ArticleNeuroradiology2026
Multi-pedicle versus single-pedicle middle meningeal artery embolization for nonacute subdural hematoma.
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101 authors.
Garrett W ThrashUniversity of Alabama at Birmingham, Birmingham, USA. gthrash@uab.edu.
Bluyé DeMessieDepartment of Neurological Surgery and Radiology, Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, USA.ORCID https://orcid.org/0000-0001-9456-8630
Elijah L WangUniversity of Alabama at Birmingham, Birmingham, USA. elw2@uab.edu.ORCID https://orcid.org/0009-0000-0512-4123
Jesse G JonesUniversity of Alabama at Birmingham, Birmingham, USA. jessejones@uabmc.edu.ORCID https://orcid.org/0000-0002-2682-9736
Muhammed Amir EssibayiDepartment of Neurological Surgery and Radiology, Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, USA.ORCID https://orcid.org/0000-0001-8325-2382
Hamza Adel SalimDepartment of Neuroradiology, The University of Texas MD Anderson Cancer Center, Houston, USA.ORCID https://orcid.org/0000-0002-5208-8425
Alireza KarandishDepartment of Neurological Surgery and Radiology, Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, USA.ORCID https://orcid.org/0000-0001-7482-8247
Deepak KhatriDepartment of Neurological Surgery and Radiology, Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, USA.
Neil HaranhalliDepartment of Neurological Surgery and Radiology, Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, USA.
Amanda BakerDepartment of Neurological Surgery and Radiology, Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, USA.
Richard ZampolinDepartment of Neurological Surgery and Radiology, Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, USA.
Allan L BrookDepartment of Neurological Surgery and Radiology, Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, USA.
Seon-Kyu LeeDepartment of Neurological Surgery and Radiology, Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, USA.
Nimer AdeebDepartment of Neurosurgery, Ochsner-Louisiana State University, Shreveport, USA.
Dhairya A LakhaniDepartment of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, USA.ORCID https://orcid.org/0000-0001-7577-1887
Yan-Lin LiNuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, Oxford, UK.ORCID https://orcid.org/0000-0002-1722-4188
Davide SimonatoNuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, Oxford, UK.
Diego Alejandro OrtegaNeurovascular Centre & RADIS Lab, University of Toronto, Toronto, Canada.
Nicole CancelliereNeurovascular Centre & RADIS Lab, University of Toronto, Toronto, Canada.
Jose Danilo DiestroNeurovascular Centre & RADIS Lab, University of Toronto, Toronto, Canada.ORCID https://orcid.org/0000-0001-8450-2021
Joseph CarnevaleDepartment of Neurological Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA.
Craig SchreiberDepartment of Neurological Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA.
Atakan OrscelikDepartment of Neurological Surgery and Radiology, Mayo Clinic Rochester, Rochester, USA.ORCID https://orcid.org/0000-0001-6481-3076
Zachary AbecassisDepartment of Neurological Surgery, University of Washington, Seattle, USA.
Spencer RaubDepartment of Neurological Surgery, University of Washington, Seattle, USA.
Georgios S SioutasDepartment of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, USA.
Abdulrhman AlsalamaDepartment of Neurosurgery, University of Illinois at Chicago, Chicago, USA.ORCID https://orcid.org/0009-0004-5653-2150
Clairice PearceDepartment of Neurosurgery, University of Illinois at Chicago, Chicago, USA.
Giancarlo SalsanoUnit of Neuroradiology, Ospedale Policlinico San Martino, Genoa, Italy.ORCID https://orcid.org/0000-0003-0602-7952
Rahim Abo KasemDepartment of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, USA.ORCID https://orcid.org/0000-0002-9635-7471
Svetlana KvintDepartment of Radiology and Neurosurgery, NYU Langone Health, New York, USA.
Andrew FalzonAtkinson Morley Regional Neurosciences Centre, St George's University Hospitals NHS Foundation Trust, London, UK.ORCID https://orcid.org/0000-0003-2212-6635
Vance CantrellDepartment of Radiology, Interventional Neuroradiology, Lehigh Valley Health Network, Allentown, USA.
Brian HollidayDepartment of Radiology, Interventional Neuroradiology, Lehigh Valley Health Network, Allentown, USA.
Jefferson O AbariciaDepartment of Interventional Radiology and Neurosurgery, Oregon Health & Science University, Portland, USA.
Pedram D MalekniaDepartment of Neurosurgery, Baylor College of Medicine, Houston, USA.
