Perceived Safety and Efficacy of Middle Meningeal Artery Embolization: Results from an International Survey

BACKGROUND: Middle meningeal artery embolization (MMAE) is a promising new treatment for chronic SDH (cSDH). We conducted an international multi-disciplinary survey among physicians involved in the care of cSDH patients to understand the perceived safety profile and efficacy of MMAE in real-world clinical practice. METHODS: The survey was distributed via several neurointerventional society mailing lists. We collected data on participant demographics, practice patterns, volumes and experience, perceived MMAE safety, complication tolerance, and decision-making. Data were analyzed using descriptive statistics, non-parametric tests and multi-variable regression. RESULTS: Five-hundred-seventy-seven physicians completed the survey between November 20th, 2024 and May 1st, 2025 (median age 42.0 years, 489 [84.7%] male, comprised of endovascular neurosurgeons [185/577, 32.1%], interventional neuroradiologists [181/577, 31.4%]). The recent positive MMAE trials led to cSDH management, particularly in among endovascular neurosurgeons (adjusted odds ratio 2.56 [95% CI 1.51-4.35] compared to interventional neuroradioligists [reference]), and less so among other specialties. There were region-specific differences in rates of practice change and a negative association of physician age and practice change (adjusted odds ratio 0.72 [95% CI 0.53-0.99]). Most participants would now consider MMAE in patients with a new cSDH diagnosis with high perceived recurrence risk (192/424 [45.3%]), while 101/424 (23.8%) would consider MMAE for all cSDH patients. The highest acceptable risk for major complications was 4.0% (median, IQR, 2-5%), although this differed between regions and specialties. CONCLUSION: Recent trials on MMAE for cSDH treatment have changed practice patterns of cSDH management globally. MMAE is now considered a viable option by most physicians even for patients with first-time cSDH. Most would tolerate a maximum of 4% major complications, although rates of practice change and acceptable risk thresholds vary by region and specialty.