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. 2026 Jul 31;18(7):e113715. doi: 10.7759/cureus.113715

Comparative Outcomes of Surgical, Endovascular, Radiosurgical, and Multimodal Management of Cerebral Arteriovenous Malformations: A Systematic Review

Flora Alrumaih 1,✉, Abdulrahman M Alharbi 1, Fadwa M Albattah 1, Deem A Almethen 1, Dhay S Alharbi 1, Faris A Alalwan 1, Bader S Alharbi 1, Raghad S Albiyebi 1, Fisal T Alrogibah 1, Ohud T Alharbi 2, Muath I Alfallaj 1
Editors: Alexander Muacevic, John R Adler
PMCID: PMC13526310  PMID: 42670483

Abstract

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.

Keywords: brain arteriovenous malformation (bavm), cerebral arteriovenous malformation, endovascular embolization, hybrid neurovascular surgery, microsurgical resection, multimodal treatment, neurological outcomes, obliteration rate, stereotactic radiosurgery, treatment complications

Introduction and background

Brain arteriovenous malformations (bAVMs) are rare congenital vascular anomalies characterized by tangles of dilated arteries and veins lacking a normal capillary bed, which predispose patients to hemorrhage, neurological deficits, and even death [1]. Although often asymptomatic, their first presentation can be catastrophic. Due to their rarity and frequent subclinical course, the exact incidence remains uncertain, but estimates suggest a prevalence of 1.3 cases per 100,000 person-years [2]. Complete eradication of the nidus is the primary treatment goal to prevent hemorrhagic events and improve outcomes.

Current therapeutic options for bAVMs include microsurgical excision, endovascular embolization, stereotactic radiosurgery (SRS), or a combination of these modalities [1]. Treatment decisions are often guided by the Spetzler-Martin (S-M) grading system, introduced in 1986 and revised in 2011, which stratifies arteriovenous malformations (AVMs) based on size, venous drainage, and eloquence of adjacent brain tissue. Microsurgery is typically favored for low-grade lesions (S-M I-II), while S-M III lesions may require multimodal strategies. Higher grade lesions (S-M IV-V) are often approached conservatively or with radiosurgery and/or embolization, depending on individual risk-benefit profiles. Embolization is frequently used as an adjunct to reduce nidus size, facilitate surgery or radiosurgery, or, in select cases, achieve complete obliteration with agents such as Onyx (Medtronic, Minneapolis, MN) or coils [3].

Recent advancements in imaging, embolic materials, and surgical techniques have improved treatment safety and efficacy. However, management of unruptured AVMs remains controversial, especially following the A Randomised trial of Unruptured Brain Arteriovenous malformations (ARUBA) trial, which reported worse outcomes with intervention compared to medical management. These findings, though influential, have been challenged due to limitations in methodology, short follow-up, and narrow generalizability. Clinical practice continues to vary widely across centers, particularly in the use of multimodal therapy and selection criteria for surgery, highlighting the need for high-quality, comparative outcome data [2].

While many studies have evaluated individual treatment modalities, few have systematically compared their long-term outcomes or examined multimodal strategies in a standardized fashion. Moreover, functional outcomes, such as neurological status and quality of life, are often underreported in favor of angiographic obliteration or hemorrhage rates. There is a pressing need for updated and comprehensive synthesis of the available evidence to guide clinical decision-making and refine treatment algorithms.

This systematic review aims to evaluate and compare the clinical outcomes of surgical, endovascular, radiosurgical, and multimodal treatment strategies for cerebral AVMs. Key outcomes of interest include nidus obliteration, hemorrhage rates, neurological status, complications, and mortality. To ensure full transparency, we note that this work has not been previously presented or disseminated in any form, including abstracts, posters, or oral presentations.

Review

Materials and methods

Study Design and Reporting Standards

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines [4]. The protocol was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO; Registration ID: CRD420251066493) [5].

Eligibility Criteria

Studies were eligible for inclusion if they reported clinical outcomes of cerebral AVMs treated with surgical, endovascular, radiosurgical, or multimodal approaches. All patient populations were considered, including individuals of any age with either ruptured or unruptured AVMs. Eligible study designs consisted of randomized controlled trials, cohort studies, and case series that enrolled at least 10 patients. To be included, studies were required to report at least one clinically relevant outcome, such as obliteration rate, hemorrhage, neurological outcomes, complications, or mortality.

Studies were excluded if they were case reports, conference abstracts, narrative or systematic reviews, or animal studies. Research focusing exclusively on diagnostic techniques without reporting treatment outcomes was also excluded. In addition, studies that evaluated spinal AVMs rather than cerebral AVMs were not considered eligible.

Search Strategy

A comprehensive search strategy was developed using controlled vocabulary (Medical Subject Headings (MeSH) and Emtree terms) and free-text keywords. Searches were conducted in PubMed, Embase, and MyEBSCO and were limited to English-language studies published between January 1, 2000, and June 1, 2025. Additional eligible studies were identified by manually screening the reference lists of included articles.

