PRECISION MIDDLE MENINGEAL ARTERY EMBOLIZATION FOR CHRONIC SUBDURAL HEMATOMA: RANDOMIZED EVIDENCE, EMBOLIC-AGENT SELECTION, RECURRENCE PHENOTYPING, AND INTEGRATION WITH SURGICAL DRAINAGE

Аннотация

Background. Chronic subdural hematoma is one of the most common neurosurgical disorders in older adults and is increasingly encountered in patients receiving antiplatelet or anticoagulant therapy.  Burr-hole  evacuation  with  closed-system  drainage  remains  the  standard  treatment  for symptomatic lesions producing significant mass effect, but recurrence after apparently successful decompression remains a clinically important problem. Middle meningeal artery embolization has emerged as a pathophysiologically targeted treatment aimed at interrupting the vascular supply of the inflammatory neomembranes responsible for persistent exudation and recurrent bleeding.
Materials and Methods. A structured narrative review was performed using randomized controlled trials, prospective multicenter studies, large observational cohorts, surgical trials, and embolization  studies  available  through  August  2026.  Particular  attention  was  directed  toward EMBOLISE, MAGIC-MT, STEM, EMPROTECT, and MEMBRANE; surgical drainage; recurrence- risk factors; liquid and particulate embolic agents; anatomical safety; radial versus femoral access; radiographic resorption; and patient selection for adjunctive or stand-alone embolization.
Results. Contemporary randomized evidence supports a clinically meaningful role for middle meningeal artery embolization, but treatment effects differ according to patient selection, embolic agent, timing, and definition of treatment failure. EMBOLISE demonstrated lower recurrence or progression requiring repeat surgery when embolization was added to surgical evacuation. STEM demonstrated a reduction in a broader composite treatment-failure endpoint across surgical and nonsurgical management pathways. MAGIC-MT showed a numerically lower rate of symptomatic recurrence  or  progression  but  did  not  demonstrate  superiority  for  its  primary  90-day  endpoint. EMPROTECT, which used microparticle embolization after surgery in high-risk patients, did not achieve  a  statistically  significant  reduction  in  six-month  recurrence.  In  contrast,  the  2026 MEMBRANE randomized trial using n-butyl cyanoacrylate demonstrated a significant reduction in residual or recurrent hematoma or surgical failure at six months. These apparently discordant findings suggest that middle meningeal artery embolization should not be viewed as a single homogeneous procedure.
Conclusion. Middle meningeal artery embolization represents a major evolution in chronic subdural hematoma management, but it should complement rather than indiscriminately replace neurosurgical decompression. The most rational strategy is phenotype-specific: urgent surgery for clinically significant mass effect, adjunctive embolization for recurrence-prone disease, and selected stand-alone embolization for stable patients without an immediate decompressive requirement. Future research should focus on individualized recurrence prediction, embolic penetration, standardized radiographic endpoints, cost-effectiveness, and long-term functional outcomes.