I commend the authors for a well-written and timely submission of this manuscript with a comprehensive overview of the complications of a technically relatively straightforward but clearly not a risk-free intervention. ^{Reference Jindal, Sharafaddin-zadeh, Bukhari, Goyal and Ospel1} Awareness of the potentially severe and permanent morbidity from this procedure is of paramount importance to the interventionists, especially now that middle meningeal artery (MMA) embolization is gaining traction in light of recently published randomized controlled trials. ^{Reference Liu, Ni and Zuo2–Reference Davies, Knopman and Mokin4}

It is important to realize that this population is expected to be elderly and frail, and one must be mindful of renal function, access related difficulties and poor resilience to deal with any complications in this population, especially with a procedure that is not yet a “standard of care” component of treatment, so as to justify the benefits of offering MMA embolization to patients. As with any surgical intervention, anatomy is your best friend. One of my colleagues and mentors used to say that there are no dangerous anastomoses, but only dangerous interventionists! It is imperative to be aware of the different anatomical variations of the MMA to ensure a safe embolization without inadvertent reflux into intracranial circulation. ^{Reference Bonasia, Smajda, Ciccio, Robert, Smajda, Ciccio and Robert5} The initial baseline external carotid /internal carotid angiogram must be carefully studied every single time to look for potential variations and anastomoses. Polyvinyl alcohol particles or proximal coil embolization should be preferred in case of concerning anatomy for better safety and reasonable efficacy. ^{Reference Shehabeldin, Amllay and Jabre6}

My personal practice is to routinely perform n-butyl cyanoacrylate or ethylene vinyl alcohol copolymer embolization under high magnification, clearly noting where the deflection at the foramen spinosum is – this helps define the reflux margin. Keeping it in true frontal and true lateral projections helps to avoid anatomical disorientation. One good trick is to ensure the embolysate remains distal to orbits on frontal projection and that nothing goes posteriorly along the petrous ridge on lateral view. If satisfactory distal navigation of the microcatheter is not achievable, then liquid embolics should be avoided, and either particles or proximal coiling should be performed.

The only way MMA embolization can become established as a standard therapy for chronic subdural hematoma is by ensuring the complications are avoided, to allow a favorable risk-benefit analysis.