Effectiveness of subdural evacuating port system (SEPS) and middle meningeal artery embolization (MMAE) for chronic subdural hematomas – a multicenter experience

by

In a retrospective multicenter cohort study Lim et al. from the University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Departments of Neurosurgery, Radiology, Bioinformatics, and Canon Stroke and Vascular Research Center, Gates Vascular Institute, Albany Medical Center, Icahn School of Medicine at Mount Sinai, New York, University of South Florida Morsani College of Medicine, Tampa, Florida, USA – Department of Neurosurgery and Brain Repair Yale University, New Haven, Connecticut, USA – Department of Molecular Biophysics and Biochemistry published in the Journal of NeuroInterventional Surgery to o evaluate the combined effectiveness of the Subdural Evacuating Port System (SEPS) and Middle Meningeal Artery Embolization (MMAE) in chronic subdural hematoma treatment (cSDH). Specifically, the authors aimed to assess: How well the combination of SEPS + MMAE reduces hematoma volume, The safety profile of this combined approach, Predictive factors influencing drainage success and recurrence rates, and concluded that the combined use of SEPS and MMAE is a safe and effective treatment option for patients with chronic subdural hematomas (cSDH). It resulted in significant hematoma volume reduction and a relatively low recurrence rate. Several clinical and radiographic factors were identified as predictors of treatment success

📉 1. The Myth of Innovation-by-Combination

Pairing two well-known procedures—SEPS and MMAE—does not inherently create innovation. Yet, the authors present this as a groundbreaking paradigm, despite:

  • No control group (e.g., SEPS alone, MMAE alone),
  • No randomization,
  • No comparative outcome measures beyond radiographic volume.

It’s procedural layering disguised as progress.

📊 2. Radiographic Fetishism Over Functional Outcomes

While hematoma volume reduction is carefully charted with decimal-level precision, functional neurological outcomes are glaringly absent. No mRS, no GCS trends, no cognitive follow-up. Just numbers on a CT scan — because nothing says “clinical relevance” like milliliters.

📚 3. The P-Value Machine

This study is a statistical buffet, offering P-values for everything from coronary artery disease to embolization laterality. But:

  • No adjustment for multiple comparisons,
  • No multivariate regression transparency,
  • No discussion on effect size or clinical significance.

Just noise disguised as nuance.

💸 4. Conflict of Interest? More Like Conflict of Ecosystem

The disclosure section reads like a startup incubator brochure, featuring:

  • Consulting ties to every major device company,
  • Equity in dozens of neurotech ventures,
  • Involvement in trials that would financially benefit from a positive narrative.

This isn’t a conflict of interest — it’s an industry echo chamber wearing a white coat.

🧪 5. General Anesthesia for “Minimally Invasive” Procedures

Almost 70% of MMAEs were performed under general anesthesia. So much for the bedside-friendly, low-risk branding of SEPS+MMAE. The study touts minimal invasiveness while quietly inflating procedural burden.

⚠️ 6. Multicenter ≠ Multistandardized

The multicenter nature of the study brings heterogeneity, not strength:

  • Different operators, protocols, and thresholds for intervention.
  • No mention of interrater reliability for volume measurement.
  • An “experience,” not a trial — and certainly not a guideline.

🧠 Takeaway Message for the Neurosurgeon

This study reflects the growing trend of procedural maximalism: if one device is good, two must be better. But without functional outcomes, proper controls, or independent validation, SEPS+MMAE remains a well-marketed guess — not an evidence-based protocol.

📌 Final Verdict

A radiographically rich but clinically impoverished study. Technological overreach + conflict-laden enthusiasm = the illusion of progress.

The next time you’re asked to combine SEPS and MMAE based on this paper, ask: Where’s the patient in all this data?

Lim J, Jaikumar V, Paul AR, Cullen M, Kellner CP, Mocco J, Philbrick BD, Vakharia K, Wahlig P, Kruk MD, Snyder KV, Levy EI, Davies JM, Siddiqui AH. Effectiveness of subdural evacuating port system (SEPS) and middle meningeal artery embolization (MMAE) for chronic subdural hematomas – a multicenter experience. J Neurointerv Surg. 2025 Jun 19:jnis-2025-023489. doi: 10.1136/jnis-2025-023489. Epub ahead of print. PMID: 40537256.

Leave a Comment