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Standalone middle meningeal artery embolization versus middle meningeal artery embolization with concurrent surgical evacuation for chronic subdural hematomas: a multicenter propensity score matched analysis of clinical and radiographic outcomes
  1. Huanwen Chen1,2,
  2. Mohamed M Salem3,
  3. Marco Colasurdo4,
  4. Georgios S Sioutas3,
  5. Jane Khalife5,
  6. Okkes Kuybu6,
  7. Kate T Carroll7,
  8. Alex Nguyen Hoang8,
  9. Ammad A Baig9,
  10. Mira Salih10,
  11. Mirhojjat Khorasanizadeh10,
  12. Cordell Baker11,
  13. Aldo Mendez Ruiz6,
  14. Gustavo M Cortez12,
  15. Zack Abecassis13,
  16. Juan Francisco Ruiz Rodríguez13,
  17. Jason M Davies14,
  18. Sandra Narayanan15,
  19. C Michael Cawley16,
  20. Howard Riina17,
  21. Justin Moore10,
  22. Alejandro M Spiotta18,
  23. Alexander Khalessi19,
  24. Brian M Howard20,21,
  25. Ricardo A Hanel22,
  26. Omar Tanweer23,
  27. Daniel Tonetti24,
  28. Adnan H Siddiqui25,26,
  29. Michael Lang27,
  30. Elad I Levy28,
  31. Tudor G Jovin29,
  32. Ramesh Grandhi11,
  33. Visish M Srinivasan30,
  34. Michael R Levitt7,
  35. Christopher S Ogilvy31,
  36. Brian Jankowitz32,
  37. Ajith J Thomas24,
  38. Bradley A Gross33,
  39. Jan Karl Burkhardt3,
  40. Peter Kan34
  1. 1National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
  2. 2Neurology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
  3. 3Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
  4. 4Interventional Radiology, Oregon Health and Science University, Portland, Oregon, USA
  5. 5Department of Neurosurgery, Cooper Medical School of Rowan University, Camden, New Jersey, USA
  6. 6Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Kansas, USA
  7. 7Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
  8. 8Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
  9. 9Neurosurgery, Buffalo State, The State University of New York, Buffalo, New York, USA
  10. 10Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  11. 11Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
  12. 12Neurosurgery, Lyerly Neurosurgery, Jacksonville, Florida, USA
  13. 13Department of Neurosurgery, University of Washington, Seattle, Washington, USA
  14. 14Neurosurgery and Biomedical Engineering, Toshiba Stroke and Vascular Research Institute, University at Buffalo, State University of New York, Buffalo, New York, USA
  15. 15Department of Neurology, Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
  16. 16Neurosurgery, Emory University, Atlanta, Georgia, USA
  17. 17Neurosurgery, NYU, New York, New York, USA
  18. 18Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
  19. 19Department of Neurological Surgery, University of California San Diego, La Jolla, California, USA
  20. 20Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
  21. 21Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
  22. 22Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
  23. 23Department of Neurosurgery, NYU Langone Health, New York, New York, USA
  24. 24Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
  25. 25Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
  26. 26Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
  27. 27Department of Neurosurgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
  28. 28Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
  29. 29Neurology, Cooper University Hospital, Camden, New Jersey, USA
  30. 30University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
  31. 31Department of Neurosurgery, BIDMC, Boston, Massachusetts, USA
  32. 32Neurosurgery, University of Pennsylvania, Camden, Pennsylvania, USA
  33. 33Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  34. 34Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
  1. Correspondence to Dr Peter Kan, Neurosurgery, University of Texas Medical Branch at Galveston, 250 Blossom St, Webster, Texas 77598, USA; ptkan{at}


Background Middle meningeal artery embolization (MMAE) has emerged as a promising therapy for chronic subdural hematomas (cSDHs). The efficacy of standalone MMAE compared with MMAE with concurrent surgery is largely unknown.

Methods cSDH patients who underwent successful MMAE from 14 high volume centers with at least 30 days of follow-up were included. Clinical and radiographic variables were recorded and used to perform propensity score matching (PSM) of patients treated with standalone MMAE or MMAE with concurrent surgery. Multivariable logistic regression models were used for additional covariate adjustments. The primary outcome was recurrence requiring surgical rescue, and the secondary outcome was radiographic failure defined as <50% reduction of cSDH thickness.

Results 722 MMAE procedures in 588 cSDH patients were identified. After PSM, 230 MMAE procedures remained (115 in each group). Median age was 73 years, 22.6% of patients were receiving anticoagulation medication, and 47.9% had no preoperative functional disability. Median midline shift was 4 mm and cSDH thickness was 16 mm, representing modestly sized cSDHs. Standalone MMAE and MMAE with surgery resulted in similar rates of surgical rescue (7.8% vs 13.0%, respectively, P=0.28; adjusted OR (aOR 0.73 (95% CI 0.20 to 2.40), P=0.60) and radiographic failure (15.5% vs 13.7%, respectively, P=0.84; aOR 1.08 (95% CI 0.37 to 2.19), P=0.88) with a median follow-up duration of 105 days. These results were similar across subgroup analyses and follow-up durations.

