Statins and Middle Meningeal Artery Embolization in the Treatment of Chronic Subdural Hematoma: A Comprehensive Systematic Review and Network Meta-Analysis

Chronic subdural hematoma (cSDH) is a common neurosurgical condition, particularly in elderly patients. Middle meningeal artery embolization (MMAE) has emerged as a promising intervention, while statins have been explored for their anti-inflammatory and angiogenesis-modulating properties. This study aims to evaluate the impact of MMAE and statins, alone and in combination with surgery, on cSDH outcomes. A systematic review and network meta-analysis was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of PubMed, Scopus, and Web of Science was performed to identify comparative studies on MMAE, statins, and surgery for cSDH. A total of 42 studies (38 cohort studies and 4 randomized controlled trials) were included. MMAE alone significantly reduced recurrence rates compared with surgery alone (OR 0.37, 95% CI 0.23-0.58). However, MMAE with statins showed no significant difference from surgery alone (OR 0.40, 95% CI 0.15-1.06). In addition, surgery with statins had a significantly higher recurrence rate compared with MMAE alone (OR 3.08, 95% CI 1.77-5.36), adjunctive MMAE (OR 3.08, 95% CI 1.77-5.36), and statin with MMAE (OR 0.33, 95% CI 0.11-0.97). No significant differences were observed between treatment groups in terms of complications or mortality. MMAE alone appears to be the most effective strategy for reducing recurrence in cSDH. The addition of statins provided no added benefit, and surgery with statins was associated with higher recurrence compared with MMAE-based treatments, although no significant difference was found when compared with surgery alone. Clinical decision-making should remain individualized, and future research should focus on clarifying patient selection and optimizing treatment strategies by incorporating detailed baseline hematoma characteristics to improve generalizability and long-term outcomes.