{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T12:49:05Z","timestamp":1792673345926,"version":"4.5.0"},"reference-count":30,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,10,1]]},"abstract":"\n OBJECTIVE<\/jats:title>\n Chronic subdural hematoma (cSDH) is one of the most common diseases treated by neurosurgeons. While surgical evacuation has been the traditional way to address symptomatic lesions, there is expanding evidence of the beneficial use of middle meningeal artery (MMA) embolization as a treatment or as an adjunct for cSDH. With the current strain on healthcare resources, physicians must balance providing the best care for patients and making cost-conscious decisions. Therefore, the aim of this study was to compare the cost of surgery alone versus surgery plus MMA embolization for treatment of cSDH, and to calculate an institutional tipping point for cost benefit.<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n This is a retrospective study of patients with symptomatic cSDH requiring surgical intervention at a single institution from May 2019 to December 2022. The patients were concurrently enrolled in a prospective randomized controlled trial. To compare the cost of surgical treatment alone versus surgical treatment plus MMA embolization, all charges related to cSDH treatment from admission to the last follow-up were categorized (procedure, radiology, pharmacy, intensive care unit bed, laboratory, floor bed, and other) and assessed. The institutional tipping point (point at which it becomes financially beneficial to add MMA embolization to surgical evacuation during the same admission) was calculated to help guide decision-making.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n Forty-one patients (28 male, mean age 67.9 years) were included in the analysis, and were previously randomized to surgical intervention only (n = 21) or surgical intervention plus MMA embolization (n = 20). The groups were comparable in terms of demographic and cSDH characteristics. The overall mean cost for the index admission was lower in the surgery only group (US$158,320 vs $235,263; p = 0.037). This was also true for all categories of charges. Throughout the duration of the study there were 27 admissions in the surgery only group and 20 admissions in the surgery plus MMA embolization group (p = 0.0052). When analyzing costs per patient instead of per admission, no differences were observed between treatment groups for any of the categories. Likewise, the overall mean costs related to the care of patients in either treatment group showed no statistical difference ($203,554 vs $235,263; p = 0.25). Consequently, the institutional tipping point for the addition of MMA embolization was 20.8%.<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n MMA embolization can be considered as an adjunct to surgery in the treatment of symptomatic cSDH, decreasing the overall cost by lowering rates of readmission and repeat intervention. The tipping point formula used in this study is versatile and adaptable. It can be a useful guide to determine appropriate treatment options for patients with symptomatic cSDH according to institutional or national standards.<\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2025.7.focus25528","type":"journal-article","created":{"date-parts":[[2025,10,1]],"date-time":"2025-10-01T11:12:16Z","timestamp":1759317136000},"page":"E10","source":"Crossref","is-referenced-by-count":4,"title":["Tipping point in middle meningeal artery embolization: a cost-effectiveness and algorithm-based analysis"],"prefix":"10.3171","volume":"59","author":[{"given":"Luca H.","family":"Debs","sequence":"first","affiliation":[{"name":"Neurosurgery Department, Medical College of Georgia, Augusta, Georgia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Scott Y.","family":"Rahimi","sequence":"additional","affiliation":[{"name":"Neurosurgery Department, Medical College of Georgia, Augusta, Georgia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fernando L.","family":"Vale","sequence":"additional","affiliation":[{"name":"Neurosurgery Department, Medical College of Georgia, Augusta, Georgia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1","series-title":"World Neurosurg","first-page":"339","article-title":"Updates in chronic subdural hematoma: epidemiology, etiology, pathogenesis, treatment, and outcome","volume":"141","author":"Feghali J","year":"2020","unstructured":"Feghali J, Yang W, Huang J. Updates in chronic subdural hematoma: epidemiology, etiology, pathogenesis, treatment, and outcome. World Neurosurg. 