Management Of Chronic Subdural Hematoma Research Articles

Postoperative elevated bed header position versus supine in the management of chronic subdural hematoma:a systematic review and meta-analysis.

Chronic subdural hematoma (CSDH) is a prevalent type of intracranial hemorrhage. Surgical interventions, such as Twist Drill Craniostomy and Burr Hole Craniostomy, are employed for its treatment. However, limited information exists regarding the impact of postoperative head position (supine vs. elevated) on clinical outcomes. We aim to assess whether patients' head position after surgery influences their prognosis. We conducted a PRISMA-compliant systematic review and meta-analysis. Our search encompassed PubMed, Cochrane CENTRAL, Scopus, Web of Science, and Embase databases to identify relevant published studies. Data were meticulously extracted, pooled using a fixed model, and reported as risk ratios (RR) with 95% confidence intervals (CI). Statistical analysis was performed using R and Stata MP v.17. Five studies involving 284 patients were included in our meta-analysis. We focused on three primary clinical outcomes, comparing the supine and elevated header positions. Notably, there was no statistically significant difference between the supine and elevated positions in terms of recurrence rate (RR 0.77, 95% CI [0.44, 1.37]), second intervention for recurrence (RR 1.07, 95% CI [0.42, 2.78]) and postoperative complications (RR 1.16, 95% CI [0.70, 1.92]). Current studies have proved no difference between supine and elevated bed header positions regarding recurrence rate, second intervention for recurrence, and postoperative complications. Future RCTs with long-term follow-ups are recommended.

Mini-Craniotomy for Chronic Subdural Hematoma: A Reliable Surgical Option

Abstract Introduction Chronic subdural hematoma (SDH) is one of the most common conditions encountered in the neurosurgical practice. Surgical modalities like twist drill craniostomy, burr hole evacuation, mini-craniotomy, and craniotomy are practiced in the management of chronic SDH. Mini-craniotomy without excision of membranes may help to achieve best results with decreased complication rate. Materials and Methods Patients with chronic SDH operated from September 2013 to September 2022 were included in the study. Mini-craniotomy (40–60 mm) was done and cruciate incision was given over the dura. Dura was left wide open by reflecting and suturing the cut edges of the dural leaflets to the craniotomy edge allowing to evacuate subdural space under vision during surgery and to allow any residual collection to drain out freely in the postoperative period. A drain was placed between the inner membrane and the bone flap. Preoperative and postoperative clinical and radiological parameters were recorded. Complications, recurrence, and residual collections were noted. Results Seventy-seven patients were included in the study. Mean age was 57.32 years. Median Glasgow Coma Scale (GCS) at presentation was 13 while median GCS at discharge was 15. Two patients with preexisting comorbidities expired after surgery due to medical causes. No recurrences were noted. Fourteen patients had residual collections which resolved by 6 weeks. Two patients had wound infection. One of these patients later needed a bone flap removal due to osteomyelitis. Conclusion Mini-craniotomy without membranectomy is a good option for complete evacuation of chronic SDH under vision mainly avoiding the complication of membranectomy. It is not associated with increased complications rate. It needs fewer follow-ups as brain expansion can be established radiologically in a short period.

Technical report: clinical feasibility of augmented reality-navigated chronic subdural hematoma evacuation

Abstract Management of chronic subdural hematoma (cSDH) poses unique challenges and can be fraught with complications. Understanding the spatial relationships of cSDH to adjacent brain tissue and skull topography is critical for successful surgical treatment. The aim of this report is to highlight the feasibility and efficacy of a novel augmented reality (AR) overlay tool for surgical planning with technical description of two surgical cases using AR for surgical management of cSDH. This report describes a fiducial-less AR system for surgical planning of surgical evacuation of cSDH. The AR system was used to superimpose 3D anatomy onto the patients head to provide image guidance during two cases of evacuation. Imaging demonstrated convexity cSDH. A 3D model of the patient’s anatomy was created and registered onto the patients’ heads using a novel AR system. Surgical evacuation of the cSDH was completed in each case with surgical planning assisted by AR overlay.

ARISE I Consensus Statement on the Management of Chronic Subdural Hematoma.

