Comparative Efficacy of Microsurgery vs. Stereotactic Radiosurgery for Brain Arteriovenous Malform

Introduction Brain arteriovenous malformations (bAVMs) pose a significant risk of hemorrhage, often affecting young patients. While microsurgery and stereotactic radiosurgery (SRS) are definitive treatment options, the optimal choice remains debated due to differences in efficacy, safety, and long‐term outcomes. This systematic review and meta‐analysis aimed to directly compare the obliteration rates, hemorrhagic risks, neurological deficits, and mortality associated with these modalities to guide evidence‐based clinical decision‐making. Methods Following PRISMA guidelines, we systematically reviewed literature from PubMed and MEDLINE databases up to June 2022. Eight high‐quality studies were included, encompassing 817 patients (432 microsurgery; 385 SRS). Extracted data included obliteration rates, follow‐up hemorrhagic events, permanent neurological deficits, modified Rankin Scale (mRS) outcomes, and mortality. Statistical analysis was performed using R with a random‐effects model. Odds ratios (OR) and hazard ratios (HR) were calculated with 95% confidence intervals (CI), and heterogeneity was assessed using the I 2 statistic. Results Microsurgery demonstrated significantly higher obliteration rates compared to SRS (OR = 18.51; 95% CI: 11.05‐31.01; p < 0.000001), a difference upheld across all Spetzler‐Martin grades. Furthermore, microsurgery reduced the risk of follow‐up hemorrhage (HR = 0.47; 95% CI: 0.23‐0.97; p = 0.04), supporting its role in early and complete nidus eradication. However, the incidence of permanent neurological deficits was higher in the microsurgery group (OR = 2.85; 95% CI: 1.63‐4.97; p = 0.0002), often attributed to surgical manipulation near eloquent areas. Despite this, no significant differences were observed in worsened mRS (OR = 1.24; p = 0.52), functional independence (mRS > 2: OR = 0.78; p = 0.53), or mortality (OR = 1.17; p = 0.77) between both groups, indicating overall comparable long‐term quality‐of‐life outcomes. Conclusion Microsurgery offers superior efficacy in bAVM obliteration and hemorrhage prevention, particularly in low‐to‐moderate Spetzler‐Martin grades, with a tradeoff of increased but often transient neurological morbidity. SRS remains a safer alternative for lesions in deep, eloquent, or surgically inaccessible areas, especially when patient comorbidities contraindicate open surgery. These findings support a risk‐stratified approach to treatment, underscoring the importance of individualized care plans informed by lesion characteristics and patient‐specific factors. Further prospective studies with long‐term follow‐up are warranted to refine treatment algorithms and improve patient outcomes.