2020;141:339\u2013345."},{"issue":"27","key":"b2","series-title":"N Engl J Med","first-page":"2616","article-title":"Trial of dexamethasone for chronic subdural hematoma","volume":"383","author":"Hutchinson PJ","year":"2020","unstructured":"Hutchinson PJ, Edlmann E, Bulters D, Trial of dexamethasone for chronic subdural hematoma. N Engl J Med. 2020;383(27):2616-2627."},{"issue":"7","key":"b3","series-title":"J Neurointerv Surg","first-page":"695","article-title":"Middle meningeal artery embolization as an adjuvant treatment to surgery for symptomatic chronic subdural hematoma: a pilot study assessing hematoma volume resorption","volume":"12","author":"Ng S","year":"2020","unstructured":"Ng S, Derraz I, Boetto J, Middle meningeal artery embolization as an adjuvant treatment to surgery for symptomatic chronic subdural hematoma: a pilot study assessing hematoma volume resorption. J Neurointerv Surg. 2020;12(7):695\u2013699."},{"issue":"Pt A","key":"b4","series-title":"J Clin Neurosci","first-page":"147","article-title":"An open label randomized trial to assess the efficacy of tranexamic acid in reducing post-operative recurrence of chronic subdural haemorrhage","volume":"82","author":"Wan KR","year":"2020","unstructured":"Wan KR, Qiu L, Saffari SE, An open label randomized trial to assess the efficacy of tranexamic acid in reducing post-operative recurrence of chronic subdural haemorrhage. J Clin Neurosci. 2020;82(Pt A):147-154."},{"issue":"6","key":"b5","series-title":"Geroscience","first-page":"6537","article-title":"Newer treatment paradigm improves outcomes in the most common neurosurgical disease of the elderly: a literature review of middle meningeal artery embolization for chronic subdural hematoma","volume":"46","author":"Debs LH","year":"2024","unstructured":"Debs LH, Walker SE, Rahimi SY. Newer treatment paradigm improves outcomes in the most common neurosurgical disease of the elderly: a literature review of middle meningeal artery embolization for chronic subdural hematoma. Geroscience. 2024;46(6):6537-6561."},{"issue":"4","key":"b6","series-title":"J Neurosurg","first-page":"1208","article-title":"A propensity-adjusted comparison of middle meningeal artery embolization versus conventional therapy for chronic subdural hematomas","volume":"135","author":"Catapano JS","year":"2021","unstructured":"Catapano JS, Ducruet AF, Nguyen CL, A propensity-adjusted comparison of middle meningeal artery embolization versus conventional therapy for chronic subdural hematomas. J Neurosurg. 2021;135(4):1208\u20131213."},{"key":"b7","series-title":"J Clin Neurosci","first-page":"110783","article-title":"Middle meningeal artery embolization following surgical evacuation of symptomatic chronic subdural hematoma improves outcomes, interim results of a prospective randomized trial","volume":"128","author":"Debs LH","year":"2024","unstructured":"Debs LH, Vale FL, Walker S, Middle meningeal artery embolization following surgical evacuation of symptomatic chronic subdural hematoma improves outcomes, interim results of a prospective randomized trial. J Clin Neurosci. 2024;128:110783."},{"issue":"3","key":"b8","series-title":"Ann Surg","first-page":"449","article-title":"Chronic subdural hematoma management: a systematic review and meta-analysis of 34,829 patients","volume":"259","author":"Almenawer SA","year":"2014","unstructured":"Almenawer SA, Farrokhyar F, Hong C, Chronic subdural hematoma management: a systematic review and meta-analysis of 34,829 patients. Ann Surg. 2014;259(3):449-457."},{"issue":"5","key":"b9","series-title":"J Neurosurg","first-page":"1209","article-title":"Actual and projected incidence rates for chronic subdural hematomas in United States Veterans Administration and civilian populations","volume":"123","author":"Balser D","year":"2015","unstructured":"Balser D, Farooq S, Mehmood T, Reyes M, Samadani U. Actual and projected incidence rates for chronic subdural hematomas in United States Veterans Administration and civilian populations. J Neurosurg. 2015;123(5):1209-1215."},{"key":"b10","series-title":"Front Public Health","first-page":"1160691","article-title":"Rationing in healthcare-a scoping review","volume":"11","author":"Berezowski J","year":"2023","unstructured":"Berezowski J, Czapla M, Manulik S, Ross C. Rationing in healthcare-a scoping review. Front Public Health. 2023;11:1160691."