Middle meningeal artery embolization for chronic subdural hematoma: a meta-analysis of randomized controlled trials with trial sequential analysis.

Middle meningeal artery embolization (MMAE) has gained attention as an innovative approach for chronic subdural hematoma (cSDH). It can be utilized either as a standalone treatment or as an adjunct to surgical evacuation, with the primary goal of reducing the risk of cSDH recurrence. Therefore, we aim to investigate the efficacy and safety of MMAE in cSDH patients. Databases were systematically searched for randomized controlled trials (RCTs) reporting the use of MMAE in cSDH patients. All statistical analyses were performed using Review Manager 5.4.1. We employed risk ratio (RR) and Mean Differences (MD) with 95% confidence intervals (CIs) as the measure of effect size using a random-effects model. We included seven RCTs (1,623 patients; mean age, 72.7 ± 10.9 [MMAE group] and 72.3 ± 11.0 [usual-care group] years; 74.9% [MMAE] and 77.3% [usual-care] were male). MMAE significantly reduced recurrence (RR 0.47, 95% CI: 0.34 to 0.65, p < 0.001). No statistically significant differences were observed in good (RR 1.01, 95% CI: 0.97 to 1.05, p = 0.77) and favorable functional outcome (RR 1.01, 95% CI: 0.96 to 1.07, p = 0.69). Hematoma volume was only significantly reduced in the adjunctive MMAE subgroup analysis (MD -6.49, 95% CI: -12.21 to -0.78, p = 0.03). No statistically significant differences were observed in adverse events (RR 0.97, 95% CI: 0.68 to 1.39, p = 0.885), serious adverse events (RR 0.78, 95% CI: 0.59 to 1.04, p = 0.09), and mortality (RR 0.98, 95% CI: 0.42 to 2.30, p = 0.97). MMAE significantly reduced recurrence risk compared to usual care, with benefits observed in adjunctive MMAE, including lower reoperation rates and reduced hematoma volume at 90 days. Functional outcomes at 90 days were not significantly different between groups. Similarly, adverse events and mortality rates were comparable between groups Clinical trial number: Not applicable.