ARISE (Aneurysm/AVM/cSDH Roundtable Discussion With Industry and Stroke Experts) organized a one-and-a-half day meeting and workshop and brought together representatives from academia, industry, and government to discuss the most promising approaches to improve outcomes for patients with chronic subdural hematoma (cSDH). The emerging role of middle meningeal artery embolization in clinical practice and the design of current and potential future trials were the primary focuses of discussion. Existing evidence for imaging, indications, agents, and techniques was reviewed, and areas of priority for study and key questions surrounding the development of new and existing treatments for cSDH were identified. Multiple randomized, controlled trials have met their primary efficacy end points, providing high-level evidence that middle meningeal artery embolization is a potent adjunctive therapy to the standard (surgical and nonsurgical) management of neurologically stable cSDH patients in terms of reducing rates of disease recurrence. Pooled data analyses following the formal conclusion and publication of these trials will form a robust foundation upon which guidelines can be strengthened for cSDH treatment modalities and optimal patient selection, as well as delineate future lines of investigation.

Endoscopic Management of Chronic Subdural Hematoma Using a Novel Brain Retractor

Endoscopic Management of Chronic Subdural Hematoma Using a Novel Brain Retractor

Efficacy and safety of tranexamic acid in the management of chronic subdural hematoma: a systematic review and meta-analysis.

Chronic subdural hematoma (CSDH) is a prevalent neurosurgical condition, particularly among the elderly. Various treatment options exist, but recurrence rates remain high. This systematic review and meta-analysis aims to assess the efficacy and safety of tranexamic acid (TXA) in the management of CSDH. The authors conducted a comprehensive literature search adhering to the 2020 PRISMA guidelines, involving three primary databases (Scopus, PubMed, and Web of Science) that were searched for articles compiled from inception until October 20, 2023. The primary outcome was recurrence of CSDH, and secondary outcomes included complications and SDH volume following TXA treatment. The mean difference and odds ratios with 95% confidence intervals were calculated using the random-effects model. A total of 5 studies, involving 643 patients in the TXA group and 736 patients in the non-TXA group, met the inclusion criteria. The meta-analysis revealed that TXA use led to a significantly lower CSDH recurrence (OR 0.35, 95% CI 0.23-0.53; p < 0.01) without increasing complications (OR 1.84, 95% CI 0.43-7.95; p = 0.42). Additionally, TXA users had a significantly lower CSDH volume compared to the non-TXA group at 3-month follow-up (mean difference -4.56, 95% CI -8.76 to -0.36; p = 0.03). The findings suggest that TXA might be a promising agent for reducing the risk of CSDH recurrence without elevating the risk of complications. However, these results should be interpreted cautiously due to the limited number of studies included and the methodological heterogeneity. Further large-scale randomized controlled trials are needed to confirm these findings.

Backup Frontal Drainage System for Urgent Tension Pneumocephalus Management After Chronic Subdural Hematoma Surgery: A Retrospective Cohort Study

ObjectiveTo describe a simple variation of burr hole craniostomy for the management of chronic subdural hematoma (CSDH) that uses a frontal drainage system to facilitate timely decompression in the event of tension pneumocephalus and spares the need for additional surgery. MethodsWe conducted a retrospective analysis of 20 patients with CSDH who underwent burr hole craniostomy and 20 patients who underwent the same procedure alongside the placement of a 5fr neonatal feeding tube as a backup drainage for the anterior craniostomy. Depending on the situation, the secondary drain stayed for a maximum of 72 hours to be opened and used in emergency settings for drainage, aspiration, or as a one-way valve with a water seal. ResultsThe outcomes of 20 patients who underwent this procedure and 20 controls are described. One patient from each group presented tension pneumocephalus. One was promptly resolved by opening the backup drain under a water seal to evacuate pneumocephalus and the other patient had to undergo a re-opening of the craniostomy. ConclusionsThe described variation of burr hole craniostomy represents a low-cost and easy-to-implement technique that can be used for emergency decompression of tension pneumocephalus. It also has the potential to reduce re-operation rates and CSDH recurrence. Prospective controlled research is needed to validate this approach further.

Risk Factors for Pneumocephalus Following the Surgical Management of Chronic Subdural Hematoma

Risk Factors for Pneumocephalus Following the Surgical Management of Chronic Subdural Hematoma

Immediate procedural safety of adjunctive proximal coil occlusion in middle meningeal artery embolization for chronic subdural hematomas: Experience in 137 cases.