Conclusions Standalone MMAE led to similar and durable clinical and radiographic outcomes as MMAE combined with surgery in select patients with moderately sized cSDHs and mild clinical disease.

  • Subdural
  • Embolic
  • Hemorrhage

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Twitter @HAlvinChenNeuro, @amdbaig, @SandraNarayanan, @BrianHoward_MD, @DrMichaelJLang, @DrMichaelLevitt, @PeterKa80460001

  • HC and MMS contributed equally.

  • Contributors HC, MMS, MC, JKB, and PK conceived the study idea. MMS and JKB designed the study. MMS, GSS, JK, OK, KTC, ANH, AAB, MS, MK, CB, AMR, GMC, ZA, JFRR, JMD, SN, CMC, HR, JM, AMS, AK, BMH, RAH, OT, DT, AHS, ML, EIL, TGJ, RG, VMS, MRL, CSO, BJ, AJT, BAG, JKB, and PK acquired the data. HC, MC, and PK analyzed the data and wrote the manuscript. MMS, DT, RG, MRL, and JKB revised the manuscript. All authors approved the final manuscript for publication. PK is guarantor and accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

  • 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.

  • Disclaimer Dr. Huanwen Chen is an employee of the National Institutes of Health, and thus the United States Government. The opinions expressed in this article are the author's own and do not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the United States Government.

  • Competing interests AMS: grants or contracts from Penumbra, Microvention, Medtronic, and Stryker; consulting fees from Penumbra, Terumo, and Rapid AI; co-founder of the STAR collaboration; stock or stock options in Avail Medical. AHS: grants or contracts from NIH and Brain Aneurysm Foundation; consulting fees from Amnis Therapeutics, Apellis Pharmaceuticals, Boston Scientific, Canon Medical Systems USA, Cardinal Health 200, Cerebrotech Medical Systems, Cerenovus, Cordis, Corindus, Endostream Medical, Hyperfine Operations, Imperative Care, InspireMD, Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Peijia Medical, Penumbra, Piraeus Medical, Q’Apel Medical, Rapid Medical, Serenity Medical, Silk Road Medical, StimMed, Stryker Neurovascular, VasSol, and; patents planned, issued, or pending for patent No US 11,464,528 B2; stock or stock options in Adona Medical, Bend IT Technologies, BlinkTBI, Borvo Medical, Cerebrotech Medical Systems, Code Zero Medical, Cognition Medical, Collavidence, CVAID, E8, Endostream Medical, Galaxy Therapeutics, Hyperion Surgical, Imperative Care, InspireMD, Instylla, Launch NY, Neurolutions, NeuroRadial Technologies (sold to Medtronic in 2021), Neurovascular Diagnostics, Peijia Medical, PerFlow Medical, Piraeus Medical, Q’Apel Medical,, Radical Catheter Technologies, Rebound Therapeutics (purchased in 2019 by Integra Lifesciences), Rist Neurovascular (purchased in 2020 by Medtronic), Sense Diagnostics, Serenity Medical, Silk Road Medical, Sim & Cure, Spinnaker Medical, StimMed, Synchron, Tulavi Therapeutics, Vastrax, Viseon, Whisper Medical, and Willow Medtech; national PI/steering committees for Cerenovus (EXCELLENT and ARISE II trial), Medtronic (SWIFT-PRIME, VANTAGE, EMBOLISE, and SWIFT DIRECT trials), MicroVention (FRED trial and CONFIDENCE study), MUSC (POSITIVE trial), Penumbra (3D Separator trial, COMPASS trial, INVEST trial, MIVI neuroscience EVAQ trial), Rapid Medical (SUCCESS trial), and InspireMD (C-GUARDIANS IDE Pivotal trial).TGJ: consulting fees from Stryker, Silk Road Medical, Blockade Medical, FreeOx Biomedical, Route 92, Neurotrauma Science,, Corindus, Anaconda, Medtronic, Contego, Methinks DAWN, AURORA, and Stryker Neurovascular. RG: consulting fees from Medtronic, Stryker, Cerenovus, Balt, and Rapid Medical. MRL: grants or contracts from NIH, The Aneurysm and AVM Foundation, Society of NeuroInterventional Surgery, and Congress of Neurosurgeons; consulting fees from Metis Innovative and Aeaean Advisers; support for attending meetings and/or travel from Penumbra; participated on the DSMB of Arsenal Medical; serves on the editorial boards of Journal of NeuroInterventional Surgery and Frontiers in Surgery; equity interest in Hyperion Surgical, Proprio, Apertur, Cerebrotech, Synchron, Fluid Biomed, and Stereotaxis; unrestricted educational grants from Medtronic and Stryker. CSO: DSMB for Medtronic (EMBOLISE) and Contour. BAG: consultant for Medtronic, Stryker, and Microvention. PK: grants or contracts from NIH, Siemens, Medtronic, and Joe Niekro Foundation; consulting fees from Stryker Neurovascular and Imperative Care; editorial board of Journal of NeuroInterventional Surgery; stock or stock options in Vena Medical.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.