Middle meningeal artery embolization for chronic subdural hematoma using Nester pushable coils versus Onyx: a multicenter propensity score-matched analysis

Background Middle meningeal artery embolization (MMAE) has been shown to be an efficacious treatment for chronic subdural hematomas (cSDH). Liquid or particulate embolic agents are most commonly used, although coil embolization offers proximal vessel occlusions that may provide comparable efficacy. This multicenter propensity score-matched study compares outcomes of MMAE performed with Nester pushable coils versus Onyx. Methods We retrospectively reviewed patients that underwent MMAE with either Nester coils or Onyx at two institutions between March 2019 and February 2025. Propensity score matching (1:1) was performed based on patient and hematoma characteristics. Primary outcomes included radiologic improvement or need for surgical rescue. Secondary outcomes included complication rate and procedure time. Results A total of 183 patients were included (91 Nester coil, 92 Onyx) with similar baseline characteristics. More patients incurred general anesthesia for Onyx embolization compared with coiling (60.9% vs 15.4%; p < 0.001), although the patients that underwent coiling more often had bilateral embolization performed (64.8% vs 23.9%, p < 0.001). After propensity matching (n=67 per group), rates of radiologic improvement (>50% hematoma reduction), need for surgical rescue, and symptom recurrence were similar between the coil and Onyx cohorts (53.7% vs 44.8%, p=0.300; 14.5% vs 18.8%, p = 0.524, and 17.0% vs 15.9%, p = 0.872, respectively). Coil embolization had a significantly shorter median procedure time (34 vs 63 min, p<0.001) compared with Onyx embolization. Conclusions Embolization using Nester pushable coils yields similar clinical outcomes to Onyx. Pushable coils are safe, efficient, and allow for shorter procedural times, providing an effective, cost-efficient option for cSDH.