Best practice in the use of middle meningeal artery embolisation for chronic subdural haematoma

Chronic subdural haematoma (cSDH) is a common neurosurgical disorder in older people and projected to become the most common cranial neurosurgical pathology by 2030. Incidence of cSDH has risen in recent years as a consequence of improved access to brain imaging, and the increased prescribing of antithrombotic medication for both primary and secondary prevention of vascular disease. Chronic SDH typically presents with an insidious onset of broad-ranging symptoms including impaired cognition, gait, balance and mobility, often with headache. It progresses to more fulminant symptoms of hemiplegia, dysphasia and eventually coma. Although the established standard of care for clearly symptomatic cSDH is burr hole trephination, Middle Meningeal Artery Embolisation (MMAE) has emerged as a minimally invasive treatment option for some patients with cSDH. This is a rapidly evolving field: recently published randomised control trials have provided an evidence-base supporting the use of MMAE not only as an adjunct to burr hole trephination, but also in patients in whom trephination is contraindicated, or in patients with mild symptomatology who are not considered appropriate for immediate burr hole trephination. This article provides practical, real-world guidance on current best practice based on our experience and the published evidence available to date. We use case studies and treatment algorithms from the UK's highest volume MMAE centre to illustrate collaborative care pathways for patients with cSDH between neurosurgery, interventional neuroradiology and trauma geriatricians.