Endovascular embolization of the middle meningeal artery (MMA) has emerged as an adjunctive and stand-alone modality for the management of chronic subdural hematomas (cSDH). We report our experience utilizing proximal MMA coil embolization to augment cSDH devascularization in MMA embolization. MMA embolization cases with adjunctive proximal MMA coiling were retrospectively identified from a prospectively maintained IRB-approved database of the senior authors. Of the 137 cases, all patients (n = 89, 100%) were symptomatic and underwent an MMA embolization procedure for cSDH. 50 of the patients underwent bilateral embolizations, with 53% (n = 72) for left-sided and 47% (n = 65) for right-sided cSDH. The anterior MMA branch was embolized in 19 (14%), posterior in 16 (12%), and both in 102 (74.5%) cases. Penetration of the liquid embolic to the contralateral MMA or into the falx was present in 38 (28%) and 31 (23%) cases, respectively, and 46 (34%) cases had ophthalmic or petrous collateral (n = 41, 30%) branches. MMA branches coiled include the primary trunk (25.5%, n = 35), primary and anterior or posterior MMA trunks (20%, n = 28), or primary with the anterior and posterior trunks (54%, n = 74). A mild ipsilateral facial nerve palsy was reported, which remained stable at discharge and follow-up. Absence of anterograde flow in the MMA occurred in 137 (100%) cases, and no cases required periprocedural rescue surgery for cSDH evacuation. The average follow-up length was 170 ± 17.9 days, cSDH was reduced by 4.24 ± 0.5(mm) and the midline shift by 1.46 ± 0.27(mm). Complete resolution was achieved in 63 (46.0%) cases. Proximal MMA coil embolization is a safe technique for providing additional embolization/occlusion of the MMA in cSDH embolization procedures. Further studies are needed to evaluate the potential added efficacy of this technique.

Efficacy and safety of steroids for chronic subdural hematoma: A systematic review and meta-analysis

Background: Chronic subdural hematoma (CSDH) is a condition characterized by the accumulation of fluid, blood, and blood breakdown products between the brain’s arachnoid and dura mater coverings. While steroids have been explored as a potential treatment option, their efficacy and safety remain uncertain. This meta-analysis and systematic review aimed to assess the impact of steroids on CSDH management, including mortality, recurrence, complications, and functional outcomes. Methods: We conducted a comprehensive literature search in major electronic databases up to June 2023, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Cochrane Handbook for Systematic Reviews and Interventions. Inclusion criteria encompassed adult patients with CSDH, the use of steroids as monotherapy or adjuvant therapy, and clearly defined outcomes. Randomized controlled trials and cohort studies meeting these criteria were included in the study. Results: The initial search yielded 4315 articles, with 12 studies meeting the inclusion criteria. Our findings indicate a non-significant trend toward reduced mortality with steroids in combination with standard care (Odds ratios [OR] = 0.66, 95% confidence interval [CI] 0.20–2.18). However, substantial heterogeneity was observed (I2 = 70%). Sensitivity analysis, excluding influential studies, suggested a potential increased mortality risk associated with steroids (OR = 1.47, 95% CI 0.87–2.48). Steroids showed a possible benefit in reducing the recurrence of CSDH (OR = 0.58, 95% CI 0.20–1.67), but with significant heterogeneity (I2 = 89%). No clear advantage of steroids was observed in terms of functional outcomes at three months (modified Rankin scale scores). Furthermore, steroids were associated with a significantly higher incidence of adverse effects and complications (OR = 2.17, 95% CI 1.48–3.17). Conclusion: Steroids may have a potential role in reducing CSDH recurrence but do not appear to confer significant advantages in terms of mortality or functional outcomes. However, their use is associated with a higher risk of adverse effects and complications. Given the limitations of existing studies, further research is needed to refine the role of steroids in CSDH management, considering patient-specific factors and treatment protocols.

Emerging Management of Chronic Subdural hematoma (CSDH) in High-Income Country (HIC) and Low-Income Country (LIC)

Chronic Subdural Hematoma (CSDH) is a common neurosurgical condition that affects individuals worldwide. However, the management of CSDH varies significantly between high-income and low-income countries due to disparities in healthcare resources, infrastructure, and access to advanced medical technologies. In this literature review, we aim to compare and contrast the management approaches of CSDH in high-income and low-income countries. By adopting a global health perspective, we highlight the challenges faced by healthcare systems in both settings and offer insights and recommendations for improving the management of CSDH in low-income countries. This topic is unique and important as it sheds light on the ethical dilemmas posed by the differences in healthcare access and outcomes between high-income and low-income countries and emphasizes the importance of equitable healthcare distribution.

