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Background To determine whether a history of cranial trauma influences subdural hematoma (SDH) resolution and clinical outcomes after middle meningeal artery embolization (MMAE) for chronic SDH (cSDH).Methods We conducted a retrospective cohort study using the Multicenter Embolization of Subdural Hematoma (MESH) Registry. Patients with cSDH treated with MMAE were stratified by documented cranial trauma history (TBI vs No TBI). The primary outcome was radiographic SDH resolution; secondary outcomes included reoperation, recurrence, good functional outcome (modified Rankin Scale [mRS] 0-2), mortality, and SDH thickness change. Confounding was addressed using inverse probability of treatment weighting (IPTW) with stabilized weights estimated from 11 covariates selected via a directed acyclic graph. IPTW-adjusted risk ratios (RR) were estimated using modified Poisson regression with robust standard errors. Sensitivity analyses included Benjamini-Hochberg correction, complete-case analysis, weight trimming, and an extended propensity score model.Results Of 1,781 registry patients, 1,331 had documented trauma status (797 [59.9%] TBI, 534 [40.1%] No TBI). After IPTW, all covariates were balanced (maximum standardized mean difference<0.02). SDH resolution was similar between groups (TBI 92.4% vs No TBI 93.2%; IPTW RR 0.99, 95% CI 0.96-1.03; P=0.63). Reoperation was more than two-fold higher in the TBI group (7.6% vs 3.1%; IPTW RR 2.41, 95% CI 1.30-4.46; P=0.005), a finding that remained significant after Benjamini-Hochberg correction for five comparisons. Recurrence (4.1% vs 2.8%; P=0.27), functional independence (73.5% vs 70.9%; P=0.45), and mortality (9.2% vs 11.6%; P=0.26) did not differ. Significant effect modification was observed for anticoagulant use (P for interaction=0.004): anticoagulated TBI patients had lower SDH resolution (89.1% vs 97.1%). Results were robust across all sensitivity analyses ( figure 1).Conclusions In this large multicenter cohort, cranial trauma history did not affect radiographic SDH resolution, functional outcome, or mortality after MMAE. The significantly higher reoperation rate in the trauma group, robust to multiplicity correction, warrants prospective confirmation. These findings support the generalizability of MMAE efficacy irrespective of traumatic etiology.Disclosures M. Essibayi: None. A. Karandish: None. H. Salim: None. M. Collaborators: None.Abstract E-284 Figure 1