Liquid Embolic Volume Does Not Predict Outcome After Middle Meningeal Artery Embolization for Chronic Subdural Hematoma

PURPOSE: Middle meningeal artery embolization (MMAE) is increasingly used for chronic subdural hematoma (CSDH), but the relationship between injected liquid-embolic volume and outcomes is unclear. We evaluated dose-outcome associations and searched for a minimum effective dose. METHODS: This retrospective multicenter cohort included 313 patients treated with liquid embolic agents at 12 MESH Registry centers from 2016 to 2024. MMAE was performed alone in 172 patients (55.0%) and adjunctively with surgical evacuation in 141 (45.0%). Dose was assessed as total injected volume per patient and normalized to middle meningeal artery diameter, baseline hematoma thickness, and estimated hematoma volume. The primary outcome was a 180-day composite of retreatment, residual or recurrent hematoma > 10 mm, or death. Logistic regression with multiple imputation, restricted cubic splines, and sensitivity analyses evaluated associations and nonlinearity. RESULTS: Median injected volume was 0.60 mL (interquartile range, 0.50-0.90). Center accounted for 44.5% of variation in log volume, whereas hematoma burden accounted for 0.3%. No dose metric was significantly associated with the primary outcome or 90-day recurrence/reoperation. For absolute volume, the odds ratio per interquartile-range increment was 0.80 (95% confidence interval, 0.56-1.16; p = 0.24). No reliable minimum effective dose was identified. Findings remained consistent across sensitivity analyses and treatment indications (interaction p = 0.30). Procedural complications occurred in 6.4% and were not dose-associated. CONCLUSION: Within the observed range, injected volume alone was not a consistent determinant of outcome and should not be a procedural target after a satisfactory angiographic endpoint. Future studies should evaluate embolic distribution, distal penetration, and vascular territory coverage.

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Journal
Clinical Neuroradiology
Published
2026-10-15
DOI
https://doi.org/10.1007/s00062-026-01729-2
Primary Topic
Neurosurgical Procedures and Complications
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article
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article

Liquid Embolic Volume Does Not Predict Outcome After Middle Meningeal Artery Embolization for Chronic Subdural Hematoma

Eytan Raz, Christopher S. Ogilvy, Thien J Huynh, Visish Mani Srinivasan et al.
Clinical Neuroradiology
Neurosurgical Procedures and Complications
article

Liquid Embolic Volume Does Not Predict Outcome After Middle Meningeal Artery Embolization for Chronic Subdural Hematoma

Eytan Raz, Christopher S. Ogilvy, Thien J Huynh, Visish Mani Srinivasan, Giancarlo Salsano, Matthew David Alexander, Jefferson O. Abaricia, Zachary A. Abecassis, Bruno Del Sette, Anil Gopinathan, Luca Scarcia, Georgios S. Sioutas, Santiago Ortega‐Gutiérrez, Dominik F. Vollherbst, Markus Alfred Möhlenbruch, Hamza Adel Salim, Pedram Daniel Maleknia, Pietro Panni, Atakan Orscelik, Nimer Adeeb, David Altschul, Rabih G. Tawk, Mohamad Ezzeldin, Michael R. Levitt, Jared Cooper, Muhammed Amir Essibayi, Pascal J. Mosimann, Dhairya A. Lakhani, Jesse George Atherton Jones, Bluyé DeMessie, Clemens Maria Schirmer, Tufail F. Patankar, Fawaz Al‐Mufti, Adam Andrew Dmytriw, Fabio Settecase, Marco Colasurdo, Domagoj Gajski, Giuseppe S Lanzino, Davide Saraceno, Joseph A. Carnevale, Gaultier Marnat, Caterina Michelozzi, Robert William Regenhardt, Pascal M. Jabbour, Vladimir Kalousek, Hussein H. Nasser, Rahim Abo Kasem, Yan-Lin Li, Mario Zanaty, Kunal V. Vakharia, Peter Bernhard Sporns, Spiros Blackburn, Ahmed Aljuboori, Sri Hari Sundararajan, Andrew Falzon, Jared Knopman, Jan‐Karl Burkhardt, Basel Musmar, Samantha J. Schimmel, Omar Alwakaa, Vitor Mendes Pereira, A Alaraj, Leonardo Cruz‐Criollo, Alireza Karandish, Pietro Mario Santini, Diego Alejandro Ortega, Tang Si Zhao, Abdulrhman Alsalama, Alejandro M. Spiotta, Erez Nossek
article en