Leonardo Cruz-CriolloDepartment of Neurology, Neurosurgery & Radiology, University of Iowa Health Care, Iowa City, USA.ORCID https://orcid.org/0009-0007-6751-9463
Samantha SchimmelDepartment of Neurosurgery & Brain Repair, University of South Florida, Tampa, USA.ORCID https://orcid.org/0000-0001-9860-8820
Basel MusmarDepartment of Neurological Surgery, Thomas Jefferson University, Philadelphia, USA.ORCID https://orcid.org/0009-0000-4910-6090
Matthew AlexanderNeurointerventional Surgery, Sutter Medical Center, Sacramento, USA.
Jorge Rios ZermenoDepartment of Neurological Surgery and Radiology, Mayo Clinic Jacksonville, Jacksonville, USA.
Prateeka KoulDepartment of Neurosurgery, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, USA.
Ahmed AljubooriDepartment of Neurosurgery, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, USA.
Dominik F VollherbstDepartment of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany.
Domagoj GajskiDepartment of Neurosurgery, Sisters of Charity Hospital, Zagreb, Croatia.
Jared CooperDepartment of Neurosurgery-Westchester Medical Center, New York Medical College, Valhalla, USA.
Omar AlwakaaNeurosurgical Division, Beth Israel Deaconess Medical Center, Boston, USA.
Mohamad EzzeldinNeuro endovascular surgery, HCA Houston Healthcare, Kingwood, USA.
James GristOxford Centre for Clinical Magnetic Resonance (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK.ORCID https://orcid.org/0000-0001-7223-4031
Fulvio ZaccagnaOxford Centre for Clinical Magnetic Resonance (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
Christopher S OgilvyNeurosurgical Division, Beth Israel Deaconess Medical Center, Boston, USA.ORCID https://orcid.org/0000-0003-4600-8545
Fawaz Al-MuftiDepartment of Neurosurgery-Westchester Medical Center, New York Medical College, Valhalla, USA.
Vladimir KalousekDepartment of Radiology, Sisters of Charity Hospital, Zagreb, Croatia.
Markus A MöhlenbruchDepartment of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany.
Luca ScarciaDepartment of Neuroradiology, Hôpitaux Universitaires Henri-Mondor, Créteil, France.ORCID https://orcid.org/0000-0002-1316-0383
William W WroeDepartment of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, USA.
Hussein A ZeineddineDepartment of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, USA.
Si Zhao TangDivision of Interventional Radiology, Department of Diagnostic Imaging, National University Hospital, National University Health System, Singapore, Singapore.
Peter B SpornsDepartment of Radiology and Neuroradiology, Triemli Hospital, Zurich, Switzerland.
Anil GopinathanDivision of Interventional Radiology, Department of Diagnostic Imaging, National University Hospital, National University Health System, Singapore, Singapore.ORCID https://orcid.org/0000-0002-8192-1287
Robert W RegenhardtDepartment of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, USA.
Spiros L BlackburnDepartment of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, USA.ORCID http://orcid.org/0000-0003-2902-5079
Clemens M SchirmerDepartment of Neurosurgery, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, USA.
Thien HuynhDepartment of Neurological Surgery and Radiology, Mayo Clinic Jacksonville, Jacksonville, USA.ORCID https://orcid.org/0000-0001-9319-952X
Rabih G TawkDepartment of Neurological Surgery and Radiology, Mayo Clinic Jacksonville, Jacksonville, USA.ORCID https://orcid.org/0000-0002-2695-0042
Fabio SettecaseNeurointerventional Surgery, Sutter Health California Pacific Medical Center, San Francisco, USA.
Stavropoula TjoumakarisDepartment of Neurological Surgery, Thomas Jefferson University, Philadelphia, USA.
Pascal JabbourDepartment of Neurological Surgery, Thomas Jefferson University, Philadelphia, USA.ORCID https://orcid.org/0000-0002-8965-2413
Kunal VakhariaDepartment of Neurosurgery & Brain Repair, University of South Florida, Tampa, USA.
Mario ZanatyDepartment of Neurology, Neurosurgery & Radiology, University of Iowa Health Care, Iowa City, USA.
Santiago Ortega-GutierrezDepartment of Neurology, Neurosurgery & Radiology, University of Iowa Health Care, Iowa City, USA.
Marco ColasurdoDepartment of Interventional Radiology and Neurosurgery, Oregon Health & Science University, Portland, USA.ORCID https://orcid.org/0000-0002-7823-3088
Hussein H NasserDepartment of Radiology, Interventional Neuroradiology, Lehigh Valley Health Network, Allentown, USA.
Sri Hari SundararajanDepartment of Radiology, Interventional Neuroradiology, Lehigh Valley Health Network, Allentown, USA.
Pascal J MosimannInterventional and Diagnostic Neuroradiology, UMIT-JDMI-UHN INR, University of Toronto, Toronto Western Hospital, Toronto, Canada.
