Safety and efficacy of combined subdural evacuating port system (SEPS) and middle meningeal artery embolization (MMAE) for chronic subdural hematomas: a systematic review and meta-analysis.

BACKGROUND

The combined use of the Subdural Evacuating Port System (SEPS) and middle meningeal artery embolization (MMAE) offers a less invasive alternative to conventional surgical drainage of chronic subdural hematomas (cSDH), while potentially maintaining low retreatment rates. We aimed to perform the first systematic review and meta-analysis to evaluate the outcomes of combined SEPS and MMAE in the treatment for cSDH.

METHODS

Searches of the following three electronic databases were undertaken: Ovid Medline, Ovid Embase, and Cochrane Central Register of Controlled Trials. Searches were performed in each database from its inception until 19th August 2025. The primary outcome was recurrence requiring re-evacuation. Secondary outcomes included perioperative complications, mortality, length of stay (LOS), functional and radiological outcomes.

RESULTS

Four studies comprising 341 cases of SEPS and MMAE were included. Pooled recurrence rate after SEPS and MMAE was 9.1% (95% CI: 5.6-13.2, I2 = 0% [p = 0.521]). Reported complication rates varied between studies (4.0% and 30.4). Pooled 30-day mortality was 2.1% (95% CI: 0.2-5.3, I2 = 23.6% [p = 0.271]). Pooled mean length of stay (LOS) was 6.6 days (95% CI: 6.1-7.2, I2 = 0% [p = 0.478]). Functional outcomes were variably reported. In two studies, 64% and 75.4% of patients achieved postoperative mRS 0-2, with one of these studies showing an improvement in mRS among 53% of patients. In another study, median discharge mRS was 2 (IQR 2-3). Radiological improvement including reduction in the volume of cSDH or midline shift, was reported in two studies.

CONCLUSION

Preliminary evidence of combined SEPS and MMAE demonstrated its potential to achieve promising retreatment rates for well-selected cSDH patients. However, these results are hypothesis-generating, and prospective randomized controlled trials are required to inform on its feasibility and safety for routine clinical use.