Advances in endovascular therapy for chronic subdural hematoma: from adjunctive treatment toward first-line therapy

Chronic subdural hematoma (CSDH) is one of the most prevalent conditions in neurosurgical practice. Its incidence continues to rise in the context of global population aging and the widespread use of anticoagulant and antiplatelet medications. Although conventional burr-hole drainage is the most widely adopted approach, its recurrence rates remain considerable high, and surgical tolerance is poor in elderly patients. Therefore, we should underscore the urgent need to reassess clinical strategies for this disease. Middle meningeal artery embolization (MMAE) exerts a therapeutic effect by interrupting the blood supply to the hematoma capsule, thereby targeting the pathological source of disease progression. In particular, 4 recent large-scale multicenter randomized controlled trials (EMBOLISE, MAGIC-MT, STEM, and EMPROTECT) have preliminary provided evidence-based validation of the safety and efficacy of MMAE. The clinical benefit of MMAE is particularly pronounced in symptomatic patients without emergency surgical indications, those on anticoagulant/antiplatelet therapy, patients with recurrent hematoma, and those at high surgical risk. Meanwhile, perioperative multimodality imaging assessment of the architecture of feeding arteries and the perfusion of hematoma capsule facilitates the prediction for therapeutic efficacy, early warning of recurrence, and formulation of individualized embolization strategies. Technically, hybrid surgical approaches and transradial artery access provide safer treatment options for high-risk patients, while the selection of embolic materials varies according to specific clinical scenarios. Based on the evolving evidence and clinical experience in MMAE, we propose a core conceptual advancement in the endovascular treatment of CSDH which is a shift from isolated middle meningeal artery embolization toward precise embolization of the hematoma capsule arterial supply under the guidance of imaging assessment of capsule blood supply, thereby achieving the goal of precise and effective individualized treatment.