N-hexyl cyanoacrylate (Magic Glue) for middle meningeal artery embolization: a retrospective multicenter analysis

BACKGROUND: Chronic subdural hematoma (cSDH) is common, with an incidence of up to 5/100,000, increasing with age. Surgery carries a recurrence risk of around 20%. Three randomized controlled trials demonstrated the benefit of middle meningeal artery embolization (MMAE) using ethylene vinyl alcohol (EVOH)-based embolics like Onyx (Medtronic) or Squid (Balt Group). Other agents, including particles and N-butyl cyanoacrylate (NBCA), are under investigation. N-hexyl cyanoacrylate (Magic Glue, Balt Group) is a newer NBCA-based embolic with slower precipitation, enabling potentially safer and more effective embolization. Unlike EVOH-based agents, Magic Glue does not require dimethyl sulfoxide (DMSO) flushing, which can cause discomfort and trigeminocardiac reflex and thus often necessitates general anesthesia. We present the first case series of MMAE with Magic Glue. METHODS: This retrospective study included patients from three neurointerventional centers treated with MMAE for cSDH using Magic Glue. Patient characteristics (age, sex, antiplatelet or anticoagulant use, symptoms) were assessed. The primary endpoint was the need for repeat surgery or MMAE for recurrence or progression. Secondary endpoints included technical complications, hematoma size reduction, and modified Rankin Scale (mRS) score at last follow-up. RESULTS: 58 patients (48 male; mean age 73.9±10.3 years) were included. 31.0% received antiplatelets and 34.5% anticoagulants; 96.6% had symptoms. Repeat treatment was necessary in 15.5%. Technical complications occurred in 5.2%, none requiring intervention. Four procedure-related or presumably procedure-related complications occurred, including one ischemic stroke; all resolved by final follow-up. Initial cSDH size averaged 19.0±6.8 mm, with a mean reduction of 12.5±5.7 mm. CONCLUSIONS: This multicenter study suggests MMAE with Magic Glue may be a safe and effective alternative to established liquid embolics.