Multi-pedicle versus single-pedicle middle meningeal artery embolization for nonacute subdural hematoma

Abstract Introduction Nonacute subdural hematomas (nSDH) are common yet serious extra-axial hemorrhages that result in significant morbidity and mortality. Middle meningeal artery (MMA) embolization (MMAE) is a recent endovascular treatment that involves occlusion of the MMA, inducing hemostasis in and around the hematoma. While many aspects of MMAE have been explored, there is currently limited data on the optimal extent of embolization. Objective To determine whether single or multiple pedicle embolization of the MMA is superior in inducing hemostasis in nSDH. Methods We compared single versus multi pedicle embolization by a retrospective multicenter analysis of nSDH patients who underwent MMAE between 2019 and 2024 at participating centers in the MESH (MMA Embolization for Subdural Hematoma) Registry. 679 patients who received a liquid embolic agent with branch-level embolization data were included. Results While multi-pedicle embolization hastened nSDH thinning at 1 month (5.7 vs. 3.3 mm reduction; difference 2.4 mm, 95% CI 1.0–3.8; P = .002), by 3 months thickness reduction had converged between groups (8.2 vs. 8.4 mm; P = .91). Among 679 patients (456 multi-pedicle, 223 single-pedicle), favorable functional outcome (mRS 0–2) was more frequent with multi-pedicle embolization (53.5% vs. 43.0%; adjusted OR 1.81, 95% CI 1.26–2.60; P = .001), whereas recurrence, rescue surgery, and treatment failure did not differ. Conclusion Future, multi-center randomized prospective trials are warranted to address confounding variables that limit this observational study. Follow-up beyond 3 months was limited, so durability is unknown.

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Journal
Neuroradiology
Published
2026-09-21
DOI
https://doi.org/10.1007/s00234-026-04187-2
Primary Topic
Neurosurgical Procedures and Complications
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article
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article

Multi-pedicle versus single-pedicle middle meningeal artery embolization for nonacute subdural hematoma

Nicole Cancelliere, Si Zhao Tang, Elijah Wang, Christopher S. Ogilvy et al.
Neuroradiology
Neurosurgical Procedures and Complications
article

Multi-pedicle versus single-pedicle middle meningeal artery embolization for nonacute subdural hematoma

Nicole Cancelliere, Si Zhao Tang, Elijah Wang, Christopher S. Ogilvy, Thien J Huynh, Jose Danilo Bengzon Diestro, Visish Mani Srinivasan, Giancarlo Salsano, Maurizio Fuschi, Jefferson O. Abaricia, Bruno Del Sette, Anil Gopinathan, Luca Scarcia, Georgios S. Sioutas, Santiago Ortega‐Gutiérrez, Hussein A. Zeineddine, Davide Simonato, Hamza Adel Salim, Pedram Daniel Maleknia, Pietro Panni, Atakan Orscelik, Julian Spears, Deepak Khatri, David Altschul, Rabih G. Tawk, Ali M. Alaraj, Michael R. Levitt, Muhammed Amir Essibayi, Pascal J. Mosimann, Dhairya A. Lakhani, Jesse George Atherton Jones, Bluyé DeMessie, Fulvio Zaccagna, Prateeka Koul, Fabio Settecase, Marco Colasurdo, Davide Saraceno, Gaultier Marnat, Caterina Michelozzi, Robert William Regenhardt, Pascal M. Jabbour, Lucio Castellan, Vladimir Kalousek, Rahim Abo Kasem, Yan-Lin Li, Mario Zanaty, Spiros Blackburn, James T. Grist, Craig Schreiber, Ahmed Aljuboori, Sri Hari Sundararajan, Brian Holliday, Andrew Falzon, Jan‐Karl Burkhardt, Svetlana Kvint, Basel Musmar, Samantha J. Schimmel, Domagoj Gajski, Omar Alwakaa, Hussein H. Nasser, Vitor Mendes Pereira, Seon-Kyu Lee, Leonardo Cruz‐Criollo, Alireza Karandish, Vance Cantrell, Jorge Rios Zermeno, Kunal Vakharia, Mohamad Ezzeldin, Clemens M. Schirmer, Joseph Carnevale, Neil Haranhalli, Tufail Patankar, Pietro Mario Santini, Diego Alejandro Ortega, Zachary Abecassis, Spencer Raub, Thomas Marotta, Richard Zampolin, Clairice Pearce, Matthew Alexander, Abdulrhman Alsalama, Jared Cooper, Jared Knopman, Eytan Raz, Nimer Adeeb, Tareq Kass-Hout, Garrett W Thrash, Peter B Sporns, Amanda Baker, Erez Nossek, William W Wroe, Waleed Brinjikji, Sami Al Kasab, Alejandro M Spiotta, Giuseppe Lanzino, Fawaz Al-Mufti, Markus A Möhlenbruch, Dominik F Vollherbst, Allan L Brook, Stavropoula Tjoumakaris
article en

