Impact of middle meningeal artery embolization timing on chronic subdural hematoma resolution and functional outcomes - 26/08/26

Doi : 10.1016/j.neurad.2026.101584

Bluyé DeMessie ^a,^{^{1
These authors contributed equally as co-first authors}}, Muhammed Amir Essibayi ^a,^{^{1
These authors contributed equally as co-first authors},}^⁎ , Hamza Adel Salim ^b,^{^{1
These authors contributed equally as co-first authors}}, Alireza Karandish ^a, Nathan Farkas ^a, Deepak Khatri ^a, Neil Haranhalli ^a, Amanda Baker ^a, Richard Zampolin ^a, Allan L. Brook ^a, Seon-Kyu Lee ^a, Nimer Adeeb ^c, James Grist ^d, Fulvio Zaccagna ^d, Yan-Lin Li ^d, Davide Simonato ^d, Diego Alejandro Ortega ^e, Nicole Cancelliere ^e, Jose Danilo Diestro ^e, Dhairya A. Lakhani ^hh, Joseph Carnevale ^f, Craig Schreiber ^f, Atakan Orscelik ^g, Zachary Abecassis ^h, Spencer Raub ^h, Georgios S. Sioutas ⁱ, Giancarlo Salsano ^j, Svetlana Kvint ^k, Andrew Falzon ^l, Vance Cantrell ^m, Brian Holliday ^m, Jefferson O. Abaricia ⁿ, Pedram D. Maleknia ^o, Leonardo Cruz-Criollo ^p, Samantha Schimmel ^q, Basel Musmar ^r, Matthew Alexander ^s, Jorge Rios Zermeno ^t, Koul Prateeka ^u, Ahmed Aljuboori ^u, Dominik F. Vollherbst ^v, Domagoj Gajski ^w, Jared Cooper ^x, Rahim Abo Kasem ^y, Sami Al Kasab ^y, Alejandro M. Spiotta ^y, Fawaz Al-Mufti ^x, Vladimir Kalousek ^z, Markus A. Möhlenbruch ^v, Luca Scarcia ^aa, Clemens M. Schirmer ^u, Thien Huynh ^t, Rabih G. Tawk ^t, Fabio Settecase ^bb, Stavropoula Tjoumakaris ^r, Pascal Jabbour ^r, Kunal Vakharia ^q, Mario Zanaty ^p, Santiago Ortega‐Gutierrez ^p, Jesse G. Jones ^o, Marco Colasurdo ⁿ, Hussein H. Nasser ^m, Sri Hari Sundararajan ^m, Pascal J. Mosimann ^cc, Erez Nossek ^k, Eytan Raz ^k, Lucio Castellan ^j, Bruno Del Sette ^j, Caterina Michelozzi ^dd, Davide Saraceno ^dd, Pietro Panni ^dd, Visish Srinivasan ⁱ, Jan-Karl Burkhardt ⁱ, Gaultier Marnat ^ee, Pietro Mario Santini ^ee, Michael R. Levitt ^h, Giuseppe Lanzino ^g, Waleed Brinjikji ^g, Jared Knopman ^f, Tareq Kass-Hout ^ff, Julian Spears ^e, Thomas Marotta ^e, Max Wintermark ^b, Vitor Mendes Pereira ^e, Maurizio Fuschi ^d, Adam A. Dmytriw ^e,^gg,^{^{†
These authors contributed equally as co-senior authors}}, David J. Altschul ^a,^{^{†
These authors contributed equally as co-senior authors}}
on behalf of the
MESH collaborators ^{^#}
MESH Collaborators: Alex Kostynskyy, MBBS, CCRP ¹ , Milagros Galecio-Castillo, MD ² , Jorge Cespedes, MD ² , Oded, Goren, MD ³ , Jeffrey Daniel Oliver, MD ³ , Malgorzata Milnerowicz, MD ⁴ , Jean Papaxanthos, MD ⁴ ; Omer Eker, MD-PhD ⁴ ; Xavier Barreau, MD ⁴ ; Thomas Courret, MD ⁴ ; Jerome Berge, MD ⁴ ; Vincent Jecko, MD-PhD ⁵ ; Julien Engelhardt, MD-PhD ⁵ ¹Interventional and Diagnostic Neuroradiology, UMIT-JDMI-UHN INR, UofT, Toronto Western Hospital, Toronto, Canada²Department of Neurology, Neurosurgery & Radiology, University of Iowa Healthcare, Iowa City, Iowa³Department of Neurosurgery, Geisinger, Wilkes-Barre, Pennsylvania, USA ⁴ Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France ⁵ Neurosurgery Department, Bordeaux University Hospital, Bordeaux, France

^a Department of Neurological Surgery and Radiology, Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA

^b Department of Neuroradiology, MD Anderson Medical Center, Houston, TX, USA

^c Department of Neurosurgery, Ochsner-Louisiana State University, Shreveport, Louisiana, USA

^d Department of Neuroradiology, Oxford University Hospitals NHS Foundation Trust, Nuffield Departments of Clinical Neurosciences and Surgical Sciences, University of Oxford, UK