PubMed: The PubMed search combined AVM-related MeSH terms and keywords (“brain arteriovenous malformation”, “cerebral arteriovenous malformation”, “cerebral AVM”, “brain AVM”) with treatment-related terms (“surgery”, “microsurgery”, “resection”, “embolization”, “endovascular”, “radiosurgery”, “stereotactic radiosurgery”, “Gamma Knife”, “treatment outcomes”) using the Boolean operator AND. The full Boolean structure was: (brain arteriovenous malformation OR cerebral arteriovenous malformation OR cerebral AVM OR brain AVM) AND (surgery OR microsurgery OR resection OR embolization OR endovascular OR radiosurgery OR stereotactic radiosurgery OR Gamma Knife OR treatment outcomes) AND (publication date: 2000-2025).

Embase: The Embase search used the Emtree term “brain arteriovenous malformation” (exploded) together with the keywords “cerebral arteriovenous malformation” and “brain AVM”. These terms were combined with treatment-related terms (“microsurgery”, “neurosurgery”, “embolization”, “endovascular procedure”, “radiosurgery”, “Gamma Knife”, “stereotactic radiosurgery”, “treatment outcome”) using AND. Publication years were limited to 2000-2025, and results were restricted to English-language articles.

MyEBSCO: The MyEBSCO search combined AVM-related keywords (“brain AVM”, “cerebral AVM”, “arteriovenous malformation”) with treatment terms (“surgery”, “microsurgical resection”, “endovascular embolization”, “radiosurgery”, “treatment outcome”, “complications”, “obliteration”) using AND. Filters limited results to English-language studies published between 2000 and 2025.

Data Extraction

Data extraction was performed independently by two reviewers using a standardized Excel form (Microsoft Corporation, Redmond, WA). Extracted information included key study characteristics such as the study title, authors, year of publication, country of origin, and study design. Patient and lesion characteristics were also recorded, including sample size, AVM size, anatomical location, and S-M grade. Treatment-related variables were documented for each study, including the specific modality applied and the embolic agent used when applicable.

Primary outcomes consisted of the reported obliteration rate and each study’s definition of cure. Secondary outcomes included hemorrhage rates, complications, mortality, types of complications, duration of follow-up, and functional outcomes, with good functional status defined as a modified Rankin Scale (mRS) score of 2 or lower. Key findings from each study were recorded in detail. Any discrepancies between reviewers were resolved through discussion and consensus.

RoB Assessment

Randomized controlled trials were evaluated using the Cochrane Risk of Bias 2.0 (RoB 2.0) tool (Cochrane, London, UK) [6]. Observational cohort and case-control studies were assessed using the Newcastle-Ottawa Scale (NOS) [7]. Case series, for which NOS is not applicable, were appraised with the National Institutes of Health (NIH) Quality Assessment Tool for Case Series Studies [8]. All assessments were performed independently by two reviewers, with disagreements resolved through discussion.

Study Selection

Two reviewers independently screened titles and abstracts for eligibility, followed by full-text assessment. Disagreements were resolved by consensus or, when necessary, adjudication by a third reviewer. The study selection process is detailed in the PRISMA 2020 flow diagram (Figure 1). The characteristics of the included studies, including authors, publication year, country, study design, sample size, AVM location, S-M grade, treatment modality, and follow-up duration, are summarized in Table 1.

Table 1. Characteristics of the included studies.

Values reported under “Analyzed Patients” represent the final analyzed patient populations contributing extractable outcome data within each included study. These values correspond to the populations included in outcome analyses rather than initially screened or treated populations. The cumulative total is consistent with the 27,541 patients reported in the Results section. Values represent data extracted from all included studies

AVM: arteriovenous malformation; S-M: Spetzler-Martin grade; NR: not reported; SRS: stereotactic radiosurgery; HFSRT: hypofractionated stereotactic radiosurgery; LINAC: linear accelerator-based radiosurgery; NBCA: n-butyl cyanoacrylate; RCT: randomized controlled trial

