurology and neurosurgery 186: 105464 | Systematic review n=18 studies (190 patients) | MMAE is a feasible technique for CSDH, but the current body of evidence does not yet support its use as a standard treatment. Further studies with a higher level of evidence are necessary before MMAE can be formally recommended. | Of the 18 studies, 13 studies were included in Ironside (2021) or Haldrup (2020), and 5 studies with small samples (a total of 15 patients). |
Di Cristofori A, Remida P, Patassini M et al. (2022) Middle meningeal artery embolization for chronic subdural hematomas. A systematic review of the literature focused on indications, technical aspects, and future possible perspectives. Surgical Neurology International 13: a4 | Systematic review n=35 studies | The global impression deriving from the data available, and the literature is that MMAE is a safe procedure with very low complications and with a low failure rate, both when associated with surgery or in case of a standalone treatment. | Of the 35 studies, 25 studies were included in Ironside (2021), Haldrup (2020) and Piergallini (2019), 10 small scale studies had a total of 57 patients). No meta-analysis was conducted. |
Dian J, Linton J and Shankar JJ (2021) Risk of recurrence of subdural hematoma after EMMA vs surgical drainage - Systematic review and meta-analysis. Interventional neuroradiology: journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences 27(4): 577-83 | Systematic review and meta-analysis n=4 studies | Based on limited data, MMAE reduces the risk of recurrence by 20% compared to surgical treatment for CSDH. | All 4 studies were included in Ironside (2021) |
Dowlati E, Chesney K, Carpenter AB et al. (2021) Awake transradial middle meningeal artery embolization and twist drill craniostomy for chronic subdural hematomas in the elderly: case series and technical note. Journal of neurosurgical sciences | Case series n=20 follow up: mean 3.6 months | In select elderly patients with high perioperative risk factors, primary treatment of CSDH using awake transradial MMAE and subdural evaluation port system placement is a minimally invasive, feasible, and safe option. Further comparative studies are warranted to evaluate efficacy of the treatment. | Small sample. |
Entezami P, Field NC and Dalfino JC (2021) Outpatient management of chronic expanding subdural hematomas with endovascular embolization to minimize inpatient admissions during the COVID-19 viral pandemic. Interventional neuroradiology: journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences 27(5): 716-21 | Case series n=5 | MMAE as a primary treatment for chronic expanding SDH in the outpatient setting is safe. Giving the current viral pandemic, outpatient management of elderly patients is an attractive option, providing neurosurgeons the ability to procedurally manage patients with progressive haemorrhage while minimising or eliminating the length of inpatient admission. | Small sample |
Entezami P, Nourollahzadeh E and Dalfino J (2019) Embolization of middle meningeal artery for the treatment of headaches induced by chronic subdural hematoma: A Case Report. Headache 59(4): 615-618 | Case report n=1 follow up: 3 months | As embolisation techniques improve, its utility continues to increase. Authors believe that using MMAE as the first-line treatment in difficult CSDH cases (elderly patients, those needing anticoagulation resumption, etc) or in patients who are only mildly symptomatic with minimal mass effect from the subdural hematoma is a powerful new adjunct to the management of CSDH. | Single case report |
Entezami P, Boulos A, Paul A et al. (2019) Contrast enhancement of chronic subdural hematomas after embolization of the middle meningeal artery. Interventional neuroradiology: journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences 25(5): 596-600 | Case report n=2 | Embolisation of the MMA may be a useful adjunct in the management of CSDHs, although further investigation is needed. Minimally invasive angiographic embolisation procedures may be an attractive option in patients who are poor candidates for more invasive surgery. Contrast staining of the haematoma following embolisation may suggest sufficient penetration into the fragile neovasculature that accounts for the persistent nature of CSDHs. More cases and dedicated outcomes research is needed to evaluate better this radiographic feature postembolisation, and determine its utility in predicting outcomes following MMAE for CSDHs. | Small sample |
Feghali J, Yang WYand Huang J (2020) Updates in chronic subdural hematoma: epidemiology, etiology, pathogenesis, treatment, and outcome. World neurosurgery 141: 339-345 | Review | MMAE represents one of the latest additions to the therapeutic arsenal of cerebrovascular specialists in treating CSDH and is being critically evaluated in numerous ongoing clinical trials. | Review article |
