Embolization of the middle meningeal artery (EMMA) is an emerging neuroendovascular therapy for chronic subdural hematoma (CSDH). Recently, three landmark randomized trials (MAGIC-MT, EMBOLISE, STEM) were published. We performed a systematic review and meta-analysis of randomized trials for EMMA.

The authors systematically searched MEDLINE, EMBASE, Cochrane and ClinicalTrials.gov (National Library of Medicine) through March 6, 2025. Prospective randomized controlled trials comparing EMMA and standard care versus standard care alone were included. Primary (symptomatic recurrence, symptomatic progression, major adverse event, neurological deterioration, stroke, myocardial infarction and/or death) and secondary endpoints (serious adverse events, stroke, death from any cause and death from neurological causes) were analyzed. The review was registered on PROSPERO (CRD42024512049).

Four randomized trials (Lam et al., MAGIC-MT, EMBOLISE, STEM) were meta-analyzed. A total of 1468 patients were included. The primary endpoint was met in 50 patients (7.5%) in the EMMA group compared to 106 patients (15.5%) in the control group (RR 0.49 [95% CI, 0.36–0.67]; P < 0.001, I2 = 0.0%), with a number needed to treat of 13. There was no difference in serious adverse events (RR 0.88 [95% CI 0.68–1.13]; P = 0.31, I2 = 50.2%), stroke (RR 1.51 [95% CI 0.46–5.01]; P = 0.50, I2 = 0.0%), death from any cause (RR 1.03 [95% CI 0.37–2.85]; P = 0.95, I2 = 58.1%) or death from neurological causes (RR 1.29 [95% CI 0.53–3.09]; P = 0.58, I2 = 25.4%).

EMMA is effective in reducing symptomatic recurrence, progression and/or reoperation among patients with CSDH and is not associated with a greater incidence of serious adverse events, stroke or death.