Adjunctive middle meningeal artery embolization after surgical evacuation of chronic subdural hematoma: An updated meta-analysis of randomized controlled trials

Background: Middle meningeal artery embolization (MMAE) has emerged as a promising adjunctive treatment for chronic subdural hematoma (cSDH); however, the efficacy and safety of adjunctive MMAE compared with surgery alone remains uncertain. Methods: We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception through June 2026. Randomized controlled trials comparing adjunctive MMAE plus surgical evacuation with surgical evacuation alone in patients with cSDH were included. The primary outcome was hematoma recurrence. Pooled odds ratios (ORs) with 95% CIs were calculated using a random-effects model. Results: A total of eight randomized controlled trials were included. The mean age of participants ranged from 64 to 77 years, and most participants were male. Adjunctive MMAE was associated with significantly lower odds of recurrence compared with surgery alone (OR, 0.31 [95% CI, 0.16–0.59]). No significant differences were observed in all-cause mortality (OR, 0.91 [95% CI, 0.24–3.42]), good functional outcome (OR, 1.23 [95% CI, 0.23–6.42]), or overall adverse events (OR, 1.02 [95% CI, 0.35–2.91]) between the groups. Conclusions: In this updated meta-analysis of randomized controlled trials, adjunctive MMAE significantly reduced recurrence without increasing complication rates. Although no significant improvements were observed in functional outcomes or mortality, these findings support adjunctive MMAE as an effective and safe strategy for improving disease control in patients undergoing surgical treatment for cSDH. © 2026 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license. http://creativecommons.org/licenses/by-nc-nd/4.0/