Study (year) Country Design Analyzed patients AVM location S-M grade Treatment modality Follow-up  
Oulasvirta et al. [9] (2023) Finland Cohort 41 Supratentorial l-V Multimodality Median 19.1 years  
Gawish et al. [10] (2022) Germany Cohort 68 NR NR LINAC SRS Mean 35 months  
Ozden et al. [11] (2023) Turkey Cohort 62 Mixed III-IV Multimodality NR  
Loebel et al. [12] (2022) Germany and Italy Cohort 123 Mixed I-V Multimodality Median 48.1 months  
Zhu et al. [13] (2024) China Cohort 201 Mixed I-IV Gamma knife SRS NR  
Jiang et al. [1] (2022) China Cohort 130 Mixed I-V Multimodality Mean 37.4 months  
Sato et al. [14] (2020) Japan Cohort 788 Mixed I-V Endovascular embolization 30 days  
Shah et al. [15] (2024) USA Cohort 37 Cortical NR Cyberknife SRS Mean 26.2 months  
Walcott et al. [16] (2014) USA Case series 44 Mixed NR Proton beam SRS Median 52 months  
Baharvahdat et al. [17] (2014) France Cohort 408 Mixed l-V Endovascular embolization Short-term only (≤1 month; no long-term duration reported)  
van Essen et al. [18] (2018) The Netherlands Cohort 25 Mixed I-V Multimodality Mean 11.5 years  
Brauner et al. [19] (2025) France Case series 46 Mixed I-V Multimodality Median 6 months  
Potts et al. [20] (2015) USA Cohort 232 Mixed I-II Surgery Mean 1.7 years  
Jordan et al. [21] (2014) Cuba Cohort 71 Mixed l-V Endovascular embolization Mean 31.1 months  
Baharvahdat et al. [22] (2019) France Cohort 224 Mixed I-II Endovascular embolization Mean 9.7 months  
Lv et al. [23] (2010) China Cohort 30 Supratentorial NR Endovascular embolization Mean 80 months  
Kim et al. [24] (2019) South Korea Cohort 264 Mixed I-IV Gamma knife SRS Mean 55.5 months  
Shekhtman et al. [25] (2015) Russia Cohort 93 Mixed I-V Multimodality Mean 27.6 months  
Hellstern et al. [26] (2022) Germany Case series 47 NR I-V Endovascular embolization NR  
Hancevic et al. [27] (2025) Croatia Cohort 241 Mixed l-V Gamma knife SRS Mean 3 years  
Gao et al. [28] (2022) China Cohort 88 Mixed I-V Gamma knife SRS Median 65 months  
Rutledge et al. [29] (2014) USA Cohort 74 Mixed I-V Multimodality Mean 21 months  
Pierot et al. [30] (2013) France Case series 20 Supratentorial I-IV Multimodality Median 3.5 years  
Smrcka et al. [3] (2021) Czech Republic Case series 50 Mixed I-IV Surgery 3 months  
Abla et al. [31] (2015) USA Case series 16 Supratentorial lll-V Multimodality Mean 6.9 years  
Sanchez-Mejia et al. [32] (2009) USA Cohort 42 NR I-IV Multimodality Mean 7.1 years  
Arslan et al. [33] (2017) Turkey Cohort 199 Mixed I-V Gamma knife SRS Median 60 months  
Lee et al. [34] (2024) United Kingdom Cohort 88 Mixed I-III Multimodality NR  
van Rooij et al. [35] (2012) The Netherlands Case series 23 Mixed NR Endovascular embolization Mean 21 months  
van Rooij et al. [36] (2012) The Netherlands Case series 24 Supratentorial I-III Curative embolization 3 months  
Josephson et al. [37] (2012) United Kingdom Cohort 229 Supratentorial NR Multimodality Median 9 years  
Tos et al. [38] (2025) North America and Europe Cohort 96 Mixed IV Multimodality Median 24 months  
Pan et al. [39] (2009) China Case series 20 Supratentorial l-lV Multimodality 3-24 months  
Chen et al. [40] (2023) China Cohort 622 NR I-V Endovascular embolization Median 5.5 years  
Maryashev et al. [41] (2015) Russia Case series 315 Mixed II-V SRS Median 2.5 years  
He et al. [42] (2018) China Cohort 10 Supratentorial I-IV Transvenous embolization Median 8 months  
Mohr et al. [43] (2017) Multinational RCT 223 NR I-II Comparative multimodality study Median 33.3 months  
Chen et al. [44] (2021) China Cohort 71 Supratentorial I-V Comparative multimodality study Mean 4.2 years  
Liu et al. [45] (2010) China Case series 126 Supratentorial NR Onyx embolization Median 33 months  
Tos et al. [46] (2025) Multicenter (USA and Europe) Cohort 180 Mixed I-II Comparative multimodality study Median 12-36 months  
Branko et al. [47] (2025) Italy Cohort 209 Mixed I-V Multimodality Median 54 months  
Mounayer et al. [48] (2007) France Case series 94 Mixed I-V Onyx embolization Median 4.5 months  