Fiorella D and Arthur AS (2019) Middle meningeal artery embolization for the management of chronic subdural hematoma. Journal of neurointerventional surgery 11(9): 912-5 | Review | Based on the existing literature, it is difficult to ascertain a sense of the natural history of the group of CSDH patients who do not need emergency surgery. Superimposed on this background of uncertainty is the new minimally invasive technique of MMAE. While the existing studies suggest a robust treatment effect, they are relatively small and also not prospective or randomized. As such, an adequately sized, multicentre, prospective RCT of MMAE both as sole therapy and as a surgical adjunct is needed. Such a trial will be critical in defining the safety and effectiveness (or lack thereof) of MMAE. Moreover, the data on conventional management will also be important in defining both the natural history and surgical outcomes for this disease state. | Review article |
Gomez-Paz S, Akamatsu Y, Salem MM et al. (2021) Upfront middle meningeal artery embolization for treatment of chronic subdural hematomas in patients with or without midline shift. Interventional neuroradiology: journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences 27(4): 571-6 | Case series n=23 follow up: 90 days | Upfront MMAE for CSDH with a thickness up to 25 mm provides adequate symptom relief, stabilisation and/or progressive resorption of the CSDH during follow up in carefully selected asymptomatic or mildly symptomatic patients even in the presence of a midline shift greater than 5 mm. | Small sample |
Hashimoto T, Ohashi T, Watanabe D et al. (2013) Usefulness of embolization of the middle meningeal artery for refractory chronic subdural hematomas. Surgical Neurology International 4:104 | Case series n=3 | Embolisation of the MMA is effective for refractory CSDH or CSDH patients with a risk of recurrence, and is considered an effective therapeutic method to stop hematoma enlargement and promote resolution. | Small sample |
Hirai S, Ono J, Odaki M et al. (2004) Embolization of the middle meningeal artery for refractory chronic subdural haematoma. Usefulness for patients under anticoagulant therapy. Interventional Neuroradiology 10(suppl2): 101-4 | Case series n=2 | Endovascular embolisation of the MMA was done in 2 patients with refractory CSDH after repeated burr hole and irrigation surgeries. The embolisation prevented expansion of the CSDH in both patients, and the haematoma disappeared completely in one case. The expansion of CSDH is considered to result from repeated bleeding from the macrocapillaries on the haematoma capsule. Embolisation of the MMA appears to be useful to eliminate the blood supply to this structure. | Small sample |
Imai R, Akiyama T, Mizutani K et al. (2022) A case of refractory chronic subdural hematoma and internal carotid artery stenosis sequentially treated with surgical drainage, middle meningeal artery embolization, and carotid artery stenting. Surgical Neurology International 13 | Case report n=1 | Under the circumstances where CSDH is present but antiplatelet therapy is inevitable, MMAE could be a reasonable treatment option to avoid additional surgical procedures. Furthermore, early intervention should be considered even for asymptomatic carotid stenosis in terms of shortening the administration period of antiplatelet agents. | Single case report |
Ishihara H, Ishihara S, Kohyama S et al. (2007) Experience in endovascular treatment of recurrent chronic subdural hematoma. Interventional Neuroradiology 13(suppl1): 141-4 | Case series n=7 follow up: up to 15 months | Seven cases of intractable CSDH were treated by MMAE and no recurrence took place in all cases for up to 15 months. Endovascular treatment may be a good alternative modality for recurrent CSDH. | Small sample |
Joyce E, Bounajem MT, Scoville J et al. (2020) Middle meningeal artery embolization treatment of nonacute subdural hematomas in the elderly: a multiinstitutional experience of 151 cases. Neurosurgical focus 49(4): e5 | Non-randomised comparative study n=121 (age 65 to 79 years, n=70; age 80 years and above, n=51) follow up: 90 days | MMAE can be used safely and effectively as an alternative or adjunctive minimally invasive treatment for nonacute subdural haematomas in elderly and advanced elderly patients. | This study was included in Ironside (2021). |