Erez NossekDepartment of Radiology and Neurosurgery, NYU Langone Health, New York, USA.
Eytan RazDepartment of Radiology and Neurosurgery, NYU Langone Health, New York, USA.
Sami Al KasabDepartment of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, USA.
Alejandro M SpiottaDepartment of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, USA.
Lucio CastellanUnit of Neuroradiology, Ospedale Policlinico San Martino, Genoa, Italy.
Bruno Del SetteUnit of Neuroradiology, Ospedale Policlinico San Martino, Genoa, Italy.
Ali AlarajDepartment of Neurosurgery, University of Illinois at Chicago, Chicago, USA.ORCID https://orcid.org/0000-0002-1491-4634
Caterina MichelozziDepartment of Neuroradiology and Neurosurgery, Interventional Neuroradiology Division, San Raffaele University Hospital, Milan, Italy.
Davide SaracenoDepartment of Neuroradiology and Neurosurgery, Interventional Neuroradiology Division, San Raffaele University Hospital, Milan, Italy.
Pietro PanniDepartment of Neuroradiology and Neurosurgery, Interventional Neuroradiology Division, San Raffaele University Hospital, Milan, Italy.ORCID https://orcid.org/0000-0001-8109-9118
Visish M SrinivasanDepartment of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, USA.
Jan-Karl BurkhardtDepartment of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, USA.
Gaultier MarnatNeuroradiology Department, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
Pietro Mario SantiniNeuroradiology Department, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
Michael R LevittDepartment of Neurological Surgery, University of Washington, Seattle, USA.
Giuseppe LanzinoDepartment of Neurological Surgery and Radiology, Mayo Clinic Rochester, Rochester, USA.
Waleed BrinjikjiDepartment of Neurological Surgery and Radiology, Mayo Clinic Rochester, Rochester, USA.
Jared KnopmanDepartment of Neurological Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, USA.
Tareq Kass-HoutDepartment of Neurology, University of Chicago, Chicago, USA.
Julian SpearsNeurovascular Centre & RADIS Lab, University of Toronto, Toronto, Canada.
Thomas MarottaNeurovascular Centre & RADIS Lab, University of Toronto, Toronto, Canada.
Vitor Mendes PereiraNeurovascular Centre & RADIS Lab, University of Toronto, Toronto, Canada.
Maurizio FuschiNuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, Oxford, UK.ORCID https://orcid.org/0009-0004-3049-175X
Tufail PatankarDepartment of Neuroradiology, Queens Hospital, Barking, Havering And Redbridge University Hospitals NHS Trust, Romford, UK.
David J AltschulDepartment of Neurological Surgery and Radiology, Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, USA.ORCID https://orcid.org/0000-0002-5130-1378
Adam A DmytriwNuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, Oxford, UK.ORCID http://orcid.org/0000-0003-0131-5699
Funding
No grant is acknowledged in the PubMed record.
Abstract
introductionNonacute subdural hematomas (nSDH) are common yet serious extra-axial hemorrhages that result in significant morbidity and mortality. Middle meningeal artery (MMA) embolization (MMAE) is a recent endovascular treatment that involves occlusion of the MMA, inducing hemostasis in and around the hematoma. While many aspects of MMAE have been explored, there is currently limited data on the optimal extent of embolization.
objectiveTo determine whether single or multiple pedicle embolization of the MMA is superior in inducing hemostasis in nSDH.
methodsWe compared single versus multi pedicle embolization by a retrospective multicenter analysis of nSDH patients who underwent MMAE between 2019 and 2024 at participating centers in the MESH (MMA Embolization for Subdural Hematoma) Registry. 679 patients who received a liquid embolic agent with branch-level embolization data were included.
resultsWhile multi-pedicle embolization hastened nSDH thinning at 1 month (5.7 vs. 3.3 mm reduction; difference 2.4 mm, 95% CI 1.0-3.8; P = .002), by 3 months thickness reduction had converged between groups (8.2 vs. 8.4 mm; P = .91). Among 679 patients (456 multi-pedicle, 223 single-pedicle), favorable functional outcome (mRS 0-2) was more frequent with multi-pedicle embolization (53.5% vs. 43.0%; adjusted OR 1.81, 95% CI 1.26-2.60; P = .001), whereas recurrence, rescue surgery, and treatment failure did not differ.
conclusionFuture, multi-center randomized prospective trials are warranted to address confounding variables that limit this observational study. Follow-up beyond 3 months was limited, so durability is unknown.
Indexed as
Chronic subdural hematomaMiddle meningeal artery embolizationMulti pedicleNonacute subdural hematomaSingle pedicle
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