},{"issue":"10","key":"b11","series-title":"J Neurointerv Surg","first-page":"951","article-title":"Middle meningeal artery embolization for chronic subdural hematoma: a systematic review and meta-analysis","volume":"13","author":"Ironside N","year":"2021","unstructured":"Ironside N, Nguyen C, Do Q, Middle meningeal artery embolization for chronic subdural hematoma: a systematic review and meta-analysis. J Neurointerv Surg. 2021;13(10):951-957."},{"issue":"1","key":"b12","series-title":"Neurosurg Rev","first-page":"270","article-title":"Risk factors for recurrence of chronic subdural hematoma after surgical evacuation: a systematic review and meta-analysis","volume":"46","author":"Maroufi SF","year":"2023","unstructured":"Maroufi SF, Farahbakhsh F, Macdonald RL, Khoshnevisan A. Risk factors for recurrence of chronic subdural hematoma after surgical evacuation: a systematic review and meta-analysis. Neurosurg Rev. 2023;46(1):270."},{"issue":"6","key":"b13","series-title":"J Korean Neurosurg Soc","first-page":"518","article-title":"Postoperative course and recurrence of chronic subdural hematoma","volume":"48","author":"Oh HJ","year":"2010","unstructured":"Oh HJ, Lee KS, Shim JJ, Yoon SM, Yun IG, Bae HG. Postoperative course and recurrence of chronic subdural hematoma. J Korean Neurosurg Soc. 2010;48(6):518\u2013523."},{"key":"b14","series-title":"World Neurosurg","first-page":"613","article-title":"Middle meningeal artery embolization for chronic subdural hematoma: meta-analysis and systematic review","volume":"122","author":"Srivatsan A","year":"2019","unstructured":"Srivatsan A, Mohanty A, Nascimento FA, Middle meningeal artery embolization for chronic subdural hematoma: meta-analysis and systematic review. World Neurosurg. 2019;122:613\u2013619."},{"key":"b15","series-title":"EClinicalMedicine","first-page":"101234","article-title":"Factors correlated with the postoperative recurrence of chronic subdural hematoma: an umbrella study of systematic reviews and meta-analyses","volume":"43","author":"Zhu F","year":"2022","unstructured":"Zhu F, Wang H, Li W, Factors correlated with the postoperative recurrence of chronic subdural hematoma: an umbrella study of systematic reviews and meta-analyses. EClinicalMedicine. 2022;43:101234."},{"key":"b1","series-title":"World Neurosurg","first-page":"339","article-title":"Updates in chronic subdural hematoma: epidemiology, etiology, pathogenesis, treatment, and outcome","volume":"141","author":"Feghali J","year":"2020","unstructured":"Feghali J, Yang W, Huang J. Updates in chronic subdural hematoma: epidemiology, etiology, pathogenesis, treatment, and outcome. World Neurosurg. 2020;141:339\u2013345."},{"issue":"27","key":"b2","series-title":"N Engl J Med","first-page":"2616","article-title":"Trial of dexamethasone for chronic subdural hematoma","volume":"383","author":"Hutchinson PJ","year":"2020","unstructured":"Hutchinson PJ, Edlmann E, Bulters D, Trial of dexamethasone for chronic subdural hematoma. N Engl J Med. 2020;383(27):2616-2627."},{"issue":"7","key":"b3","series-title":"J Neurointerv Surg","first-page":"695","article-title":"Middle meningeal artery embolization as an adjuvant treatment to surgery for symptomatic chronic subdural hematoma: a pilot study assessing hematoma volume resorption","volume":"12","author":"Ng S","year":"2020","unstructured":"Ng S, Derraz I, Boetto J, Middle meningeal artery embolization as an adjuvant treatment to surgery for symptomatic chronic subdural hematoma: a pilot study assessing hematoma volume resorption. J Neurointerv Surg. 2020;12(7):695\u2013699."},{"issue":"Pt A","key":"b4","series-title":"J Clin Neurosci","first-page":"147","article-title":"An open label randomized trial to assess the efficacy of tranexamic acid in reducing post-operative recurrence of chronic subdural haemorrhage","volume":"82","author":"Wan KR","year":"2020","unstructured":"Wan KR, Qiu L, Saffari SE, An open label randomized trial to assess the efficacy of tranexamic acid in reducing post-operative recurrence of chronic subdural haemorrhage. J Clin Neurosci. 2020;82(Pt A):147-154."},{"issue":"6","key":"b5","series-title":"Geroscience","first-page":"6537","article-title":"Newer treatment paradigm improves outcomes in the most common neurosurgical disease of the elderly: a literature review of middle meningeal artery embolization for chronic subdural hematoma","volume":"46","author":"Debs LH","year":"2024","unstructured":"Debs LH, Walker SE, Rahimi SY. Newer treatment paradigm improves outcomes in the most common neurosurgical disease of the elderly: a literature review of middle meningeal artery embolization for chronic subdural hematoma. Geroscience. 2024;46(6):6537-6561."