Jumah F, Osama M, Islim AI et al. (2020) Efficacy and safety of middle meningeal artery embolization in the management of refractory or chronic subdural hematomas: a systematic review and meta-analysis. Acta neurochirurgica 162(3): 499-507 | Systematic review and meta-analysis n=11 studies (3 cohort studies and 8 case series) | Although MMAE appears to be a promising treatment for refractory or CSDH, drawing definitive conclusions remains limited by paucity of data and small sample sizes. Multicentre, randomised, prospective trials are needed to compare embolisation to conventional treatments like watchful waiting, medical management, or surgical evacuation. More extensive research on MMAE could begin a new era in the minimally invasive management of CSDH. | Of the 11 studies, 8 studies (3 cohort studies and 5 case series) were included in Ironside (2021) and 3 studies had small sample (<10 patients in each study). |
Kan P, Maragkos GA, Srivatsan A et al. (2020) Middle meningeal artery embolisation for chronic subdural hematoma: a multi-center experience of 154 consecutive embolisations. Neurosurgery 88: 268-77 | Case series n=138 follow up: mean 95 days | MMAE may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques. | This study was included in Ironside (2021). |
Kanazawa T, Miwa, Tomoru A, Takenori et al. (2019) A case of aggressive recurrent intracranial subdural hematoma associated with angiosarcoma originating from the skull. World neurosurgery 126: 120-123 | Case report n=1 follow up: 16 days after the first surgery | In addition to cancers metastatic to the skull or dura mater, angiosarcoma should be included in the differential diagnosis for patients with repeated SDH and bone defect. An effective treatment for angiosarcoma with SDH that shows an unfavourable prognosis has not been established; however, an early diagnosis might be useful for a novel treatment. | Single case report |
Kim E (2017) Embolization therapy for refractory hemorrhage in patients with chronic subdural hematomas. World neurosurgery 101: 520-527 | Non-randomised comparative study n=43 follow up: 3 months | This pilot study indicated that perioperative MMAE could be offered as the least invasive and most effectual means of treatment for resistant patients of CSDHs with 1 or more recurrences. | Small sample |
Kocharian G, Zappi KB, Carnevale J et al. (2022) Recent advances and future directions in middle meningeal artery embolization for chronic subdural hematomas. Current pain and headache reports 26(8): 657-65 | Review | In reviewing the literature on MMAE, there are numerous retrospective studies and systematic reviews demonstrating its safety and efficacy, and some prospective dual-arm studies that present novel information. The numerous clinical trials that are currently underway should help to further establish MMAE as standard of care in the management of CSDH. | Review article |
Komiyama M, Yasui T, Tamura K et al. (1994) Chronic subdural hematoma associated with middle meningeal arteriovenous fistula treated by a combination of embolization and burr hole drainage. Surgical neurology 42(4): 316-9 | Case report n=1 follow up: 2 months | A rare case of CSDH associated with a middle meningeal arteriovenous fistula was treated by a combination of embolisation and burr hole drainage. The patient was discharged without any neurologic deficit about 2 months later. | Single case report |
Kosaka T, Ikeda N, Furuse M et al. (2020) Refractory chronic subdural hematoma associated with dural metastasis of lung adenocarcinoma treated with endovascular embolization for the middle meningeal artery: a case report and review of the literature. World neurosurgery 133: 256-259 | Case report n=1 follow up: 1 month | Embolisation of the MMA has few surgical risks and could be a treatment option for refractory CSDH associated with dural metastasis because it might prolong the therapeutic time window until radical therapies are administered. | Single case report |
Larson A, Savastano L, Rammos S et al. (2020) Middle meningeal artery embolixation for chronic subdural hematoma: rationale, technique, and results. Contemporary Neurosurgery 42 | Review | As with any currently investigated and proposed procedure that has the potential to incur additional cost and/or risk, it will be of pivotal importance to properly select patients who could significantly benefit from embolisation at minimal risk. Although demographics and clinical features are expected to play a predominant role in patient selection, imaging features on standard axial and perfusion studies, such as the presence of hyperdense, densely septated pseudomembranes, or ones with increased blood flow or metabolic activity, are expected to steer rigorous selection of patients for embolization either as an exclusive or adjunctive CSDH treatment option in the future. | Review article |
