Single-Session Middle Meningeal Artery Embolization With Concomitant Evacuation Surgery for Chronic Subdural Hematoma: Impact of Surgical Approach

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BACKGROUND AND OBJECTIVES: Single-session middle meningeal artery embolization (MMAE) combined with surgical evacuation is a rapidly emerging strategy in the treatment of chronic subdural hematoma (cSDH). However, the effect of different evacuation techniques within this approach remains unclear. METHODS: We conducted a retrospective multicenter cohort study across 8 US institutions of patients with cSDH who underwent single-session MMAE with concomitant surgical evacuation between 2018 and 2024. Surgical techniques were categorized as craniotomy or burr-hole evacuation (twist drill, electric drill, or subdural evacuating port systems). Primary outcomes included procedural time, adverse events, and early clinical outcomes. RESULTS: The 205 included patients (30.2% female) underwent 276 procedures (35 craniotomies, 241 burr-hole evacuations). The median patient age was 75 years, and 157 (76.6%) patients were functionally independent at baseline. Subdural characteristics were similar in the craniotomy (n = 26) and the burr-hole evacuation (n = 179) groups. Patients who underwent craniotomy had longer drainage durations ( P < .001) and longer operative times (209 vs 190 min, P = .015). Patients undergoing craniotomy were also less likely to be discharged by postoperative day 6 ( P = .040). Procedural mortality rates were low overall (0.4%) and did not differ significantly between groups. Early postoperative mortality rates (3.3% overall) were also comparable across both groups. Overall mortality was higher in craniotomy patients (34.3% vs 10.4%, adjusted odds ratio = 3.69; 95% confidence interval: 1.23-11.06; P = .019), mainly because of late mortality and not attributable to the index procedure. CONCLUSION: In this multicenter study of single-session MMAE with concomitant evacuation for cSDH, burr-hole-based techniques were associated with shorter operative times and with postprocedural patterns such as earlier drain removal, which correlated with earlier discharge. These findings support the preferential use of minimally invasive evacuation methods within the single-session paradigm when anatomically and technically appropriate.

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