},{"issue":"4","key":"b6","series-title":"J Neurosurg","first-page":"1208","article-title":"A propensity-adjusted comparison of middle meningeal artery embolization versus conventional therapy for chronic subdural hematomas","volume":"135","author":"Catapano JS","year":"2021","unstructured":"Catapano JS, Ducruet AF, Nguyen CL, A propensity-adjusted comparison of middle meningeal artery embolization versus conventional therapy for chronic subdural hematomas. J Neurosurg. 2021;135(4):1208\u20131213."},{"key":"b7","series-title":"J Clin Neurosci","first-page":"110783","article-title":"Middle meningeal artery embolization following surgical evacuation of symptomatic chronic subdural hematoma improves outcomes, interim results of a prospective randomized trial","volume":"128","author":"Debs LH","year":"2024","unstructured":"Debs LH, Vale FL, Walker S, Middle meningeal artery embolization following surgical evacuation of symptomatic chronic subdural hematoma improves outcomes, interim results of a prospective randomized trial. J Clin Neurosci. 2024;128:110783."},{"issue":"3","key":"b8","series-title":"Ann Surg","first-page":"449","article-title":"Chronic subdural hematoma management: a systematic review and meta-analysis of 34,829 patients","volume":"259","author":"Almenawer SA","year":"2014","unstructured":"Almenawer SA, Farrokhyar F, Hong C, Chronic subdural hematoma management: a systematic review and meta-analysis of 34,829 patients. Ann Surg. 2014;259(3):449-457."},{"issue":"5","key":"b9","series-title":"J Neurosurg","first-page":"1209","article-title":"Actual and projected incidence rates for chronic subdural hematomas in United States Veterans Administration and civilian populations","volume":"123","author":"Balser D","year":"2015","unstructured":"Balser D, Farooq S, Mehmood T, Reyes M, Samadani U. Actual and projected incidence rates for chronic subdural hematomas in United States Veterans Administration and civilian populations. J Neurosurg. 2015;123(5):1209-1215."},{"key":"b10","series-title":"Front Public Health","first-page":"1160691","article-title":"Rationing in healthcare-a scoping review","volume":"11","author":"Berezowski J","year":"2023","unstructured":"Berezowski J, Czapla M, Manulik S, Ross C. Rationing in healthcare-a scoping review. Front Public Health. 2023;11:1160691."},{"issue":"10","key":"b11","series-title":"J Neurointerv Surg","first-page":"951","article-title":"Middle meningeal artery embolization for chronic subdural hematoma: a systematic review and meta-analysis","volume":"13","author":"Ironside N","year":"2021","unstructured":"Ironside N, Nguyen C, Do Q, Middle meningeal artery embolization for chronic subdural hematoma: a systematic review and meta-analysis. J Neurointerv Surg. 2021;13(10):951-957."},{"issue":"1","key":"b12","series-title":"Neurosurg Rev","first-page":"270","article-title":"Risk factors for recurrence of chronic subdural hematoma after surgical evacuation: a systematic review and meta-analysis","volume":"46","author":"Maroufi SF","year":"2023","unstructured":"Maroufi SF, Farahbakhsh F, Macdonald RL, Khoshnevisan A. Risk factors for recurrence of chronic subdural hematoma after surgical evacuation: a systematic review and meta-analysis. Neurosurg Rev. 2023;46(1):270."},{"issue":"6","key":"b13","series-title":"J Korean Neurosurg Soc","first-page":"518","article-title":"Postoperative course and recurrence of chronic subdural hematoma","volume":"48","author":"Oh HJ","year":"2010","unstructured":"Oh HJ, Lee KS, Shim JJ, Yoon SM, Yun IG, Bae HG. Postoperative course and recurrence of chronic subdural hematoma. J Korean Neurosurg Soc. 2010;48(6):518\u2013523."},{"key":"b14","series-title":"World Neurosurg","first-page":"613","article-title":"Middle meningeal artery embolization for chronic subdural hematoma: meta-analysis and systematic review","volume":"122","author":"Srivatsan A","year":"2019","unstructured":"Srivatsan A, Mohanty A, Nascimento FA, Middle meningeal artery embolization for chronic subdural hematoma: meta-analysis and systematic review. World Neurosurg. 2019;122:613\u2013619."},{"key":"b15","series-title":"EClinicalMedicine","first-page":"101234","article-title":"Factors correlated with the postoperative recurrence of chronic subdural hematoma: an umbrella study of systematic reviews and meta-analyses","volume":"43","author":"Zhu F","year":"2022","unstructured":"Zhu F, Wang H, Li W, Factors correlated with the postoperative recurrence of chronic subdural hematoma: an umbrella study of systematic reviews and meta-analyses. 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