Lee S, Srivatsan A, Srinivasan VM et al. (2021) Middle meningeal artery embolization for chronic subdural hematoma in cancer patients with refractory thrombocytopenia. Journal of neurosurgery: 1-5 | Case series n=22 follow up: up to 453 days | Transfemoral or transradial MMAE is a potential therapeutic option for thrombocytopenic cancer patients with SDH. However, treatment benefit may be marginal for patients with high disease burden and limited life expectancy. A prospective trial is warranted to address these questions. | Small sample |
Li G, Zhang Y, Zhao J et al. (2019) Isolated subdural hematoma secondary to Dural arteriovenous fistula: a case report and literature review. BMC neurology 19(1): 43 | Case report n=1 follow up: 1 month | Isolated SDH is a rare complication of DAVF. In this report, a rare case of CSDH secondary to an intracranial DAVF was presented. The so-called benign type of DAVF without cortical venous drainage does not always warrant a benign process and might be complicated with SDH. Careful preoperative investigation is needed for relatively young patients presenting with idiopathic or atypical SDH. | Single case report |
Link TW, Boddu S, Marcus J et al. (2018) Middle meningeal artery embolization as treatment for chronic subdural hematoma: a case series. Operative neurosurgery (Hagerstown, Md.) 14(5): 556-62 | Case series n=6 follow up: 3 to 31 weeks | In this case series of 6 patients harbouring 7 recurrent, chronic SDHs, 6 of the 7 were successfully treated with MMAE and able to avoid surgery for reevacuation, suggesting that this minimally invasive technique may represent an effective alternative to surgery. | Small sample |
Majidi S, Matsoukas S, De Leacy RA et al. (2022) Middle meningeal artery embolization for chronic subdural hematoma using N-Butyl cyanoacrylate with d5w push technique. Neurosurgery 90(5): 533-7 | Case series n=61 follow up: 6 months | MMAE using diluted n-BCA with concomitant D5W injection is associated with a high degree of distal penetration and complete branch occlusion and minimal risk of cranial nerve palsy or other thromboembolic complications. | Studies with larger samples or better designs are included in the main evidence. |
Mandai S, Sakurai M and Matsumoto Y (2000) Middle meningeal artery embolization for refractory chronic subdural hematoma. Case report. Journal of neurosurgery 93(4): 686-8 | Case report n=1 | Embolisation therapy for CSDH is a possible new treatment. Although a single case does not establish a management regimen, authors believe that this represents a significant fronted with this challenging clinical situation. | Single case report |
Matsumoto H, Hanayama H, Okada T et al. (2018) Which surgical procedure is effective for refractory chronic subdural hematoma? Analysis of our surgical procedures and literature review. Journal of clinical neuroscience: official journal of the Neurosurgical Society of Australasia 49: 40-7 | Case series n=14 (irrigation, n=8; MMAE and irrigation, n=4; craniotomy, n=2) | When selecting a surgical procedure for refractory CSDH, assessing whether CSDH is organised is crucial. Because embolisation of the MMA was effective for refractory CSDH, the surgical procedure may be considered as one of the treatment options for refractory CSDH without organised hematoma. On the other hand, for refractory cases of organized CSDH, hematoma evacuation with craniotomy or endoscope rather than embolization of the MMA may be suitable, as previous reports have recommended. | Small sample |
Mewada T, Ohshima T, Yamamoto T et al. (2016) Usefulness of embolization for iatrogenic dural arteriovenous fistula associated with recurrent chronic subdural hematoma: a case report and literature review. World neurosurgery 92: 584e7-584e10 | Case report n=1 | Refractory chronic subdural hematoma with reaccumulation within a short interval should be subjected to digital subtraction angiography of the MMA. Embolisation of ipsilateral MMA is safe, effective, and a useful option for the treatment of iatrogenic DAVF and resolution of hematoma | Single case report |
Mino M, Nishimura S, Hori E et al. (2010) Efficacy of middle meningeal artery embolisation in the treatment of refractory chronic subdural hematoma. Surgical Neurology International 1:78 | Case series n=4 follow up: more than 6 months | MMAE can be an effective adjuvant procedure in preventing the recurrence of CSDH. | Small sample |
Mohamed S, Villabona A, Kennion O et al. (2022) Middle meningeal artery embolisation for chronic subdural haematomas: the first prospective UK study. British Journal of Neurosurgery | Case series n=15 follow up: 3 months | For select patients, MMAE is a safe alternative treatment option for chronic subdural haematoma. As more experience is gained, the procedure could be done under local anaesthetic. | Small sample |
