Middle meningeal artery embolisation cuts recurrence and reoperation in chronic subdural haematoma

Design

Systematic review and meta-analysis of randomised controlled trials, RoB-2 assessed, registered protocol

Population

1,889 adults with confirmed chronic subdural haematoma across seven randomised trials

Primary outcome

Haematoma recurrence or persistence

Effect

Recurrence RR 0.63 (95% CI 0.46 to 0.85); reoperation RR 0.39 (0.28 to 0.56); serious adverse events RR 0.87 (0.72 to 1.06)

Seven randomised trials with 1,889 adults were pooled, comparing middle meningeal artery embolisation added to standard treatment against standard treatment alone in chronic subdural haematoma, with RoB-2 risk of bias assessment and a registered protocol. Recurrent or residual haematoma fell with embolisation, RR 0.63 (95% CI 0.46 to 0.85), and reoperation fell further, RR 0.39 (0.28 to 0.56). Serious adverse events did not rise, RR 0.87 (0.72 to 1.06), and neurological death, all-cause mortality and poor functional outcome were unchanged. Haematoma resorption itself did not differ significantly. Subgroup and sensitivity analyses held across age, timing of the procedure and length of follow-up.

The mechanism explains the pattern of results. Embolisation devascularises the dural membrane that keeps rebleeding into the collection; it does not clear the blood already there. So resorption is unchanged while recurrence and the need to go back to theatre both drop — a reduction of roughly 60% in reoperation is the number that reaches a service.

The timing finding is what makes this actionable. Benefit appeared independent of whether embolisation was done early or later, which removes the argument that it must be arranged within a narrow window to be worth doing. For a unit with interventional cover, that turns it from an emergency decision into a planned adjunct — worth discussing in the older patient on antithrombotics who has already recurred once, where the alternative is a second and third burr hole. Where neurointerventional access means a transfer, the recurrence reduction has to be weighed against that, and the trials do not settle it.

• Discuss embolisation as an adjunct in a patient who has already recurred after burr-hole drainage.
• Do not treat the timing as urgent — benefit was similar early and late.
• Expect fewer returns to theatre rather than faster clearance of the collection.
• Set the expectation with the family: mortality and functional outcome were unchanged.
• Where the procedure means an inter-hospital transfer, weigh that against a recurrence risk this reduces but does not remove.

The statistics, in plain English

A risk ratio of 0.39 for reoperation, with an interval of 0.28 to 0.56 that stays well below 1.0, is a clear and clinically large reduction, not merely a statistically significant one — that is the distinction worth making, because the same pooled analysis shows no change in mortality or functional outcome. What improves is the surgical course, not survival. The serious adverse event interval, 0.72 to 1.06, crosses 1.0 and so shows no increase in harm; with 1,889 patients it is tight enough to rule out anything but a small excess. Note that resorption was unchanged: this is a result about rebleeding, and reading it as faster clearance would misdescribe what the procedure does.

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