Embolizing the middle meningeal artery to treat chronic subdural hematoma: a systematic review and meta-analysis.

BACKGROUND: Comparative studies on the middle meningeal artery (MMA) embolization versus conventional management (CM) to treat chronic subdural hematoma (CSDH) yield inconsistent findings. OBJECTIVE: This systematic review sought to meta-analyze studies comparing MMA embolization versus CM for treating CSDH. METHODS: Terms including "hematoma", "subdural", "chronic", "meningeal arteries", "embolization", and "therapeutic" were applied to search PubMed, Embase, the Cochrane Library, and Web of Science databases from their inception to July 11, 2025. After independent reading, screening, and evaluation by two researchers, data were analyzed and processed using RevMan v5.4. RESULTS: Initially, 1,883 articles were retrieved. After eliminating 692 duplicates and excluding 1,087 articles that are conference abstracts, letters, or have ineligible research objectives, interventions, or outcomes, 104 articles were identified as potentially eligible. These articles were subsequently screened according to the eligibility criteria, and 20 studies were ultimately included. According to the meta-analysis, in the 20 studies involving 255,057 patients, 181,993 (71.4%) and 73,064 (28.6%) patients received MMA embolization and CM, respectively. MMA embolization performed better than CM in terms of treatment failure (relative risk [RR] = 0.40 [0.18-0.87], P = 0.007), recurrence rate (RR = 0.43 [0.32-0.57], P = 0.15), and complication rate (RR = 0.91 [0.77-1.08], P = 0.06). No difference was observed between the two groups for mortality (RR = 0.72 [0.55-0.94], P = 0.94), treatment failure rate (RR = 0.40 [0.18-0.87], P = 0.007), surgical salvage rate (RR = 0.59 [0.22-1.56], P = 0.29), rehospitalization (RR = 0.66 [0.41-1.06], P = 0.24), and improvement rate (RR = 1.05 [0.79-1.41], P = 0.43). CONCLUSION: MMA embolization may lower the failure rate of treatment and cut the demand for surgical salvage without elevating the risk. Therefore, MMA embolization may be considered in the management of CSDH. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/myprospero, PROSPERO CRD420251090976.