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Introduction Fistulas forming between cerebrospinal fluid (CSF) and spinal veins is a common cause of spontaneous intracranial hypotension (SIH). Along with orthostatic headaches, tinnitus, vision changes and vertigo, CSF-venous fistulas can also result in spontaneous subdural hematomas. Often transvenous embolization is performed to close the fistula with a combined middle meningeal artery (MMA) embolization to treat the subdural hematoma. However, the clinical benefit of dual treatment compared to transvenous embolization alone is unknown.Objective Assess the safety and efficacy of combined MMA and transvenous embolization versus transvenous embolization alone in treatment of SIH due to CSF-venous fistula.Methods We performed a retrospective case control study of 24 patients who underwent combined MMA and transvenous embolization or transvenous embolization alone for treatment of CSF-venous fistulas with chronic subdural hematomas at a single institution. Patients deemed nonsurgical candidates were excluded. Their demographics, clinical outcomes, and complications were reviewed.Results 12 patients who underwent combined MMA and transvenous embolization were case matched for age, gender and symptoms with 12 patients who underwent transvenous embolization initially alone. The median age of the combined group was 67 years and control group was 70 years. 6/12 patients in the combined group were female while 7/12 patients in the control group were female. 9/12 had complete or significant reduction in symptoms in the combined group after the procedure compared to 8/12 in the control group. No patients in the dual embolization group required repeat embolization for recurrent bleeds while two patients in the transvenous embolization only group required repeat embolization for recurrent bleeds. One patients in both groups experienced no improvement or worse clinical outcomes after the procedure.Conclusion Combined MMA and transvenous embolization was not associated with worse clinical outcomes or higher complication rates when compared to transvenous embolization alone. In patients presenting with spontaneous subdural hematoma with CSF-venous fistula, combined MMA and transvenous embolization may be a key therapy that can address all symptoms compared to transvenous embolization alone.Disclosures R. Zhou: None. C. Ranalli: None.