Comparing different techniques in the management of chronic subdural hematoma - What is the role of middle meningeal artery embolization?: A systematic review and network meta-analysis

Paleare L.F.F.; Batista S.; Camerotte R.; Gonçalves O.R.; Mitre L.P.; Borges P.G.L.B.; Vilardo M.; Maia H.; Fukunaga C.K.; Bocanegra-Becerra J.E.; Nogueira B.V.; de Figueiredo A.L.D.; Brito R.N.; Ferreira M.Y.; Noleto G.S.; Paiva W.S. · Clinical Neurology and Neurosurgery (2025) · DOI: 10.1016/j.clineuro.2025.108995

Resumen

Background: Chronic subdural hematomas (cSDHs) are potentially life-threatening neurological conditions with an increasing incidence worldwide. However, comparative data on the different cSDH managements remain limited. Herein, we aimed to conduct a network meta-analysis comparing standalone embolization (EMB), surgery, EMB plus surgery (EMBSurgery), and observation, to provide further clarity. Method: We systematically searched PubMed, Embase, Web of Science, and Cochrane Library for studies comparing at least two cSDH approaches between EMB, surgery, EMBSurgery, and observation. Primary endpoints included the need for reintervention, length of hospital stay, procedure-related complications, and mortality. Random-effects model was used to calculate mean difference (MD) and odds ratio (OR) under a 95 % confidence interval (CI). Cost-effective analysis and subanalyses for the randomized studies were conducted. Results: A total of 19 studies involving 23,996 patients were included. A significant reduction in reintervention was observed with EMBSurgery (OR 0.21, CI 0.04–0.79), while EMB showed a non-significant reduction (OR 0.41, CI 0.12–1.32), compared to surgery. EMBSurgery neither significantly increased hospital stay (MD 4.80, CI −0.435–11.4) nor yielded higher complications (OR 1.11, CI 0.49–2.36) compared to surgery. Indeed, lower mortality was observed in both groups (EMB: OR 0.61, CI 0.03–5.08; EMBSurgery: OR 0.41, CI 0.03–3.05) and procedural costs were not significantly higher for EMB and EMBSurgery compared to surgery (EMB: MD 32,000, CI –13,500–70,300; EMBSurgery: MD 16,200, CI –40,100–72,600). Subanalyses revealed significantly lower reintervention rates in the EMBSurgery group versus the surgery group (OR 0.34, CI 0.16–0.74; I2 0 %). Conclusion: EMB combined with surgery seems to reduce reinterventions in cSDH compared to surgery alone with non significant complications that need further analysis through randomized trials with longer follow-ups.

Instituciones: Universidad Peruana Cayetano Heredia