Middle Meningeal Artery Embolization for Chronic Subdural Hematoma in Patients with Coagulopathies

BACKGROUND AND PURPOSE: Impaired hemostasis complicates chronic subdural hematoma, raising the risk of both hematoma progression and procedural bleeding. We evaluated whether middle meningeal artery embolization improves 90-day outcomes compared with medical management or surgery alone in coagulopathic patients, and coagulopathy's prognostic impact. MATERIALS AND METHODS: Retrospective cohort study using the TriNetX US Collaborative Network (65 healthcare organizations), reported per STROBE. Adults with chronic subdural hematoma diagnosed on or after January 1, 2016 were identified by ICD-10-CM codes; coagulopathy was defined by coagulation defects, purpura, or other hemorrhagic conditions (D65-D69). Treatment was assigned from procedures occurring 1 day before to 7 days after the index diagnosis. Four 1:1 propensity-score-matched comparisons assessed 90-day mortality and rescue surgery. RESULTS: Among coagulopathic patients, embolization was associated with lower 90-day mortality than medical management (18.8% versus 26.6%; HR 0.64; 95% CI, 0.52-0.80) and, added to surgery, lower mortality than surgery alone (8.8% versus 20.3%; HR 0.40; 95% CI, 0.27-0.59); both p < 0.001. Rescue surgery did not differ (8.6% versus 6.6%; 13.3% versus 16.5%; both p = 0.22). Coagulopathy was associated with higher mortality and more rescue surgery among medically managed (22.8% versus 15.6%; 2.9% versus 2.3%) and surgical patients (24.8% versus 17.7%; 15.4% versus 11.1%); all p < 0.001. CONCLUSIONS: Embolization was associated with substantially lower 90-day mortality in coagulopathic chronic subdural hematoma, both as standalone treatment and as a surgical adjunct, although short-term rescue surgery was not reduced. Coagulopathy remained an adverse prognostic factor regardless of treatment. Prospective confirmation is required.