Abstract

Abstract Introduction Nonacute subdural hematomas (nSDH) are common yet serious extra-axial hemorrhages that result in significant morbidity and mortality. Middle meningeal artery (MMA) embolization (MMAE) is a recent endovascular treatment that involves occlusion of the MMA, inducing hemostasis in and around the hematoma. While many aspects of MMAE have been explored, there is currently limited data on the optimal extent of embolization. Objective To determine whether single or multiple pedicle embolization of the MMA is superior in inducing hemostasis in nSDH. Methods We compared single versus multi pedicle embolization by a retrospective multicenter analysis of nSDH patients who underwent MMAE between 2019 and 2024 at participating centers in the MESH (MMA Embolization for Subdural Hematoma) Registry. 679 patients who received a liquid embolic agent with branch-level embolization data were included. Results While multi-pedicle embolization hastened nSDH thinning at 1 month (5.7 vs. 3.3 mm reduction; difference 2.4 mm, 95% CI 1.0–3.8; P = .002), by 3 months thickness reduction had converged between groups (8.2 vs. 8.4 mm; P = .91). Among 679 patients (456 multi-pedicle, 223 single-pedicle), favorable functional outcome (mRS 0–2) was more frequent with multi-pedicle embolization (53.5% vs. 43.0%; adjusted OR 1.81, 95% CI 1.26–2.60; P = .001), whereas recurrence, rescue surgery, and treatment failure did not differ. Conclusion Future, multi-center randomized prospective trials are warranted to address confounding variables that limit this observational study. Follow-up beyond 3 months was limited, so durability is unknown.

Neuroradiology
West Virginia University (US), Barking, Havering And Redbridge University Hospitals NHS Trust (GB), Albert Einstein College of Medicine (US), Lehigh Valley Hospital-Pocono (US), Beth Israel Deaconess Medical Center (US), Westchester Medical Center (US), Mayo Clinic (US), Montefiore Medical Center (US), The University of Texas MD Anderson Cancer Center (US), Thomas Jefferson University (US), Medical University of South Carolina (US), Oregon Health & Science University (US), National University of Singapore (SG), Baylor College of Medicine (US), University of Toronto (CA), University of Washington (US), Cornell University (US), Heidelberg University (DE), University of South Florida (US), Louisiana State University in Shreveport (US), Toronto Western Hospital (CA), Sutter Medical Center (US), Hospital of the University of Pennsylvania (US), Triemli Hospital (CH), St George’s University Hospitals NHS Foundation Trust (GB), Jacksonville College (US), California Pacific Medical Center (US), Nuffield Orthopaedic Centre (GB), University Hospital Heidelberg (DE), University Hospital of Basel (CH), John Radcliffe Hospital (GB), San Raffaele University of Rome (IT), Centre Hospitalier Universitaire de Bordeaux (FR), University of Alabama at Birmingham (US), University of Illinois Chicago (US), University of Oxford (GB), University of Chicago (US), NYU Langone Health (US), Blanchette Rockefeller Neurosciences Institute (US), Lehigh Valley Health Network (US), Presbyterian Hospital (US), University of Applied Health Sciences (HR), Sisters of Charity Hospital (HR), Hôpitaux Universitaires Henri-Mondor (FR), University of Iowa Health Care (US), Oxford BioMedica (United Kingdom) (GB), Ospedale Policlinico San Martino (IT), National University Hospital (SG), Mayo Clinic in Florida (US), National University Health System (SG), Geisinger Wyoming Valley Medical Center (US), Neurological Surgery (US), Toronto Metropolitan University (CA), Seattle University (US), The University of Texas Health Science Center at Houston (US)
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