Patel et al. [49] (2008) India Case series 54 Mixed I-V LINAC SRS Median 33 months  
Karlsson et al. [50] (2022) Multinational Cohort 5,037 NR NR Gamma knife SRS 2 years  
Alexander et al. [51] (2018) USA Case control 160 NR NR Comparative multimodality study Median 1.6 years  
Nakai et al. [52] (2012) Japan Case series 19 NR I-V Multimodality Mean 39.2 months  
Panagiotopoulos et al. [53] (2009) Germany Case series 82 Mixed I-V Onyx embolization Mean 8.8 months  
Huang et al. [54] (2024) Taiwan Cohort 262 Mixed I-V SRS Median 61.8 months  
Sheth et al. [55] (2014) USA Cohort 42 Mixed II-V Gamma knife SRS 3 years  
Kondo et al. [56] (2014) Japan Cohort 987 Mixed I-V Endovascular embolization 30 days  
Weber et al. [57] (2007) Germany Case series 93 Mixed I-V Onyx embolization Mean 9.5 months  
Jayaraman et al. [58] (2008) USA Cohort 192 Deep I-V Endovascular embolization NR  
Chye et al. [59] (2020) Taiwan Cohort 1,515 NR NR Gamma Knife SRS 15 years  
Han et al. [60] (2023) China Cohort 1,348 NR I-III Surgery and SRS Mean 6.4 years  
Galaktionov et al. [61] (2017) Russia Cohort 40 Mixed I-V Multimodality NR  
Javalkar et al. [62] (2009) USA Case series 37 Mixed II-V Gamma knife SRS Median 23 months  
Ahmetspahic et al. [63] (2021) Japan Case series 11 Mixed I-V Multimodality Median 39.5 months  
Jordan et al. [64] (2014) Cuba Cohort 71 Mixed I-V Endovascular embolization Mean 31.1 months  
Chowdhury et al. [65] (2015) Bangladesh Cohort 60 Mixed NR Comparative multimodality study 1.3 years  
Peciu-Florianu et al. [66] (2020) France Cohort 172 Mixed I-IV Gamma knife radiosurgery Median 8.8 years  
Punyawai et al. [67] (2021) Thailand Cohort 166 Mixed NR CyberKnife SRS Median 72.45 months  
Iosif et al. [68] (2022) France Case series 22 Mixed I-V Transvenous embolization 12 months  
Huo et al. [69] (2015) China Cohort 86 Mixed I-V Multimodality Mean 42 months  
Heidenreich et al. [70] (2006) Germany Cohort 66 NR NR Endovascular embolization NR  
Feng et al. [71] (2017) China Case series 52 Mixed I-IV Surgery Mean 22.5 months  
Maruyama et al. [72] (2005) Japan Cohort 500 NR III Gamma knife SRS Median 7.8 years  
Morgan et al. [73] (2015) Australia Cohort 112 Supratentorial III Surgery Median 3 years  
Hauck et al. [74] (2009) USA Cohort 41 Supratentorial I-V Onyx embolization NR  
Sousa et al. [75] (2016) Brazil Cohort 90 Mixed III Multimodality 3 years  
Esteves et al. [76] (2008) Brazil Case series 61 Mixed III-IV Radiosurgery Mean 28.8 months  
Abla et al. [77] (2015) USA Cohort 174 Supratentorial I-V Surgery Median 5.3 years  
Abud et al. [78] (2011) Brazil and France Case series 17 Mixed I-IV Onyx embolization 6 months  
Dănăilă [79] (2012) Romania Case series 46 Mixed I-IV Surgery 6 months  
de los Reyes et al. [80] (2011) USA Cohort 43 Mixed I-V Onyx embolization Median 27.5 months  
He et al. [81] (2019) China Cohort 21 Mixed I-IV Transvenous embolization Median 5.5 months  
De Sousa et al. [82] (2020) France Cohort 57 Mixed I-V Endovascular embolization 6 months  
Potts et al. [83] (2014) USA Cohort 215 Mixed II-V SRS 3 years  
Gao et al. [84] (2014) China Case series 22 Mixed I-IV Endovascular embolization Mean 15 months  
Raupp and Fernandes [85] (2005) Brazil Cohort 104 Mixed NR NBCA embolization 8 years  
Komatsu et al. [86] (2020) Japan Cohort 242 NR I-V Transvenous embolization NR  
Copelan et al. [87] (2020) USA Cohort 115 Mixed NR Surgery Mean 2.3 years  
Cellerini et al. [88] (2002) Italy Case series 10 Mixed NR Multimodality Mean 23 months  
Takagi et al. [89] (2012) Japan Case series 38 NR III-V Surgery NR  
Reynolds et al. [90] (2019) USA Cohort NR NR NR Comparative multimodality study NR  
Blamek et al. [91] (2013) Poland Case series 10 Supratentorial II-IV SRS Median 38.5 months  
Mukherjee et al. [92] (2017) India Case series 14 Mixed II-V Gamma knife SRS Median 35.6 months  
Starke et al. [93] (2009) USA Cohort 202 NR I-IV Multimodality Mean 43.4 months  
Oermann et al. [94] (2016) USA Cohort 1,810 Mixed NR SRS Median 3-4 years  
Jalali et al. [95] (2009) India Case series 23 Mixed II-III SRS Median 22 months  
