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Introduction The incidence of chronic subdural hematoma (cSDH) requiring surgical evacuation is projected to rise substantially over the coming decade , driven largely by an aging population and the increasing use of antithrombotic agents. As procedural demand escalates, minimally invasive ‘bedside’ interventions have gained attention due to avoidance of general anesthesia, cost savings and improved procedural efficiency. Historically, techniques such as twist-drill craniostomy (TDC) with subdural drain (SDD) placement have been considered inferior to craniotomy due to concerns regarding incomplete hematoma evacuation and higher recurrence rates. However, the emergence of middle meningeal artery embolization (MMAE) has altered the determinants of cSDH recurrence and may improve the durability of minimally invasive strategies. We report a single-institution experience of 50 consecutive patients with cSDH treated via TDC with SDD placement and adjunctive MMAE.Methods A retrospective review of a prospectively maintained procedural database identified patients undergoing TDC with SDD and adjunctive MMAE for symptomatic cSDH between May 2022 and May 2025. Demographic, clinical, procedural and radiographic variables were collected. Subdural volume, maximum diameter and midline shift were quantified on CT imaging using an FDA cleared automated SDH volumetric analysis platform (Viz.Ai SDH+, Viz.Ai, San Francisco, CA) at four time points: pre-operative, post-operative, 1 month and 3 months).Results Fifty consecutive patients with 61 cSDHs were treated. The cohort was 70% male with a mean age of 78 years (range 58-103); 20% had bilateral hematomas and 38% were on antithrombotic therapy. Most patients presented with Markwalder grade 2 (82%), followed by grade 1 (14%) and grade 3 (4%). Mean preoperative hematoma volume was 118.1 ± 43.8 mL, with maximum diameter of 24.4mm ± 4.4 mm and midline shift of 6.8mm ± 3.4 mm; 48% demonstrated septations. All patients underwent TDC with SDD and MMAE during a single conscious sedation session without conversion to general anesthesia. Postoperatively, mean hematoma volume, diameter, and midline shift decreased by 42%, 38%, and 41%, respectively. Markwalder grades improved, with 62% of patients grade 0 and 36% grade 1. At discharge, 62% had complete symptom resolution and 34% had improving symptoms. Median post-procedural length of stay was 3 days and no patient required acute operative rescue.Clinical and radiographic improvements progressed over time. One and three-month follow up imaging showed reductions in hematoma volume (62% and 86%), diameter (52% and 76%), and midline shift (68% and 83%). At 1 month, 88% of patients were Markwalder grade 0 and 12% grade 1. One hematoma (1.6%) required repeat intervention within 90 days due to recurrence.Conclusion In this series, twist drill craniostomy with subdural drain placement and MMAE is a safe and effective option for treatment for cSDH, with low recurrence rates and no acute treatment failures. Despite incomplete initial hematoma evacuation, patients demonstrate significant early clinical improvement and progressive radiographic resolution. These findings suggest that, in conjunction with MMAE, the surgical treatment of cSDH may be guided by clinical response and hematoma volume reduction rather than complete upfront radiographic clearance, supporting a shift toward less invasive management strategies.Disclosures W. Ares: None. R. Wong: None.