Clinical Report: Middle Meningeal Embolization and Recurrence Factors in cSDH

Overview

This single-center retrospective study analyzed factors associated with recurrence requiring reoperation (RrR) in chronic subdural hematoma (cSDH) patients, focusing on the role of middle meningeal artery embolization (MMAE) as an adjunct to surgical evacuation. The study found that MMAE, alongside established clinical and radiological risk factors, may reduce recurrence rates in cSDH management.

Background

Chronic subdural hematoma (cSDH) is a common neurosurgical condition predominantly affecting the elderly, with an increasing incidence due to population aging. Surgical evacuation remains the mainstay treatment but is limited by high recurrence rates, reported up to 50%. Various factors, including hematoma architecture, volume, brain atrophy, coagulation status, and antiplatelet therapy, have been linked to recurrence risk. Recently, middle meningeal artery embolization (MMAE) has emerged as a promising adjunctive therapy to reduce recurrence.

Data Highlights

Key Findings

• MMAE was consistently offered as an adjunctive treatment from October 2022 onward, showing promise in reducing cSDH recurrence.
• Higher preoperative hematoma volume (>130 mL) and postoperative residual volume (>80 mL) were associated with increased recurrence risk.
• Internal hematoma architecture, particularly the Nakaguchi classification, correlated with recurrence, with the separated type posing the highest risk.
• Coagulation parameters, especially platelet count below 157 × 10⁹/L, and antiplatelet therapy influenced recurrence rates.
• Postoperative pneumocephalus, brain atrophy, and bilateral hematomas were additional predictors of recurrence.
• Standardized embolization technique performed by experienced neurointerventional radiologists minimized procedural variability.

Clinical Implications

Incorporating MMAE as an adjunct to surgical evacuation may reduce the high recurrence rates of cSDH, particularly in patients with known risk factors such as large hematoma volumes and adverse hematoma architecture. Careful preoperative assessment of coagulation status and management of antiplatelet therapy remain critical. Postoperative imaging to evaluate residual volume and pneumocephalus can guide prognosis and follow-up strategies.

Conclusion

This study supports the role of MMAE alongside surgical evacuation in lowering recurrence rates of cSDH and highlights multiple clinical and radiological factors that should inform individualized patient management to optimize outcomes.

References

1. Nakaguchi et al. 2001 -- Classification of cSDH and recurrence risk
2. Stanišic et al. 2022 -- Volumetric parameters and cSDH relapse
3. Eagle et al. 2020 -- Platelet count and cSDH recurrence
4. PROCESS 2023 guidelines -- Reporting case series
5. ClinicalTrials.gov NCT06835634 -- PANDA registry