Yu et al. [96] (2004) China Case series 27 Mixed I-V Endovascular embolization 2-7 years  
Stapf [97] (2010) Multinational RCT 800 NR NR Comparative multimodality study Planned ≥5 years  
Lang et al. [98] (2012) USA Cohort 28 Supratentorial I-IV Surgery Median 15 months  
Sirakov et al. [99] (2020) Bulgaria Case series 16 NR I-IV Endovascular embolization Mean 5.1 months  
Mohan et al. [100] (2024) India Case series 15 Supratentorial III LINAC SRS Median 15 months  
Qureshi et al. [101] (2020) Multinational Subgroup analysis of RCT 26 NR I-IV Endovascular embolization Median 11.8 months  
Liu et al. [102] (2014) China Case series 31 Mixed I-II Curative embolization 3-6 months  
Kim et al. [103] (2020) South Korea Cohort 98 NR I-IV Multimodality Median 47 months  
Chen et al. [104] (2021) Multinational Cohort 1,178 Mixed NR Multimodality Mean 4-6 years  
Arai et al. [105] (2006) Japan Cohort 13 Supratentorial II-IV Multimodality Mean 51.6 months  
Sobh and Hegazy [106] (2013) Egypt Case series 15 Mixed I-V Endovascular embolization 3 months  
Tomsick et al. [107] (2002) USA RCT 104 NR I-V Endovascular embolization NR  
Sun et al. [108] (2025) Taiwan Cohort 75 Mixed II-III Gamma knife SRS Median 104 months  
Bitaraf et al. [109] (2017) Iran Cohort 388 Mixed I-V Gamma knife SRS Mean 61.6 months  
Yan et al. [110] (2021) China Cohort 152 Mixed I-II Multimodality Mean 6.2 years  
Blamek et al. [111] (2013) Poland Cohort 49 Mixed II-V HFSRT Median 23.8 months  
Toader et al. [112] (2024) Romania Cohort 128 Mixed I-V Multimodality 2 years  
Shuto and Matsunaga [113] (2021) Japan Cohort 19 Mixed III-V Gamma knife SRS Mean 3.9 years  
Leonardi et al. [114] (2005) Italy Case series 34 Mixed III-V Multimodality NR  
Choe et al. [115] (2008) South Korea Case series 100 Mixed I-V Gamma knife SRS Mean 37.5 months  
Lee et al. [116] (2009) South Korea Cohort 23 Mixed II-V Gamma knife SRS Mean 41.2 months  
Conger et al. [117] (2016) USA Cohort 11 Mixed I-IV Multimodality Median 2 months  
Pierot et al. [118] (2005) France Cohort 48 Mixed NR Endovascular embolization NR  
Winkler et al. [119] (2020) USA Cohort 189 NR I-V Multimodality Mean 4.1 years  
Sethi et al. [120] (2023) USA Case series 16 Mixed II-IV SRS Median 35 months  
Koo et al. [121] (2024) Korea Cohort 154 Mixed I-V Gamma knife SRS Mean 52.1 months  
Fang et al. [122] (2022) China Case series 150 Mixed I-V Multimodality 30 days  
Miyachi et al. [123] (2017) Japan Cohort 73 Mixed I-V Multimodality 3 years  
Raymond et al. [124] (2005) Canada Cohort 227 Mixed NR Multimodality Mean 32 months  
Elewa [125] (2018) Egypt Case series 21 Supratentorial II Endovascular embolization Mean 45.5 months  
Nagashima et al. [126] (2004) Japan Cohort 126 Mixed I-V Multimodality NR  
Sugiu et al. [127] (2004) Japan Cohort 68 Mixed I-IV Endovascular embolization NR  
Wang et al. [128] (2021) China Cohort 38 Mixed IV-V Multimodality Median 4.5 months  
He et al. [129] (2022) China Cohort 27 Supratentorial I-IV Endovascular embolization Median 36 months  
Zeng et al. [130] (2022) China Cohort 132 Mixed I-IV Multimodality NR  
Maalim et al. [131] (2023) China Cohort 169 Mixed I-V Surgery Mean 28 months  
Miron et al. [132] (2024) Romania Cohort 191 Mixed I-V Surgery Mean 28 months  
Li et al. [133] (2005) China Cohort 469 NR I-V Endovascular embolization NR  
Behzadi et al. [134] (2022) USA Cohort 30 Mixed I-V Endovascular embolization Mean 39 months  
Hashim et al. [135] (2016) Malaysia Cohort 13 Mixed I-IV Endovascular embolization NR  
Song et al. [136] (2005) China Case series 50 Mixed NR Onyx embolization 6 months  
Bai et al. [137] (2019) China Case series 11 Supratentorial I-III Endovascular embolization Mean 17 months  
Hong et al. [138] (2024) South Korea Cohort 55 Mixed I-II Surgery 90 days  
Yu et al. [139] (2025) China Cohort 213 Mixed I-V Multimodality Mean 49.9 months  
De Witt et al. [140] (2021) USA Cohort 956 NR NR Gamma knife SRS 30 days  
Morgan et al. [141] (2000) Australia Cohort 250 Mixed I-V Multimodality 12 months  
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Figure 1. PRISMA 2020 flow diagram for study selection.