^e Neurovascular Centre & RADIS Lab, St. Michael's Hospital. University of Toronto and Toronto Metropolitan University, Toronto

^f Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY, USA

^g Department of Neurological Surgery and Radiology, Mayo Clinic, Rochester, MN, USA

^h Department of Neurological Surgery, University of Washington, Seattle, Washington, USA

ⁱ Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA

^j Unit of Neuroradiology, IRCCS Azienda Ospedaliera Metropolitana San Martino, Genoa, Italy

^k Department of Radiology and Neurosurgery, NYU Langone Health, New York, NY, USA

^l Atkinson Morley Regional Neurosciences Centre, St George's University Hospital, NHS Trust, Blackshaw Road, Tooting, London, UK

^m Department of Radiology, Interventional Neuroradiology, Lehigh Valley Health Network, Allentown, PA, USA

ⁿ Department of Interventional Radiology and Neurosurgery, Oregon Health and Science University, Portland, OR, USA

^o The University of Alabama at Birmingham, Birmingham, AL, USA

^p Department of Neurology, Neurosurgery & Radiology, University of Iowa Healthcare, Iowa City, Iowa, USA

^q Department of Neurosurgery & Brain Repair, University of South Florida, Tampa, Florida, USA

^r Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA

^s Neurointerventional Surgery, Sutter Sacramento Medical Center, Sacramento, California, USA

^t Department of Neurological Surgery and Radiology, Mayo Clinic, Jacksonville, Florida, USA

^u Department of Neurosurgery, Geisinger, Wilkes-Barre, Pennsylvania, USA

^v Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany

^w Department of Neurosurgery, UHC Sestre Milosrdnice, and University of Applied Health Sciences, Zagreb, Croatia

^x Department of Neurosurgery-Westchester Medical Center, New York Medical College, Valhalla, NY, USA

^y Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA

^z Department of Radiology, UHC Sestre Milosrdnice, Zagreb, Croatia

^aa Department of Neuroradiology, CHU Henri Mondor, Creteil, France

^bb Neurointerventional Surgery, Sutter Health California Pacific Medical Center, San Francisco, California, USA

^cc Interventional and Diagnostic Neuroradiology, UMIT-JDMI-UHN INR, UofT, Toronto Western Hospital, Toronto, Canada

^dd Department of Neuroradiology and Neurosurgery, Interventional Neuroradiology Division, San Raffaele University Hospital, Milano MI, Italy

^ee Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France

^ff Department of Neurology, University of Chicago, Chicago, IL, USA

^gg Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA

^hh Department of Neuroradiology, West Virginia University, 1 Medical Center Drive, Morgantown, WV, USA

^⁎ Corresponding authors. Muhammed Amir Essibayi FRCP(London) Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA Tel: +1-347-908-1889 FRCP(London) Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine Bronx NY USA

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Abstract

Background and purpose

Chronic subdural hematoma (cSDH) affects approximately 20 per 100,000 individuals annually, with surgical recurrence rates of 10–20%. Middle meningeal artery embolization (MMAE) has emerged as a promising minimally invasive treatment, but the optimal timing remains unclear. We evaluated the association between MMAE timing and radiological and functional outcomes in cSDH.

Methods

We conducted a retrospective multicenter international cohort study across 33 centres, including patients who underwent MMAE for cSDH between January 2018 and December 2024. Patients were stratified by timing from diagnosis: Q1 (≤1 day), Q2 (2 days), Q3 (3–6 days), and Q4 (>6 days). The primary composite endpoint required radiological success (hematoma thickness <5 mm at 1–3 months), absence of emergency surgical evacuation, and either functional improvement or good functional outcome (modified Rankin Scale 0–2). Propensity score matching compared Q1 and Q4.

Results

Of 1,781 patients screened, 908 met inclusion criteria. Mean age was 73.7 ± 12.2 years, and 70.9% were female. Early embolization (Q1) achieved the primary composite endpoint more frequently than delayed embolization (Q4), with concordant improvements in radiological and functional components and no difference in rescue surgery. Good functional outcome was achieved in 76.0% of Q1 patients versus 63.8% in Q4 (absolute difference, 12.2%; P=.003; number needed to treat approximately 8). Hospital length of stay was 21.0 days shorter in Q1 versus Q4 (P<.001), partly attributable to the timing definition. In 174 propensity score-matched pairs, early embolization was associated with higher odds of achieving the primary endpoint (odds ratio, 6.41; 95% confidence interval, 3.29–12.48; P<.001), with pronounced benefit among patients receiving antithrombotic therapy (odds ratio, 8.06; 95% confidence interval, 3.65–17.80).

Conclusions

Early MMAE (≤1 day from diagnosis) was overall associated with better outcomes compared with delayed intervention, particularly among patients receiving antithrombotic therapy. Prospective confirmation is warranted.

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Keywords : Interventional, Surgery, Subdural Hematoma, Traumatic Brain Injury

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Vol 53 - N° 5

Article 101584- septembre 2026 Retour au numéro

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Impact of middle meningeal artery embolization timing on chronic subdural hematoma resolution and functional outcomes - 26/08/26

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