Moshayedi P and Liebeskind DS (2020) Middle meningeal artery embolization in chronic subdural hematoma: implications of pathophysiology in trial design. Frontiers in Neurology 11: 923 | Review | Frequent multimodal imaging and CSDH sampling would enable us to understand mechanisms of MMAE in CSDH treatment and therefore improve our ability to offer MMAE to the eligible population. | Review article |
Mureb MC, Kondziolka D, Shapiro M et al. (2020) DynaCT enhancement of subdural membranes after middle meningeal artery embolization: insights into pathophysiology. World neurosurgery 139: e265-e270 | Case series n=8 follow up: mean 89 days | The data lend support to the theory of contiguous vascular networks between the MMA and SDH membranes. Targeting these leaky vascular networks might remove the source of haematoma accumulation. These data add to the pathophysiological understanding of the disease and suggests potential insights into the mechanism of action of MMAE. | Small sample |
Nakagawa I, Park HS, Kotsugi M et al. (2019) Enhanced hematoma membrane on DynaCT images during middle meningeal artery embolization for persistently recurrent chronic subdural hematoma. World neurosurgery 126: e473-e479 | Case series n=20 | Repeatedly recurrent CSDH can be safely treated and cured by MMAE. Hematoma membrane enhancement pattern using DynaCT images can predict repeated recurrences CSDH. | Small sample |
Neth BJ, Ighodaro ET, Brinjikji W et al. (2021) Management of chronic subdural hematoma in patients requiring therapeutic anticoagulation. Neurologist: a214 | Case series n=2 | The cases provide anecdotal evidence of a challenging clinical scenario where there is a necessary indication for therapeutic anticoagulation and comorbid SDH. Endovascular MMAE may be an effective adjunct therapy for clinical scenarios in patients with SDH and an urgent indication for anticoagulation. Longer follow-up, prospective series, and future RCTs are needed to objectively assess outcomes in this clinically challenging patient population. | Small sample |
Ng S, Derraz I, Boetto J et al. (2020) Middle meningeal artery embolization as an adjuvant treatment to surgery for symptomatic chronic subdural hematoma: a pilot study assessing hematoma volume resorption. Journal of neurointerventional surgery 12(7): 695-9 | Pilot study (randomised) n=41 (surgery, n=22; surgery and MMAE, n=19) follow up: 3 months | The addition of MMAE to surgery led to an increase in CSDH resorption at 3 months. One recurrence of CSDH was reported in each group, and there were no treatment-related complications. | This study was included in Ironside (2021). |
Okuma Y, Hirotsune N, Sotome Y et al. (2022) Middle meningeal artery embolization for chronic subdural hematoma with cerebrospinal fluid hypovolemia: A report of 2 cases. Neuro-Chirurgie 68(1): 123-8 | Case series n=2 | MMAE might be considered as a preferred therapeutic option for CSDHs with cerebrospinal fluid hypovolemia syndromes in order to buy time before the epidural blood patch starts working. | Small sample |
Okuma Y, Hirotsune N, Sato Y et al. (2019) Midterm follow-up of patients with middle meningeal artery embolization in intractable chronic subdural hematoma. World neurosurgery 126: e671-e678 | Case series n=17 follow up: mean 26.3 months | Despite the known unfavourable outcomes of patients with intractable CSDHs, MMAE was not associated with recurrent CSDH or rehospitalisation in the current case series. MMAE should be considered a preferred therapeutic option for intractable CSDHs. | Small sample |
Onyinzo, Christina, Berlis, Ansgar, Abel, Maria et al. (2022) Efficacy and mid-term outcome of middle meningeal artery embolization with or without burr hole evacuation for chronic subdural hematoma compared with burr hole evacuation alone. Journal of neurointerventional surgery 14(3): 297-300 | Non-randomised comparative study n=132 (burr hole irrigation and MMAE, n=31; burr hole irrigation, n=82; MMAE, n=19) follow up: mean 3.2 months | MMAE is a safe and efficacious minimal invasive adjuvant and/or alternative procedure for the treatment of CSDH with a reduced recurrence rate. | Small sample for patients who had MMAE. |
Petrov AE, Rozhchenko LV, Ivanov AA et al. (2021) The first experience of endovascular treatment of chronic subdural hematomas with non-adhesive embolization materials of various viscosities: Squid 12 and 18. Zhurnal voprosy neirokhirurgii imeni N. N. Burdenko 85(5): 80-7 | Case report n=1 | The technique protected by the RF patent confirmed an effectiveness of liquid non-adhesive embolisation agents of various viscosities for the treatment of chronic subdural hematomas. Endovascular embolisation ensures delivering the embolizing material directly into the newly formed vessels supplying hematoma capsule. Reflux of embolisation agent into dangerous anastomoses should be avoided in this case. | Single case report |
