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MAGIC-MT

Middle Meningeal Artery Embolization for Nonacute Subdural Hematoma

Year of Publication: 2024

Authors: Jianmin Liu, Wei Ni, Qiao Zuo, ..., Yong Zhen

Journal: New England Journal of Medicine

Citation: Liu J, Ni W, Zuo Q, et al. Middle Meningeal Artery Embolization for Nonacute Subdural Hematoma. N Engl J Med. 2024;391:1901-1912.

Link: https://www.nejm.org/doi/full/10.1056/NEJMoa2401201

Clinical Question

Does middle meningeal artery embolization reduce the 90-day recurrence or progression rate of nonacute subdural hematoma compared to usual care?

Bottom Line

Middle meningeal artery embolization did not significantly reduce recurrence or progression of nonacute subdural hematoma at 90 days, but it did reduce serious adverse events.

        Major Points
        722 patients randomized across 31 academic tertiary care centers in China
Most patients (78.3%) underwent burr-hole drainage, typically after embolization
Primary outcome (90-day recurrence or progression) occurred in 6.7% of embolization group vs 9.9% of usual care group (P=0.10)
Serious adverse events were lower in embolization group (6.7% vs 11.6%; P=0.02)
Mortality at 90 days was 0.6% (embolization) vs 2.2% (usual care)
Successful embolization in 98.3% of patients receiving the procedure

      

Design

Study Type: Multicenter, randomized, open-label, blinded endpoint (PROBE) trial

Randomization: 1

Blinding: Open-label treatment; blinded outcome and safety adjudication

Enrollment Period: March 2021 to May 2023

Follow-up Duration: 90 days (primary), some outcomes assessed up to 1 year

Centers: 31

Countries: China

Sample Size: 722

Analysis: Intention-to-treat; Cochran–Mantel–Haenszel chi-square test; generalized linear mixed-effects model with adjustment for covariates; no multiplicity correction for secondary endpoints

Inclusion Criteria

Age ≥18 years
Symptomatic nonacute subdural hematoma (chronic or subacute) with mass effect
Pre-event modified Rankin Scale 0–2

Exclusion Criteria

Bilateral hematoma with unknown symptomatic side
Need for craniotomy or emergency evacuation
Recurrent subdural hematoma
Pre-event mRS >2
Life expectancy <1 year
Unable to undergo embolization before drainage
Other protocol-defined exclusions (e.g., lab abnormalities, comorbidities)

Arms

Field	Middle Meningeal Artery Embolization	Control
Intervention	Endovascular embolization of the middle meningeal artery using Onyx liquid embolic system	Burr-hole drainage and best medical management as per physician discretion
Duration	Single intervention; follow-up at 90 days and 1 year	Standard care; follow-up at 90 days and 1 year

Outcomes

Outcome	Type	Control	Intervention	HR / OR / RR	P-value
Symptomatic recurrence or progression of subdural hematoma within 90 days	Primary	9.9%	6.7%	3.20%	0.10
mRS 0–2 at 90 days	Secondary	92.0%	93.1%		NS
mRS 0–3 at 90 days	Secondary	96.4%	97.8%		NS
Mean EQ-5D-5L at 90 days	Secondary	0.94	0.95		NS
Serious adverse events	Adverse	11.6%	6.7%	RR 0.58	0.02
Death (90 days)	Adverse	2.2%	0.6%	RR 0.27	NS
Embolization complications	Adverse	0%	0.8%

Subgroup Analysis

Exploratory subgroups suggested more benefit in patients without burr-hole drainage, those with midline shift <10 mm, and non-smokers, but no formal inference due to lack of multiplicity correction.

Criticisms

Primary outcome did not meet statistical significance
Unblinded treating physicians and imaging reviewers may have introduced bias
Trial limited to China; generalizability may be restricted
Only Onyx used as embolic agent—results may not generalize to other agents

Funding

Shanghai Shenkang Hospital Development Center, Changhai Hospital, Shanghai Municipal Health Commission, Covidien/Medtronic

Based on: MAGIC-MT (New England Journal of Medicine, 2024)

Authors: Jianmin Liu, Wei Ni, Qiao Zuo, ..., Yong Zhen

Citation: Liu J, Ni W, Zuo Q, et al. Middle Meningeal Artery Embolization for Nonacute Subdural Hematoma. N Engl J Med. 2024;391:1901-1912.

Content summarized and formatted by NeuroTrials.ai.

MAGIC-MT

(2024)

Objective

To evaluate the effectiveness of middle meningeal artery embolization (MMAe) in managing symptomatic subacute and chronic subdural hematomas (SDH).

Study Summary

• MMA embolization significantly reduced the primary outcome of death, symptomatic recurrence, or progression in patients with symptomatic subacute and chronic SDH compared to standard care alone..

Intervention

Standard care (medical or surgical) +/- MMA embolization.

Inclusion Criteria

Patients with symptomatic subacute and chronic SDH.

Study Design

Arms: Standard Care + MMA Embolization vs. Standard Care Alone

Patients per Arm: Standard Care + MMA Embolization: 365 (281 burr hole, 84 conservative); Standard Care Alone: 362 (284 burr hole, 78 conservative)

Outcome

• Primary Outcome (Death, Symptomatic Recurrence or Progression): MMAe 7.2%, Standard Care 12.2% (p=0.02).
• • Symptomatic Recurrence (surgical): MMAe 4.7%, Standard Care 5.2%.
• • Symptomatic Progression (conservative): MMAe 1.9%, Standard Care 4.7%.
• • 90-d mRS 0-2: MMAe 97.8%, Standard Care 96.4%..

Bottom Line

Middle meningeal artery embolization did not significantly reduce recurrence or progression of nonacute subdural hematoma at 90 days, but it did reduce serious adverse events.

Major Points

722 patients randomized across 31 academic tertiary care centers in China
Most patients (78.3%) underwent burr-hole drainage, typically after embolization
Primary outcome (90-day recurrence or progression) occurred in 6.7% of embolization group vs 9.9% of usual care group (P=0.10)
Serious adverse events were lower in embolization group (6.7% vs 11.6%; P=0.02)
Mortality at 90 days was 0.6% (embolization) vs 2.2% (usual care)
Successful embolization in 98.3% of patients receiving the procedure

Study Design

Study Type: Multicenter, randomized, open-label, blinded endpoint (PROBE) trial
Randomization: Yes
Blinding: Open-label treatment; blinded outcome and safety adjudication
Sample Size: 722
Follow-up: 90 days (primary), some outcomes assessed up to 1 year
Centers: 31
Countries: China

Primary Outcome

Definition: Symptomatic recurrence or progression of subdural hematoma within 90 days

Control	Intervention	HR/OR	P-value
9.9%	6.7%	- (-7.4 to 0.8)	0.10

Limitations & Criticisms

Primary outcome did not meet statistical significance
Unblinded treating physicians and imaging reviewers may have introduced bias
Trial limited to China; generalizability may be restricted
Only Onyx used as embolic agent—results may not generalize to other agents

Citation

Liu J, Ni W, Zuo Q, et al. Middle Meningeal Artery Embolization for Nonacute Subdural Hematoma. N Engl J Med. 2024;391:1901-1912.

View Original Publication →

MAGIC-MT

Middle Meningeal Artery Embolization for Nonacute Subdural Hematoma

Clinical Question

Bottom Line

Major Points

Design

Inclusion Criteria

Exclusion Criteria

Arms

Outcomes

Subgroup Analysis

Criticisms

Funding

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