Figure 1

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PRISMA: Preferred Reporting Items for Systematic reviews and Meta-Analyses

Data Synthesis

Data synthesis was performed qualitatively because the included studies demonstrated substantial clinical and methodological heterogeneity in study design, patient populations, AVM characteristics (including rupture status, S-M grade, and lesion morphology), treatment protocols, outcome definitions, and follow-up duration. These differences precluded meaningful quantitative pooling and made statistical comparisons across studies inappropriate. Accordingly, a meta-analysis was not performed. Instead, results were systematically organized according to treatment modality (microsurgical resection, endovascular therapy, SRS, and multimodality treatment) and synthesized descriptively to identify consistent trends in obliteration, hemorrhage, neurological outcomes, complications, mortality, and functional outcomes while acknowledging variation across studies.

Results

A total of 135 studies, comprising 27,541 analyzed patients, met the inclusion criteria (Figure 1). The included studies were published between 2000 and 2025 and originated from multiple countries, with China, the USA, and Japan among the most represented. Study designs consisted of four randomized controlled trials, 89 cohort studies, 41 case series, and one case-control study.

RoB Assessment

Using the NOS, a total of 89 observational studies were evaluated for methodological quality. Most studies demonstrated strong design features, with 57.8% rated as high quality and 31.1% rated as moderate quality. A smaller proportion, 7.8%, were considered fair, while 3.3% were classified as poor quality. The most common methodological limitations involved inadequate control for key confounders within the comparability domain, which reduced the internal validity of several studies. Other recurring issues included unclear definitions of the nonexposed cohort, insufficient detail regarding participant selection, and incomplete or inadequate follow-up durations, all of which limited the ability to assess long-term outcomes reliably.

Four randomized controlled trials were assessed using the Cochrane RoB 2 tool. Of these, two trials demonstrated “some concerns,” primarily due to issues related to the randomization process, deviations from intended interventions, or selective reporting. One trial met the criteria for low RoB across all domains, reflecting strong methodological rigor and transparent reporting practices.

Among the 41 case series evaluated with the NIH Quality Assessment Tool, the majority (92.9%) were rated as good quality, with the remaining 7.1% classified as fair. Despite generally adequate clinical descriptions, several studies demonstrated recurring weaknesses, such as incomplete follow-up, limited reporting of statistical methods, and nonconsecutive case enrollment, which may introduce selection bias and reduce the generalizability of findings.

In addition, the single case-control study included in this review was assessed using the NOS and was rated as high quality. This study demonstrated appropriate case and control selection, reliable exposure assessment, and adequate adjustment for potential confounders, supporting the overall robustness of its methodological design.

Results by Treatment Modality

Surgical resection: A total of 27 studies reported outcomes related to surgical resection, encompassing 1,641 surgically treated patients. Although 17 studies were categorized under the surgical subgroup in the characteristics table, additional outcome data were obtained from 20 multimodal studies that nevertheless presented discrete and separable results for their surgery-only cohorts. Of these, 13 studies evaluated microsurgical resection exclusively, while the remaining multimodal cohorts provided isolated surgical outcomes sufficiently detailed for inclusion. Together, these data form the most comprehensive synthesis of contemporary microsurgical results across diverse patient populations and AVM characteristics.

Functional outcomes varied substantially across studies, reflecting differences in case selection, surgical strategy, and AVM angioarchitecture. Favorable outcomes (mRS 0-2), whether directly reported or derived from postoperative Rankin distributions, ranged from 4.9% to 92.9% across included studies, with the highest rates observed in contemporary surgically treated low-grade AVM cohorts demonstrating high angiographic cure and favorable functional recovery [38]. Neurological deterioration, although generally infrequent, was observed in specific subgroups; in the series by Morgan et al., minor treatment-related neurological disability occurred in 4.9% of surgically treated patients who did not undergo preoperative embolization [141]. While most studies used the mRS, Cellerini et al. assessed functional outcome using the Barthel Index in all patients, reporting scores of 95-100 in most cases and 50 in one patient with significant residual deficit [88].

Obliteration outcomes were described in 17 studies and demonstrated a wide but clinically meaningful range from 78% to 100%. Complete obliteration was achieved in two microsurgical cohorts, both of which reported 100% angiographic cure following surgery [38,61]. Similarly, a single-center experience achieved complete bAVM resection in all treated patients with no mortality, underscoring the curative potential of microsurgical management in appropriately selected cases [63]. In contrast, a contemporary surgical series reported complete resection at first operation in 78% of cases treated with microsurgery alone, with incomplete resection occurring in 22% of patients [34].

Complication rates likewise demonstrated considerable variability. In an elderly AVM cohort undergoing intervention, perioperative complications occurred in 60% of patients, including intracranial hemorrhage (13.3%), intracranial infection (23.3%), new neurological deficits (20.0%), deep venous thrombosis (20.0%), major adverse cardiac events (6.7%), pulmonary infections (16.7%), and electrolyte disturbances (23.3%) [44]. Despite the established role of anatomical grading systems in estimating surgical risk, this prospective series found no significant association between individual anatomical variables, such as deep venous drainage, eloquence, or perforator supply, and adverse postoperative outcomes [73]. In a contemporary single-center microsurgical series, postoperative morbidity included motor deficit worsening (5.1%), aphasia (3.8%), postoperative hematoma (5.1%), cerebrospinal fluid leakage (2.5%), and late bone-flap infection (1.3%), illustrating the spectrum of surgery-related complications encountered in clinical practice [132].