Petrov A, Ivanov A, Rozhchenko L et al. (2021) Endovascular treatment of chronic subdural hematomas through embolization: A pilot study with a non-adhesive liquid embolic agent of minimal viscosity (squid). Journal of Clinical Medicine 10(19): 4436 | Case series n=10 follow up: 6 months | A distal catheterization of the MMA for the endovascular embolisation of CSDH with Squid allowed for the devascularization of the MMA and the dependent vessels of the hematoma capsule. This procedure resulted in a partial or complete resolution of the CSDH. Procedural complications were not encountered. | Small sample |
Rajah GB, Waqas M, Dossani RH et al. (2020) Transradial middle meningeal artery embolization for chronic subdural hematoma using Onyx: case series. Journal of neurointerventional surgery 12(12): 1214-8 | Case series n=46 follow up: mean 8 weeks | Transradial Onyx MMAE under conscious sedation is safe and effective for CSDH treatment. TRA may be especially useful in elderly patients with numerous comorbidities. | This study was included in Ironside (2021). |
Raviskanthan S, Mortensen PW, Zhang YJ et al. (2021) Bilateral abducens nerve palsies after middle meningeal artery embolization for chronic subdural hematoma. Journal of neuro-ophthalmology: the official journal of the North American Neuro-Ophthalmology Society | Case report n=1 follow up: 2 months | There are many potential mechanisms for abducens nerve palsy in the setting of SDH, including traumatic, ischemic, and nonlocalising, increased or decreased intracranial pressure. There was no imaging evidence for direct mass effect, tractional irritation on the abducens nerves, or typical imaging features of altered intracranial pressure or large vessel or brainstem stroke. No systemic hypotension occurred. The possible role of indirect ischemia after embolisation of the middle meningeal artery cannot be completely excluded. | Single case report |
Rennert, Janine, Seiz, Marcel, Nimsky, Christopher et al. (2008) Endovascular treatment of traumatic high flow dural arterio-venous fistula involving the middle meningeal artery and facial veins. Rontgenpraxis; Zeitschrift fur radiologische Technik 56(5): 164-8 | Case report n=1 | This case illustrates possible ''dangerous'' collateral circulation to the ophthalmic artery–a feature that should be kept in mind during endovascular treatment of this entity. | Single case report |
Rutledge C, Baranoski JF, Catapano JS et al. (2021) Republished: Resolution of an enlarging subdural haematoma after contralateral middle meningeal artery embolisation. Journal of NeuroInterventional Surgery | Case report n=1 follow up: 3 months | There are cross-midline collaterals and anastomoses between MMA branches. Distal penetration of embolic material may increase the efficacy of MMAE by occluding these collaterals and anastomoses. There may be a role for contralateral embolisation in cases where the ipsilateral proximal MMA is not navigable or is surgically truncated. | Single case report |
Sato M, Mochizuki Y, Fukuchi M et al. (2022) Middle meningeal artery embolization before craniotomy for infected organizing chronic subdural hematoma: A case report and review of the literature. Surgical Neurology International 13: 186 | Case report n=1 follow up: 6 months | Craniotomy is effective for the treatment of infected organising SDH, and MMAE is useful to reduce the risk of bleeding complications in the perioperative period and may also reduce the recurrence of CSDH. | Single case report |
Samarage HM, Kim WJ, Zarrin D et al. (2022) The "bright falx" sign-midline embolic penetration is associated with faster resolution of chronic subdural hematoma after middle meningeal artery embolization: a case series. Neurosurgery 91(3): 389-398 | Case series n=37 follow up: 6 months | Distal penetration of embolic material, particularly n-butyl cyanoacrylate, into the falx may lead to more rapid improvement of CSDH. | Small sample |
Sarma P, Garg M, Prem P et al. (2022) Embolization of the middle meningeal artery for the treatment of chronic subdural hematoma: a path less travelled so far. Journal of Neurosciences in Rural Practice 13(3): 471-5 | Case series n=5 follow up: 6 months | In carefully selected patients based on clinical profile and angiographic findings, MMAE can be an effective modality for the treatment in CSDH. | Small sample |
Sattur MG and Spiotta AM (2020) Anomalous "middle" meningeal artery from basilar artery and implications for neuroendovascular surgery: case report and review of literature. World neurosurgery 133: 84-9 | Case report n=1 follow up: 5 weeks | The embryologic origin of the entity is briefly discussed, along with suggestions for managing such an anomaly during endovascular embolisation. | Single case report |