Non-surgical management of chronic subdural hematoma: insights and future perspectives from an international survey including neurosurgeons from 90 countries worldwide

Background Chronic subdural hematoma (cSDH) is one of the most common neurosurgical conditions. Although surgical evacuation is still the gold standard for treatment, recent advances have led to the development of other management strategies, such as medical therapies and endovascular middle meningeal artery (MMA) embolization. Through this international survey, we investigated the global trends in cSDH management, focusing on medical and endovascular treatments. Design and participants A 14-question, web-based, anonymous survey was distributed to neurosurgeons worldwide. Results Most responders do not perform MMA embolization (69.5%) unless for specific indications (29.6%). These indications include residual cSDH after surgical evacuation (58.9%) or cSDH in patients on antiplatelet medications to avoid surgical evacuation (44.8%). Survey participants from teaching versus non-teaching hospitals (p = 0.002), public versus private hospitals (p = 0.022), and Europe versus other continents (p < 0.001) are the most users of MMA embolization. A large number of participants (51%) declare they use a conservative/medical approach, mainly to avoid surgery in patients with small cSDH (74.8%). Conclusions This survey highlights the current trends of cSDH management, focusing on conservative and MMA embolization treatment strategies. Most responders prefer a conservative approach for patients with small cSDHs not requiring surgical evacuation. However, in higher-risk scenarios such as residual hematomas after surgery or patients on antiplatelet medications, MMA embolization is regarded as a reasonable option by participants. Future studies should clarify the indications of MMA embolization, including appropriate patient selection and efficacy as a stand-alone procedure.

Abstract 140: Additive Contralateral MMA Injection for Recurrent Previously Operated cSDH: Experience in 8 Consecutive Cases

Introduction Middle meningeal artery (MMA) embolization has emerged as an adjunctive treatment in the management of chronic subdural hematomas (cSDH). After surgical cSDH evacuation, embolization offers enhanced resorption of cSDH fluid by infarcting the neomembranes at the capillary level. MMA embolization is typically performed on the side ipsilateral to the cSDH, but in the setting of recent surgical evacuation, the ipsilateral meningeal circulation is oftentimes disrupted and/or collateralized. In this situation, penetration of the membranes via an over‐the‐top contralateral injection may provide additional MMA occlusion and efficacy. Methods Consecutive cases of unilateral cSDH surgery with contralateral liquid embolic injection were retrospectively identified from a prospectively maintained database of the senior authors. Results Eight consecutive cases of recurrent cSDH after surgery were identified (average age = 76±3.5 years, all male). Five subjects (63%) had a previous craniotomy and 3 (38%) had previous burr holes. All subjects had a contralateral MMA embolization in addition to an ipsilateral MMA embolization with regards to their previous index surgery. Average recurrent cSDH thickness was 9.8±1.4mm, midline shift of 1.8±0.9mm. MMA branches embolized included both anterior and posterior (n=5, 63%) anterior only (n=2, 25%), and posterior only (n=1, 12.5%). The falx was penetrated in the contralateral MMA embolization in 3 (38%) cases. Injection of glue across the midline to previously non‐penetrated dura on the index surgery side was successfully achieved in all 8 cases. There were no periprocedural complications encountered. Conclusion The addition of contralateral MMA embolization for recurrent cSDH after previous surgery is a safe and potentially additive therapy that may increase the overall efficacy of MMA embolization in these challenging cases.

Management of Chronic Subdural Hematoma a Challenge in Neurosurgical Practice

Chronic subdural hematoma (CSDH) is a common neurosurgical disease encountered by neurologists, neurosurgeons, intensive care specialists, and emergency physicians in the emergency department. Although much has been published on CSDH, it remains a topic of active research, also a significant challenge in specific scenarios. The spectrum of clinical presentation varies from asymptomatic radiological entity to significant sensory-motor deterioration resulting in a comatose state. The majority of these cases have an underlying history of trivial trauma in one or the other form. More often, elderly individuals present with CSDH. Management of CSDH in elderly individuals presents specific challenges due to pre-existing comorbidities and medications which alter the pathophysiology. There exists a significant diversity in the treatment modality of CSDH amongst neurosurgeons. The treatment modality includes medical management as well as various forms of surgical manoeuvres intended to evacuate the hematoma and hence alleviate the mass effect over the surrounding brain matter. The treatment modality needs to be individualized for every case. The rationale selection of cases for medical and surgical intervention with robust follow-up results in a better prognostication of these cases.

