To educate neurologists about a highly efficacious, minimally-invasive treatment for chronic subdural hematoma.

Chronic subdural hematoma (cSDH) arises from injury to dural border cells. This initiates a self-perpetuating inflammatory response complicated by the formation of vascularized neo-membranes that are fed by the middle meningeal artery (MMA). Blood and fluid extravasation through fragile arterial vessels fill the new membrane-bound subdural space. cSDH presents clinically in a myriad of forms and may cause significant morbidity and mortality if left untreated. Symptomatic patients have traditionally undergone surgical hematoma evacuation, but MMA embolization has arisen as an alternative management strategy. MMA embolization devascularizes the neo-membrane and allows for the unopposed resorption of the hematoma while sparing the patient the risks of open surgery.

We performed a systematic review of the literature to identify reports of MMA embolization and determine the rates of technical success and complications as well as patient outcomes associated with this contemporary procedure.

Our literature search yielded 22 studies of 229 patients who underwent 242 embolization procedures for the treatment of cSDH. Median age was 70.3 years, 154 (67.2%) were male, and median follow-up duration was 4.4 months. Over half of patients were on antithrombotic therapy at the time of intervention. The procedure was selected as salvage treatment to surgical evacuation in most cases (59.5%), as primary treatment in some (36.4%), and least commonly as prophylaxis (4.1%). In 176 (72.7%) procedures, polyvinyl alcohol (PVA) particles were used to embolize. Hematoma recurrence occurred in 11 (4.5%) cases. There were no reported procedural or technical complications.

While many of the published studies to date are retrospective and small, patient outcomes are overwhelmingly favorable which suggests that MMA embolization is a highly efficacious alternative or adjunct to surgery for treatment of cSDH.