Hemorrhagic complications were among the most frequently reported adverse events in elderly patients undergoing intervention for brain AVMs. Perioperative intracranial hemorrhage occurred in 13.3% of treated patients. Delayed postoperative hemorrhage was uncommon, with only one subsequent hemorrhagic event observed during follow-up, corresponding to an annualized rupture risk of 0.8%. New-onset neurological deficits were reported in 20.0% of patients, and long-term unfavorable neurological outcome (mRS >2) was observed in 36.7% [44].

Mortality was reported in 18 studies and ranged from 0% to 13.3%. In an elderly interventional cohort, four of 30 patients (13.3%) died, reflecting the substantial procedural and comorbidity burden in this population [44]. To maintain accuracy within the surgical subgroup, studies that did not provide mortality data specifically attributable to surgical intervention were excluded from mortality synthesis.

Endovascular treatment: A total of 41 studies reported outcomes of endovascular therapy in 4,620 patients with cerebral AVMs. Although 42 studies overall described endovascular interventions, only 41 provided analyzable outcome data and were included in this synthesis. Onyx and n-butyl cyanoacrylate (NBCA) were the most frequently used embolic agents, while Glubran, silk sutures, particles, and detachable coils were utilized less commonly. Several studies described the use of multimaterial embolization, such as combining Onyx with NBCA, or staged embolization performed across multiple treatment sessions, particularly for complex or high-flow AVMs [17,85].

In a prospective series of transvenous embolization with temporary arterial flow arrest, Iosif et al. reported good clinical outcomes (mRS < 2) in 95.5% of patients at one-year follow-up, with no procedure-related mortality [68]. In a large single-center series of 224 low-grade AVMs treated endovascularly, Baharvahdat et al. reported good functional outcomes (mRS 0-2) in 80% of patients, with 94% demonstrating stable or improved neurological status and a permanent deficit rate of 5% [17].

In a nationwide Japanese registry study of 1,042 endovascular procedures, Sato et al. reported favorable 30-day functional outcomes (mRS 0-2) in 71.3% of cases, poor outcomes (mRS 3-6) in 28.7%, and a 30-day mortality rate of 0.8% [14]. Collectively, across studies reporting functional results, favorable outcomes (mRS 0-2) ranged between 71% and 95%, confirming that most patients retained functional independence following embolization.

Obliteration outcomes varied depending on AVM grade, embolic material, and treatment strategy. In a large single-center series of low-grade AVMs, Baharvahdat et al. achieved 92% complete angiographic obliteration (205/224 patients), with 62.1% cured in a single session and only 8% demonstrating residual AVM following endovascular therapy [17]. In contrast, a 2005 Arquivos de Neuro-Psiquiatria series of NBCA embolization as primary therapy reported complete obliteration in only 5% of patients, with 36% achieving >2/3 obliteration and 49% achieving 1/3-2/3 nidus reduction [85].

For high-grade AVMs, Wang et al. reported that endovascular embolization is primarily performed to reduce nidus blood flow and facilitate subsequent microsurgical resection rather than to achieve definitive cure [128]. Overall, across the included literature, complete angiographic obliteration after embolization ranged from 5% to 92%, reflecting the heterogeneity of lesion grades, embolic agents, and procedural intent.

Complications were reported in 14%-25% of patients and reflected a mixture of hemorrhagic, ischemic, and procedure-specific events. Hemorrhagic complications have also been reported in endovascular AVM treatment. In a series by Abud et al., hemorrhagic events occurred in 11.8% of patients, including pedicle artery rupture during catheter withdrawal and nidus rupture during Onyx injection [78]. Iosif et al. reported an infarction rate of 9%, including 4.5% symptomatic and 4.5% silent infarctions, all of which were nonfatal and largely reversible [68]. In the same series, vessel perforation occurred in approximately 8%, while transient neurological deficits, either symptomatic or imaging-only, were noted in 9% of cases. These findings align with broader ranges of 6%-11% for periprocedural hemorrhage and 4%-9%for ischemic complications reported across other studies.

Residual AVMs frequently required additional treatment. Pan et al. reported that among 20 patients treated with Onyx embolization, microsurgical resection was performed in 25% of cases and SRS in 10% to achieve definitive management [39]. Across the full dataset, reintervention rates ranged from 10% to 25%, consistent with the role of embolization as an adjunct or staging procedure within multimodal treatment frameworks.

Mortality following embolization was low, generally between 0% and 2%, with most deaths attributed to periprocedural hemorrhage or ischemic complications. In a series by Galaktionov et al., no treatment-related deaths occurred among 26 patients undergoing combined endovascular and surgical therapy [61].

