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This study evaluated the efficacy and safety of N-butyl-2-cyanoacrylate (NBCA)-based middle meningeal artery embolization (MMAE) in preventing recurrence of chronic subdural hematoma (CSDH) in elderly patients. We retrospectively analyzed 221 patients aged ≥ 65 years who underwent burr hole surgery (BHS) with or without adjunctive MMAE between April 2023 and March 2025. Clinical, radiological, and perioperative variables were assessed, with the primary outcome being 90-day recurrence requiring retreatment. Among the cohort, 92 patients received BHS with MMAE and 129 underwent BHS alone. The median age was 82.0 years (IQR 77.0-86.0), and 64.3% were male. The overall recurrence rate was 12.7% (n = 28). Multivariate analysis identified male sex as an independent risk factor for recurrence (OR 4.95, 95% CI 1.61-21.7, P = 0.004), while acute hemorrhage within the hematoma (OR 0.19, 95% CI 0.01-0.99, P = 0.048) and BHS combined with MMAE (OR 0.37, 95% CI 0.13-0.94, P = 0.04) were associated with reduced recurrence risk. Subgroup analyses suggested that MMAE was particularly effective in male patients and in those with septated hematomas. Additionally, the BHS with MMAE group experienced fewer symptomatic complications (0% vs. 4.6%, P = 0.044) and required postoperative Goreisan far less frequently (16.5% vs. 92.3%, P < 0.001). These findings support that NBCA-based MMAE is associated with lower odds of recurrence and fewer symptomatic complications in elderly patients with CSDH, especially in anatomically and clinically favorable subgroups.