Randomised trials have established that middle meningeal artery embolisation (MMAE) reduces recurrence or treatment failure in chronic subdural haematoma, but they have not determined whether surgical evacuation provides additional functional benefit once MMAE is performed or which patients should receive both treatments.
In this multicentre cohort, adding surgery to MMAE was associated with a higher probability of excellent functional recovery among patients impaired at admission, with larger associations in patients with greater haematoma burden, while no clear benefit was observed among patients already functionally independent.
Admission functional status, together with haematoma burden, may help identify patients most likely to benefit from adding surgical evacuation to MMAE and those in whom an operation may potentially be avoided. These findings provide a treatment-selection hypothesis that should be tested prospectively before guiding routine practice.