Rapamycin promotes hematoma resorption and enhances endothelial cell function by suppressing the mTOR/STAT3 signaling in chronic subdural hematoma

Chronic subdural hematoma (CSDH) remains a neurosurgical condition and a healthy burden especially in elderly patients. This study focuses on the functions of rapamycin and its related molecular mechanisms in CSDH management. A rat model of CSDH was induced, which developed significant hematoma on day 5 after operation. The rats were treated with rapamycin or atorvastatin, a drug with known effect on hematoma alleviation, or treated with rapamycin and atorvastatin in combination. The atorvastatin or rapamycin treatment reduced the hematoma development, blood-brain barrier permeability, neurological dysfunction in CSDH rats, and the combination treatment showed more pronounced effects. Human brain microvascular endothelial cells hCMEC/D3 were stimulated by hematoma samples to mimic a CSDH condition in vitro. The drug treatments elevated the cell junction-related factors and reduced the pro-inflammatory cytokines both in rat hematoma tissues and in hCMEC/D3 cells. Rapamycin suppressed the mTOR and STAT3 signaling pathways. Overexpression of mTOR or the STAT3 agonist suppressed the alleviating effects of rapamycin on CSDH. In summary, this study demonstrates that rapamycin promotes hematoma resorption and enhances endothelial cell function by suppressing the mTOR/STAT3 signaling.

Middle Meningeal Artery Embolization for the Management of Chronic Subdural Hematoma.

Introduction Chronic subdural hematoma (cSDH) results from neovascularization of the subdural capsular membrane and embolization of the Middle Meningeal Artery (MMA) helps inhibit the same and prevent recurrence. Materials and methods We retrospectively reviewed the endovascular management for chronic SDH in 29 patients between 2018 to 2022. The parameters analyzed were clinical history, radiologic imaging findings, procedure details, and angiographic and clinical outcomes. Results Twenty-nine MMA embolization procedures were done. Follow-up MRI or CT done in 28 subjects, showed complete resolution in 25 patients and a significant reduction in bilateral SDH in three patients. One patient died due to renal failure and aspiration pneumonia-related complications. Ninety days mRS (modified Rankin scale) was 0 in 25 patients (86%), one in two patients, and two in one patient. Conclusions MMA embolization for chronic SDH is a feasible, safe, and effective technique in patients with chronic and recurrent SDH.

Incidence, therapy, and outcome in the management of chronic subdural hematoma in Switzerland: a population-based multicenter cohort study.

Chronic subdural hematoma (cSDH) is a disease affecting mainly elderly individuals. The reported incidence ranges from 2.0/100,000 to 58 per 100,000 person-years when only considering patients who are over 70 years old, with an overall incidence of 8.2-14.0 per 100,000 persons. Due to an estimated doubling of the population above 65 years old between 2000 and 2030, cSDH will become an even more significant concern. To gain an overview of cSDH hospital admission rates, treatment, and outcome, we performed this multicenter national cohort study of patients requiring surgical treatment of cSDH. A multicenter cohort study included patients treated in 2013 in a Swiss center accredited for residency. Demographics, medical history, symptoms, and medication were recorded. Imaging at admission was evaluated, and therapy was divided into burr hole craniostomy (BHC), twist drill craniostomy (TDC), and craniotomy. Patients' outcomes were dichotomized into good (mRS, 0-3) and poor (mRS, 4-6) outcomes. A two-sided t-test for unpaired variables was performed, while a chi-square test was performed for categorical variables, and a p-value of <0.05 was considered to be statistically significant. A total of 663 patients were included. The median age was 76 years, and the overall incidence rate was 8.2/100,000. With age, the incidence rate increased to 64.2/100,000 in patients aged 80-89 years. The most prevalent symptoms were gait disturbance in 362 (58.6%) of patients, headache in 286 (46.4%), and focal neurological deficits in 252 (40.7%). CSDH distribution was unilateral in 478 (72.1%) patients, while 185 presented a bilateral hematoma with no difference in the outcome. BHC was the most performed procedure for 758 (97.3%) evacuations. CSDH recurrence was noted in 104 patients (20.1%). A good outcome was seen in almost 81% of patients. Factors associated with poor outcomes were age, GCS and mRS on admission, and the occurrence of multiple deficits present at the diagnosis of the cSDH. As the first multicenter national cohort-based study analyzing the disease burden of cSDH, our study reveals that the hospital admission rate of cSDH was 8.2/100,000, while with age, it rose to 64.2/100,000. A good outcome was seen in 81% of patients, who maintained the same quality of life as before the surgery. However, the mortality rate was 4%.

