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Introduction Non-acute subdural hematoma (NASDH) is a prevalent condition among older adults, and many hospitalized patients undergo non-evacuative management (NEM). However, many NEM patients deteriorate without surgery and may require early surgical rescue (ESR) during their hospitalization. The goal of this study is to determine the incidence, clinical consequences, and predictors of ESR among acutely hospitalized NASDH patients who underwent upfront NEM, and to assess whether early standalone middle meningeal artery embolization (MMAE) facilitates the success of NEM by reducing odds of ESR.Methods This retrospective cohort study used the 2020-2022 Nationwide Readmissions Database. Patients non-electively hospitalized for NASDH who underwent NEM (no decompression within three days of hospitalization) were included. Patients who underwent early standalone MMAE within three days of hospitalization were compared to those who underwent delayed MMAE. Primary outcome was ESR, defined as rescue surgical evacuation prior to hospital discharge after initial NEM. Other outcomes include functional independence (routine discharge to home with self-care), discharge to home, length of stay, and hospitalization costs. Multivariable logistic regression models were used to adjust for confounders and identify predictors of ESR.Results Of 5,941 included patients, 1,303 (21.9%) required ESR. Patients requiring ESR were younger (71 vs 75 years; P<.001), more often male (73.0% vs 66.7%; P=.005), and more likely to present with mass effect (58.0% vs 23.1%; P<.001). After multivariable adjustment, ESR was associated with reduced odds of functional independence (adjusted OR [aOR] 0.78 [95%CI, 0.63-0.96], P=.021), as well as increased respiratory complications (aOR, 1.29 [95%CI 1.01-1.64], P=.042) and delirium (aOR 1.77 [95%CI 1.25-2.49], P=.001). Length of stay was longer (adjusted B 4.63 [95%CI 3.88-5.38], P<.001) and hospitalization costs were higher (adjusted B $18,591 [95%CI $15,910-$21,273]; P<.001). Early MMAE was significantly associated with lower odds of ESR (aOR 0.17 [95%CI 0.10-0.30], P<.001), representing an 83% reduction.Conclusions Among acutely hospitalized NASDH patients who underwent upfront NEM, ESR occurred in approximately 1 in 5 patients and was associated with worse outcomes, prolonged hospitalization, and increased costs. Early MMAE may be a strong facilitator of NEM success by significantly reducing the odds of ESR, and should be considered in NEM patients at high risk for clinical deterioration.Disclosures M. McIntyre: 1; C; The Aneurysm & AVM Foundation. A. Malhotra: None.