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Introduction Chronic subdural hematoma (cSDH) is a common neurosurgical condition with increasing incidence in the aging population. Middle meningeal artery (MMA) embolization has emerged as a promising adjunct therapy to standard surgical treatment.Aim of Study This study evaluates the effectiveness of combining MMA embolization with surgery compared to surgery alone for cSDH management.Method We retrospectively analyzed patients with cSDH treated at our institution between January 2023 and August 2024, comparing surgery alone (n=54) versus combined surgery with MMA embolization (n=17). Primary outcomes included hematoma recurrence and thickness reduction, while secondary outcomes were procedure safety, hospital stay, and functional outcomes measured by the Modified Rankin Scale (mRS).Abstract A248 Figure 1Results The combined treatment group showed greater hematoma thickness reduction compared to surgery-only at the first follow-up (3.4mm vs. 8.26mm, p=0.0047) and in mean reduction (-15.41mm vs. -10.18mm, p=0.0082). Recurrence rates were lower in the combined group (4.7% vs 18.06%, non-significant). The combined group achieved better functional outcomes at 81.25% mRs=0 versus 36.17% in the surgery-only group (p=0.045). Neurologic complications occurred only in the surgery-only group (5.33% vs 0%). Logistic regression showed that for each millimeter increase in hematoma thickness reduction, the odds of belonging to the combined treatment group decreased by 9% (OR: 0.91, 95% CI:0.85–0.98, p=0.012).Abstract A248 Table 1Perioperative complications and functional outcomes in patients undergoing surgery, or combined treatment for hematoma managementConclusion Combined MMA embolization with surgery demonstrates superior safety and efficacy compared to surgery alone, showing significant improvements in hematoma thickness reduction and functional outcomes. Further research should address optimal timing, embolic material selection, and long-term outcomes in larger cohorts.Conflict of Interest No