Middle meningeal artery embolization in the management of chronic subdural hematoma in medically complex pediatric neurosurgical patients: technical note.

Middle meningeal artery (MMA) embolization has gained acceptance as a treatment for chronic subdural hematoma (cSDH) in adult patients but has not been well described in pediatric patients. Standard cSDH treatment has historically consisted of burr hole drainage with or without subdural drain placement. However, due to the high rate of recurrence and frequency of comorbidities within this population, as both pediatric and adult patients with cSDH frequently have concurrent cardiac disease and a need for anticoagulant therapies, MMA embolization has increasingly demonstrated its value as both an adjunctive and primary treatment. In this report, the authors present 3 cases of successful MMA embolization in medically complex children at a single institution. MMA embolization was used as a primary treatment modality and as an adjunctive therapy in the acute setting following surgical hematoma evacuation. Two patients were receiving anticoagulation treatment requiring reversal. Technical considerations specific to the pediatric population as well as those common to both the pediatric and adult populations are addressed. Further work is needed to define the optimal indications and outcomes for MMA embolization in children with cSDH.

Lidocaine for headache prevention during chronic subdural hematoma embolization.

Middle meningeal artery embolization (MMAE) for the management of chronic subdural hematomas (CSDH) with ethylene vinyl alcohol (EVOH) causes an evident patient discomfort due to meningeal nociceptors stimulation. The aim of this study was to assess safety and efficacy of intra-arterial lidocaine (IAL) before MMAE of CSDH with EVOH. We analyzed all consecutive patients with bilateral CSDH undergoing MMAE with EVOH. We used a monolateral IAL injection, with casual allocation. We assessed the headache felt by patients during embolization with the visual analog scale (VAS) and compared scores obtained after embolization of both sides. We followed the STROBE guidelines for case-control studies. Paired t-test and χ2 test were used to compare the distribution of variables in IAL vs control group. Between September 2021 and March 2023, 32 patients underwent bilateral MMAE with EVOH for a CSDH. Lidocaine treatment resulted in a substantially lower VAS score compared to the control group (median 3 vs 7, p < 0.001), with no substantial side effect. Compliance also benefited from lidocaine administration. In patients with CSDH undergoing MMAE, IAL seems to reduce pain sensation associated with EVOH injection and to increase patients' compliance during treatment.

Middle Meningeal Artery Embolization in the Management of Chronic Subdural Hematoma: a Comprehensive Review of Current Literature

Chronic subdural hematoma (cSDH) is a common intracranial hemorrhagic disorder with a high incidence rate among the elderly. While small, asymptomatic cSDH may resolve spontaneously, surgical intervention has been the treatment of choice for larger, symptomatic cases. Surgical evacuation of cSDH may be associated with high rates of recurrence, and even asymptomatic cSDH cases tend to progress. Over the last few years, middle meningeal artery (MMA) embolization has proven to be a safe non-invasive treatment of choice with favorable outcomes and a low recurrence rate. The ensuing paper discusses current treatment modalities for cSDH and reviews existing literature on the anatomy of MMA and its embolization as a treatment option for cSDH. Recent studies show that traumatic head injury leading to subdural hemorrhage can induce neovascularization that may initiate a cycle of recurrent subdural hematoma. Distal branches of MMA supply blood to the dural layers. Several studies have revealed that embolization of the MMA can stop the neovascularization process and blood flow. In addition, patients who underwent MMA embolization had a significantly quicker brain re-expansion and lower recurrence rate. Although the management of cSDH is still very much a dilemma, recent research findings bring MMA embolization to light as a promising treatment alternative and adjunctive therapy.