A novel technique for middle meningeal artery embolization with proximal coiling for subdural hematoma: Institutional predictors of surgical requirement and longitudinal outcomes

Objective: To evaluate single-operator outcomes of a standardized proximal Middle Meningeal Artery Embolization (MMAE) technique using platinum microcoils across the subdural hematoma (SDH) acuity spectrum, and to identify clinical and anatomical predictors associated with adjunct surgical drainage. Methods: We retrospectively reviewed 100 consecutive adult patients (standalone MMAE: n=53; MMAE with surgical drainage: n=47). Continuous variables were assessed for normality via the Shapiro-Wilk test. Multivariable binomial logistic regression identified independent predictors of surgical requirement. Baseline characteristics, procedural metrics, and 6-month outcomes were stratified by acuity: acute (<3 days; n=19), subacute (3-21 days; n=54), and chronic (>21 days; n=27). Results: Continuous variables exhibited non-normal distributions (p≤0.010); median cohort body mass index (BMI) was 26.6 kg/m² (IQR 22.5-29.8). In multivariable analysis (AUC 0.745), higher BMI (aOR 1.09; 95% CI 1.01-1.17; p=0.028), presentation with headache (aOR 2.86; 95% CI 1.03-7.99; p=0.045), and left-sided hematoma location (aOR 0.31; 95% CI 0.10-0.97; p=0.043) were significant independent predictors of surgical requirement. Technical success was 100%, with zero periprocedural complications and zero surgical re-evacuations at 6 months (0%). Fluoroscopy time (p=0.969) and coil count (p=0.393) were uniform across acuity cohorts. Conclusions: Proximal MMAE with microcoils is safe, highly feasible, and technically consistent across all SDH acuity phases. Although hematoma thickness traditionally guides surgical intervention, elevated BMI, headache presentation, and hemispheric laterality serve as vital independent clinical predictors for adjunct surgical drainage.