Endovascular middle meningeal artery embolization for chronic subdural hematoma in surgically ineligible patients: short-term outcomes and safety profile

Abstract

Abstract Background Chronic subdural hematoma (CSDH) carries high recurrence rates after surgical evacuation. This study evaluates endovascular middle meningeal artery (MMA) embolization as a minimally invasive alternative for patients with CSDH unsuitable for surgery due to medical contraindications. Methods We retrospectively analyzed 40 consecutive patients with CSDH treated with endovascular MMA embolization using polyvinyl alcohol particles between January 2023 and June 2025. Inclusion criteria: primary or recurrent CSDH with surgical contraindications. Exclusion criteria: acute neurological deterioration requiring urgent decompression. Clinical severity was assessed using the Markwalder grading system. Computed tomography measurements of hematoma thickness (HT) and midline shift were obtained at baseline and 3-month follow-up. Technical success was defined as successful MMA occlusion with preserved normal circulation. Results Among 40 patients (mean age 68.2 ± 11.3 years; 70% male), 24 (60%) were Markwalder grade 1 and 16 (40%) grade 2. Technical success was achieved in 38 patients (95%). Mean hematoma thickness decreased significantly from 23.2 ± 5.1 to 5.3 ± 3.8 mm (77.1% reduction, p < 0.001). Favorable radiologic outcomes (≥ 50% reduction) occurred in 36 patients (90%), including complete resolution in 15 (37.5%). The mean hospital stay was 2.1 ± 1.2 days, with no major complications. MMA diameter was the only significant predictor of a favorable outcome (OR 1.18 per 0.1 mm, p = 0.009). Conclusions Endovascular MMA embolization achieves high technical success and favorable short-term outcomes in surgically ineligible patients with CSDH, with significant hematoma reduction and an excellent safety profile.