Scerrati A, Visani J, Ricciardi L et al. (2020) To drill or not to drill, that is the question: nonsurgical treatment of chronic subdural hematoma in the elderly. A systematic review. Neurosurgical focus 49(4): e7 | Systematic review n=29 studies (pharmacological treatment, n=15 studies; MMAE, n=14 studies) | The results showed that surgery still represents the mainstay in cases of symptomatic patients with large CSDHs; however, adjuvant and alternative therapies can be effective and safe in a carefully selected population. Their inclusion in new guidelines is advisable. | No meta-analysis was conducted and limited outcomes for MMAE were reported. |
Schwarz J, Carnevale JA, Goldberg JL et al. (2021) Perioperative prophylactic middle meningeal artery embolization for chronic subdural hematoma: a series of 44 cases. Journal of Neurosurgery 135(6): 1627-35 | Case series n=44 follow up: mean 321 days | Perioperative prophylactic MMAE in the setting of surgical evacuation, via either craniotomy or SEPS, may help to lower the recurrence rate of CSDH. | Small sample |
Shotar E, Meyblum L, Premat K et al. (2020) Middle meningeal artery embolization reduces the post-operative recurrence rate of at-risk chronic subdural hematoma. Journal of neurointerventional surgery 12(12): 1209-13 | Non-randomised comparative study n=263 (MMAE, n=89; conventional management, n=174) | Postsurgical embolisation of the MMA may reduce the recurrence rate of CSDHs with a risk factor of recurrence. | This study was included in Ironside (2021) |
Shotar E, Barberis E, Chougar L et al. (2022) Long-term middle meningeal artery caliber reduction following trisacryl gelatine microsphere embolisation for the treatment of chronic subdural hematoma. Clinical Neuroradioly | Case series n=30 | Long-term follow-up MRI demonstrated a significant impact of TAGM embolisation on MMA proximal caliber as well as on the visibility of the two main MMA branches. All comparisons indicated that there was a probable lasting impact of embolisation on the patency of distal branches. | Small sample |
Shotar E, Premat K, Barberis E et al. (2021) Dural arteriovenous fistula formation following bilateral middle meningeal artery embolization for the treatment of a chronic subdural hematoma: a case report. Acta neurochirurgica 163(4): 1069-73 | Case report n=1 follow up: 3 months | The case highlights the possible role of local tissue hypoxia as a significant component of DAVF pathogenesis. Moreover, it has potential implications for MMAE as a management strategy for CSDH. | Single case report |
Shotar E, Premat K, Lenck S et al. (2022) Angiographic anatomy of the middle meningeal artery in relation to chronic subdural hematoma embolization. Clinical neuroradiology 32(1): 57-67 | Case series n=122 | In the majority of CSDH patients both anterior and posterior branches of the MMA should be targeted to achieve extensive convexity devascularisation. Frequent anatomical variations of the MMA with respect to emergence of the posterior branch and MMA orbital branches are expected to impact CSDH embolisation strategy. | This study describes MMA angiographic anatomy in relation to CSDH embolisation. |
Srivatsan A, Mohanty A, Nascimento FA et al. (2019) Middle meningeal artery embolization for chronic subdural hematoma: meta-analysis and systematic review. World neurosurgery 122: 613-619 | Systematic review and meta-analysis n=9 studies (3 double-arm studies and 6 case series) | MMAE is a promising treatment for CSDH. Future randomised clinical trials are needed. | Three double-arm studies in the meta-analysis were included in Ironside (2021). Of the 6 case series, 4 were also included in Ironside (2021) and 2 case series had a total of 9 patients. |
Stanishevskiy AV, Babichev KN, Vinogradov EV et al. (2021) Middle meningeal artery embolization for chronic subdural haematoma. Case series and literature review. Zhurnal voprosy neirokhirurgii imeni N. N. Burdenko 85(5): 71-9 | Case series n=32 (MMAE alone, n=22; MMAE followed by debridement through a milling hole, n=10) follow up: 1 to 5 months | MMAE in patients with CSDH is a justified, highly effective and relatively safe approach. This method is characterised by lower risk of recurrence compared to surgical and conservative treatments and can be considered as an alternative to traditional treatment options. | Small sample |
Tabibian BE; Liptrap E and Jones J (2021) Incidentally discovered dural arteriovenous fistula during middle meningeal artery embolization for the treatment of chronic subdural hematoma. Surgical Neurology International 12: 438 | Case series n=3 | As MMAE for CSDH becomes more frequent, so may the incidental diagnosis of DAVF. Awareness of this potential association is critical to diagnosing DAVF with angiography and altering treatment strategies as needed. | Small sample |
