Comparative Outcomes of Surgical, Endovascular, Radiosurgical, and Multimodal Management of Cerebral Arteriovenous...

Cerebral arteriovenous malformations (AVMs) pose significant therapeutic challenges, with multiple modalities offering varying degrees of cure, risk, and functional preservation. Although microsurgery, endovascular embolization, stereotactic radiosurgery, and multimodal approaches are widely used, comparative outcomes remain heterogeneous. This systematic review synthesizes contemporary evidence across treatment strategies to guide patient-specific decision-making. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines and a registered International Prospective Register of Systematic Reviews protocol (CRD420251066493), PubMed, MyEBSCO, and Embase were searched to June 1, 2025. Eligible studies included randomized trials, cohort studies, and case series (≥10 patients) reporting clinical outcomes after AVM treatment. Two reviewers independently performed study selection, data extraction, and risk-of-bias assessment (Risk of Bias 2, Newcastle-Ottawa Scale, National Institutes of Health tool). Qualitative synthesis was conducted due to substantial heterogeneity. A total of 135 studies involving 27,541 patients were included. Microsurgery achieved 78%-100% obliteration, with complication rates 6.8%-60% and mortality 0%-13.3%. Embolization demonstrated variable obliteration (13%-92%) and complications (14%-25%), with mortality (0%-2%), supporting its role primarily as an adjunct. Multimodal strategies yielded 85%-100% obliteration, 7%-36% complications, and 0%-5% mortality, with hybrid workflows showing the most favorable balance. Radiosurgery produced 22%-100% obliteration, excellent functional outcomes (modified Rankin Scale 0-2 in 80%-95%), and the lowest contemporary mortality (0%-1%). Optimal AVM management depends on individualized selection and modality sequencing rather than a single superior technique. Microsurgery provides immediate cure in suitable cases, radiosurgery offers durable long-term outcomes, and embolization enhances both when applied judiciously. Multimodal and hybrid approaches combine these strengths, achieving high cure rates with acceptable morbidity.