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Introduction Middle meningeal artery embolization (MMAE) is increasingly used as adjunctive treatment for chronic subdural hematoma (cSDH). While recent trials have demonstrated efficacy of MMAE combined with burr-hole drainage, the comparative effectiveness of MMAE across different surgical approaches, including burr-hole drainage, craniotomy, and subdural evacuating port system (SEPS), has not been systematically evaluated.Methods We performed a retrospective analysis of 1,781 patients with cSDH from a multicenter MMAE registry (2015-2024). Patients who received MMAE with surgical evacuation were categorized by approach: burr hole (n=356), craniotomy (n=235), twist drill (n=9), and SEPS (n=19). Adjusted Cox proportional hazards models estimated hazard ratios (HR) for recurrence, controlling for age, sex, antithrombotic use, SDH thickness, midline shift, membrane status, and pre-morbid mRS. Longitudinal hematoma thickness trajectories were compared across approaches.Results Primary outcomes were comparable across all surgical approaches. The 90-day reoperation rate was 5.6% for burr hole versus 5.4% for craniotomy versus 5.0% for SEPS (P=0.96), with event-free survival exceeding 95% in all groups (figure, Panel A). In the adjusted Cox model, surgical approach did not independently predict recurrence (craniotomy vs burr hole: HR 0.94, 95% CI 0.63-1.40; SEPS vs burr hole: HR 0.30, 95% CI 0.04-2.17). The presence of membranes or septations was the strongest independent predictor of favorable outcome (HR 0.64, 95% CI 0.49-0.82, P<0.001), while multiple procedures increased risk (HR 1.96, 95% CI 1.18-3.25, P=0.009). Hematoma thickness trajectories were similar across approaches, with 58-65% resolution rates and 73-83% thickness reduction by 6-12 months across all groups (figure, Panel B).Conclusions MMAE combined with surgical evacuation achieves comparable recurrence and reoperation rates regardless of the specific surgical approach. Hematoma membrane phenotype is a stronger predictor of outcome than choice of surgical technique, supporting individualized approach selection based on patient and hematoma characteristics.Disclosures B. Demessie: None. A. Karandish: None. H. Salim: None. M. Collaborators: None.