Chronic subdural hematoma (cSDH) is a common condition, especially in the older population, and causes considerable morbidity. Recently, middle meningeal artery embolization (MMAE) has shown promise as a minimally invasive intervention for cSDH by disrupting the flow to the hematoma neomembranes and thus reducing recurrence.

We performed a systematic review of the literature using PubMed/Medline and Google Scholar to identify studies reporting on MMAE for cSDH over the past 30 years. After screening 4103 articles and reviewing 600 full-text studies, 176 studies were selected, including case reports, case series, retrospective and prospective studies and randomized controlled trials. Patient demographics, embolic agents used, frequency, type and severity of complications, hematoma recurrence and need for repeat surgery were extracted from the included studies.

Our analysis included 9780 patients (75.9% male), with mean/median ages ranging from 62.1 to 82.5 years. MMAE-related complications were reported in approximately 3%. Procedure-related neurological complications were the most frequent, followed by systemic complications, access site, non-procedure-related neurological complications, procedure-linked vascular complications specific to MMA and miscellaneous complications. Hematoma recurrence was reported in 6%, and repeat or rescue surgery was necessary in 6.1%. These results are consistent with major clinical trials evaluating MMAE safety and efficacy in cSDH.

Based on current published literature, MMAE appears to be an effective and overall safe treatment option for cSDH. Complications, although infrequent, can occur, and some of these are disabling. Meticulous pre-procedural planning and imaging are essential to reduce the risk of complications.