Tavakkoli A, Montejo JD, Calnan DR et al. (2022) Intra-operative emergence of occult dural arteriovenous fistula after middle meningeal artery embolization for chronic subdural hematoma: Case report and literature review. Radiology Case Reports 17(5): 1470-4 | Case report n=1 | This is the first case of intraoperative emergence of occult MMA-DAVF with intracranial drainage during MMAE for chronic subdural hematoma treatment. This observation supports monitoring for and embolising spontaneous MMA-DAVF following MMAE. | Single case report |
Tempaku A, Yamauchi S, Ikeda H et al. (2015) Usefulness of interventional embolization of the middle meningeal artery for recurrent chronic subdural hematoma: Five cases and a review of the literature. Interventional neuroradiology: journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences 21(3): 366-71 | Case series n=5 follow up: 4 to 60 weeks | No more recurrence of CSDH was observed in any of the patients. During the follow-up period, no patients suffered from any side effects or complications from the interventional treatment. MMAE with careful attention paid to the procedure might be a treatment for recurrent CSDH. | Small sample |
Tiwari A, Dmytriw AA, Bo R et al. (2021) Recurrence and coniglobus volumetric resolution of subacute and chronic subdural hematoma post-middle meningeal artery embolization. Diagnostics 11(2): 257 | Case series n=10 follow up: 91+ days | MMAE contributed to a marked reduction in SDH volume postoperatively and can be used as a curative therapy for primary or recurrent CSDH. | Small sample |
Wang HL, Wang C and Li ZF (2020) Recurrent bilateral chronic subdural hematoma after interventional embolization combined with drilling and drainage treatment. The Journal of craniofacial surgery 31(2): e171-e173 | Case series n=2 | For unilateral CSDH, MMAE combined with drilling could be an effective strategy for treating CSDH. However, for patients with bilateral CSDH, because the recurrence mechanism of bilateral CSDH rebleeding on the contralateral side may be more similar to that of the initial occurrence mechanism of unilateral CSDH, a more effective method is needed to treat it. | Small sample |
Waqas M, Vakhari K, Weimer PV et al. (2019) Safety and effectiveness of embolization for chronic subdural hematoma: systematic review and case series. World neurosurgery 126: 228-36 | Systematic review and case series n=15 studies n=8 patients | MMAE of CSDH is safe and effective for CSDH treatment based on a documented recurrence rate of 3.6% and lack of reported complications. | Of the 15 studies, 12 studies were included in Ironside (2021) and Haldrup (2020), and 3 studies had a total of 12 patients. The case series had a small sample. |
Wei Q, Fan G, Wang Q et al. (2021) Middle meningeal artery embolization for the treatment of bilateral chronic subdural hematoma. Frontiers in Neurology 12: 651362 | Case series n=10 follow up: 4 months | Bilateral MMAE combined with bilateral burr-hole drainage is an available treatment for patients with bilateral CSDH and may have the potential for preventing recurrence. | Small sample |
Wong GK, Cheung EY, Ng RY et al. (in press) Middle meningeal embolization for chronic subdural hematoma: a case series of 7 patients and review of time course of resolution. Brain Hemorrhages | Case series n=7 follow up: 6 months | MMAE is safe and feasible within the framework of surgery to cure and prevent recurrence. | Small sample |
Yajima H, Kanaya H, Ogino M et al. (2020) Middle meningeal artery embolization for chronic subdural hematoma with high risk of recurrence: A single institution experience. Clinical neurology and neurosurgery 197: 106097 | Case series n=18 follow up: 2 to 53 months | MMAE is effective and safe in preventing recurrence of CSDH with high risk of recurrence and could be a standard treatment for such cases. | Small sample |
Yu J, Guo Y, Xu B et al. (2016) Clinical importance of the middle meningeal artery: A review of the literature. International journal of medical sciences 13(10): 790-9 | Review | For recurrent CDSHs, after burr hole irrigation and drainage have failed, MMAE may be attempted. The vessels in the outer membrane of the CSDH cross the dura mater to connect to the MMA. This becomes the basis for performing MMAE. However, MMAE was only effective when diffuse dilatation of the MMA and the abnormal vascular networks could be observed. When embolising the MMA, caution should be exercised to prevent aberrant flow into the dangerous anastomosis, which can cause complications. | Review article |
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