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Middle meningeal artery embolization for chronic subdural hematoma: an effective treatment with a bright future
  1. Michael R Levitt1,
  2. Joshua A Hirsch2,
  3. Michael Chen3
  1. 1 Departments of Neurological Surgery, Radiology, Neurology, Mechanical Engineering, and Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
  2. 2 Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  3. 3 Neurology, Neurosurgery and Radiology, Rush University Medical Center, Chicago, Illinois, USA
  1. Correspondence to Dr Michael R Levitt, Department of Neurological Surgery, University of Washington, Seattle, WA 98195, USA; mlevitt{at}

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Neurointerventionalists are participating in a transformative moment in the field, from expanded thrombectomy indications,1 to the endovascular treatment of hydrocephalus,2 and endovascular brain–computer interfaces.3 Perhaps most consequential in recent years is the endovascular treatment of subacute or chronic subdural hematoma (cSDH) via middle meningeal artery embolization (MMAE). First reported in 20004 as salvage therapy in patients with high surgical comorbidities, this treatment has grown in popularity as its safety and efficacy have been studied.

cSDH carries a high morbidity, mortality, and healthcare resource burden.5 Existing medical and surgical treatments, while effective, are imperfect, with recurrence rates of up to 20%6 and reoperation rates of 12%.7 These high rates were considered acceptable given the limited alternatives; adjunct medical treatment is at best moderately helpful,8 and at worst, harmful.9 In this setting, MMAE for cSDH emerged as a promising alternative. Recent meta-analysis found reoperation rates falling to 4.6% in cSDH treated with surgery and adjunctive MMAE, and 6.8% in cSDH treated with MMAE alone.10 These results, while favorable, were based primarily on case series and retrospective data collection.

The results of three randomized, prospective trials of MMAE for the treatment of cSDH were simultaneously reported at the International Stroke Conference 2024 meeting. Embolization of the Middle Meningeal Artery With Onyx Liquid Embolic System in the Treatment of Subacute and Chronic Subdural Hematoma (EMBOLISE) is an investigator-initiated but industry-sponsored multicenter, prospective, randomized, interventional, controlled, open label, adaptive design clinical trial of MMAE for patients with symptomatic cSDH across 39 centers in the USA using Onyx (Medtronic Neurovascular, Irvine, CA). EMBOLISE targeted enrollment of up to 600 patients across two arms. Patients with mild cSDH (defined as midline shift <5 mm, hematoma thickness ≤15 …

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  • Contributors Conceived of the work: All authors. Drafting of the paper; guarantor: MRL. Revision of the draft: All authors.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests MRL: Unrestricted educational grants from Medtronic and Stryker; consulting agreement with Medtronic, Aeaean Advisers and Metis Innovative; equity interest in Proprio, Stroke Diagnostics, Apertur, Stereotaxis, Fluid Biomed, and Hyperion Surgical; editorial board of Journal of NeuroInterventional Surgery, Data safety monitoring board of Arsenal Medical; site PI, EMBOLISE clinical trial. JAH: Consulting agreement with Medtronic, Sanofi, Relievant, and Cerenovus; data safety monitoring board for Balt, Rapid Medical, Arsenal Medical; grant Support from the Neiman Health Policy Institute; editorial board of Journal of NeuroInterventional Surgery. MC: Consulting agreement with Medtronic, Penumbra, Q’Apel, RapidPulse, Balt, DSM Biomedical, Guerbet; editorial board of Journal of Neurointerventional Surgery; Clinical Events Committee for the STEM trial.

  • Provenance and peer review Not commissioned; internally peer reviewed.