Adjunctive embolization of middle meningeal artery Reduces Recurrence in Chronic Subdural Hematoma: JAMA
According to new research published in Journal of American Medical Association that addition of embolization of the middle meningeal artery (EMMA) after surgical drainage significantly lowers symptomatic recurrence at 90 days in patients with unilateral chronic subdural hematoma compared to surgery alone. The study was conducted by J. J. Shivshankar and colleagues.
A randomized clinical trial was conducted with an open-label design and blinded-end point evaluation to ensure there would be no assessment bias in testing the clinical efficacy of this treatment combination. This study, conducted from August 2021 to April 2025, involved enrolling adult patients exhibiting unilateral symptomatic chronic subdural hematoma with a minimum thickness of 10 mm that were due to undergo surgery for the drainage procedure. Out of 192 patients randomized into two groups, 186 successfully finished the trial with an equal number of patients in each group (93).
In terms of demographic details, patients included in this trial were predominantly elderly and male with a mean age of 71.8 years; out of 186 patients, 136 (73%) were males. Patients assigned to the intervention group had an endovascular EMMA procedure using liquid Onyx-18 performed on them within 72 hours after surgery, while the control group underwent surgery only.
Key findings:
- The symptomatic recurrence of chronic subdural hematoma assessed by CT scan at 90 days after treatment was observed in only 4 patients (4.3%) in the EMMA group, whereas in the control group, the incidence of symptoms was noted in a remarkable 26 patients (28%).
- The absolute risk reduction between the groups was −23.7% (95% confidence interval, −34.1% to −13.9%; P < .001).
- Asymptomatic or radiologic recurrence was identified in 13 individuals (14%) in the EMMA group but 46 individuals (49.5%) in the control group.
- At 90 days, the mortality was 4.3% in the EMMA group but 1.1% in the control group, while the occurrence of severe adverse events was 8.6% in the former but 5.4% in the latter.
In this randomized trial, the effectiveness of middle meningeal artery embolization after surgery is established by demonstrating a significant reduction in the rate of symptomatic recurrence at 90 days on computed tomography among patients undergoing surgical drainage for unilateral chronic subdural hematomas. With an impressive reduction in the incidence of symptomatic recurrence rates from 28% to under 4%, strong and high-quality evidence can be anticipated to impact future guidelines for managing such cases globally.
Reference:
Shankar JJS, Alcock S, Kashani N, et al. Management of Chronic Subdural Hematoma With Adjunctive Embolization of Middle Meningeal Artery: The EMMA-Can Randomized Clinical Trial. JAMA. Published online April 30, 2026. doi:10.1001/jama.2026.4910