Abstract

PURPOSE: Middle meningeal artery embolization (MMAE) is increasingly used for chronic subdural hematoma (CSDH), but the relationship between injected liquid-embolic volume and outcomes is unclear. We evaluated dose-outcome associations and searched for a minimum effective dose. METHODS: This retrospective multicenter cohort included 313 patients treated with liquid embolic agents at 12 MESH Registry centers from 2016 to 2024. MMAE was performed alone in 172 patients (55.0%) and adjunctively with surgical evacuation in 141 (45.0%). Dose was assessed as total injected volume per patient and normalized to middle meningeal artery diameter, baseline hematoma thickness, and estimated hematoma volume. The primary outcome was a 180-day composite of retreatment, residual or recurrent hematoma > 10 mm, or death. Logistic regression with multiple imputation, restricted cubic splines, and sensitivity analyses evaluated associations and nonlinearity. RESULTS: Median injected volume was 0.60 mL (interquartile range, 0.50-0.90). Center accounted for 44.5% of variation in log volume, whereas hematoma burden accounted for 0.3%. No dose metric was significantly associated with the primary outcome or 90-day recurrence/reoperation. For absolute volume, the odds ratio per interquartile-range increment was 0.80 (95% confidence interval, 0.56-1.16; p = 0.24). No reliable minimum effective dose was identified. Findings remained consistent across sensitivity analyses and treatment indications (interaction p = 0.30). Procedural complications occurred in 6.4% and were not dose-associated. CONCLUSION: Within the observed range, injected volume alone was not a consistent determinant of outcome and should not be a procedural target after a satisfactory angiographic endpoint. Future studies should evaluate embolic distribution, distal penetration, and vascular territory coverage.

Clinical Neuroradiology
Sutter Health (US), West Virginia University (US), Louisiana State University (US), University of Iowa (US), Brigham and Women's Hospital (US), Barking, Havering And Redbridge University Hospitals NHS Trust (GB), St. Michael's Hospital (CA), Albert Einstein College of Medicine (US), Beth Israel Deaconess Medical Center (US), Westchester Medical Center (US), Mayo Clinic (US), Montefiore Medical Center (US), NewYork–Presbyterian Hospital (US), The University of Texas MD Anderson Cancer Center (US), Harvard University (US), Thomas Jefferson University (US), Medical University of South Carolina (US), Oregon Health & Science University (US), New York Medical College (US), University of Basel (CH), University of Washington (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), St George’s University Hospitals NHS Foundation Trust (GB), Jacksonville College (US), California Pacific Medical Center (US), University Hospital Heidelberg (DE), University of Iowa Hospitals and Clinics (US), University Hospital of Basel (CH), Centre Hospitalier Universitaire de Bordeaux (FR), Centre Hospitalier Universitaire Henri-Mondor (FR), University of Alabama at Birmingham (US), University of Illinois Chicago (US), University of Oxford (GB), University of Chicago (US), NYU Langone Health (US), Massachusetts General Hospital (US), Lehigh Valley Health Network (US), University of Applied Health Sciences (HR), Queen's Hospital (GB), Sisters of Charity Hospital (HR), Hôpitaux Universitaires Henri-Mondor (FR), IRCCS Ospedale San Raffaele (IT), Lehigh Valley Hospital (US), University of Iowa Health Care (US), Lone Star College Kingwood (US), National University Hospital (SG), Weill Cornell Medicine (US), Stadtspital Zürich (CH), New York University (US), University of Pennsylvania (US), The University of Texas Health Science Center at Houston (US)
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