Multimodality treatment: A total of 44 studies comprising 2,421 patients reported outcomes of multimodality therapy for cerebral AVMs. Although 52 studies described multimodal management strategies, only 44 provided extractable outcome data suitable for inclusion. The majority of protocols combined endovascular embolization with microsurgical resection, whereas selected cohorts incorporated adjunctive SRS or proton beam radiotherapy. Both staged and single-session hybrid workflows were represented; the latter enabled embolization and microsurgical resection within the same operative session under intraoperative digital subtraction angiography (DSA), allowing real-time confirmation of nidus eradication and minimizing interval hemorrhage. Functional outcomes across multimodality cohorts were generally favorable, with mRS 0-2 achieved in 72%-92% of patients. In the pediatric cohort by Winkler et al., mRS 0-2 was achieved in 81.5%, and 96.6% demonstrated neurological stability or improvement at last follow-up [119]. Similarly, Morgan et al. reported a total rate of mRS >2 of 10.4%, with poor outcomes strongly stratified by AVM grade: 5.4% for S-M <III, 16.8% for grade III, and 22% for grade >III lesions, highlighting the influence of lesion complexity on postoperative morbidity [141]. Long-term neurological recovery was consistently observed, and hybrid series frequently demonstrated favorable outcomes exceeding 90% at 6-12 months. In the study by Zeng et al., neurological function was improved or unchanged in 86.4% of multistage patients and 92.4% of hybrid patients at six months [130].

Obliteration rates for multimodality therapy were uniformly high, generally ranging from 90% to 100% across modern series. Zeng et al. reported complete occlusion in 96%-100% of cases following hybrid or staged embolization combined with microsurgery, with the hybrid arm achieving 100% angiographic cure on both early and mid-term imaging [130]. Single-session hybrid workflows consistently yielded the highest obliteration rates, reflecting the advantages of immediate intraoperative verification. Staged approaches demonstrated slightly lower rates attributable to small residual components in select high-grade or deep-seated lesions, whereas partial obliteration was uncommon and typically limited to diffuse nidus morphology or advanced S-M grades.

Complication rates varied with AVM complexity and institutional expertise. Hemorrhagic events occurred in approximately 6%-11%, consistent with postradiosurgical hemorrhage rates of 6.0%-8.2% reported by Chen et al. [104] and 10.6% in the Onyx plus Gamma Knife cohort described by Huo et al. [69]. Ischemic complications were reported in approximately 4%, largely attributable to embolic infarction of feeding vessels, as demonstrated by Morgan et al. [141]. Infection rates generally ranged from 10% to 13%, with Zeng et al. reporting intracranial infection in 12.9% and pulmonary infection in 4.6% of hybrid or multistage cases [130]. Neurological deficits occurred in 10%-25% of patients in the immediate postoperative period, with substantial improvement on follow-up; in the hybrid series by Zeng et al., neurological deficits decreased from 18.2% at discharge to 9.1% at three months and 5.3% at six months [130]. Residual AVM after intended curative therapy was uncommon, occurring in 2.3% of patients at three-month angiographic follow-up and 1.5% at six months [130]. Overall complication rates were lowest in hybrid series utilizing intraoperative DSA and optimized embolization strategies, which reduced ischemic injury and interval hemorrhage.

Mortality rates for multimodality therapy ranged from 1% to 4% across included studies. Most deaths were attributed to postoperative hemorrhage, cerebral edema, or herniation. The lowest mortality was reported in contemporary hybrid protocols, where immediate angiographic confirmation of cure minimized postoperative risk; Zeng et al. [130] documented 0% perioperative mortality, consistent with the 0%-2% mortality range observed in other modern cohorts [69,104].

Radiosurgery: In our review, 43 studies involving 13,162 patients reported outcomes of SRS for cerebral AVMs. These cohorts included both exclusive radiosurgery series and multimodal studies from which radiosurgery-specific data could be extracted. Across included studies, Gamma Knife and LINAC-based platforms predominated, with smaller subsets treated using CyberKnife (Accuracy Incorporated, Madison, WI) or proton beam systems. Most studies reported single-session SRS for appropriately selected lesions. Staged or repeat radiosurgery was employed for large-volume AVMs as well as for deep or residual lesions unsuitable for single-fraction treatment [116].

Functional outcomes following SRS were favorable in the majority of patients. Across studies that reported neurological status, 80%-95% of patients achieved an mRS score of 0-2 at last follow-up. Complete obliteration was achieved in 100% of patients treated with hypofractionated CyberKnife SRS in the series by Shah et al., with actuarial occlusion rates of 16.2%, 46.9%, and 81.1% at one, two, and three years, respectively [15]. Favorable outcomes were also reported by Yan et al., with 94.1% of patients achieving mRS 0-2, including 96.1% in the SRS-only cohort and 92.1% in the embolization+SRS cohort [110]. In contrast, functional deterioration was often associated with peritreatment hemorrhage. Sanchez-Mejia et al. reported neurological worsening in 24% of patients during the radiosurgical latency period, largely attributable to hemorrhagic events [32]. Long-term follow-up studies have reported favorable functional outcomes in the majority of patients after SRS. For example, Yan et al. reported that 94.1% of patients achieved mRS 0-2, including 96.1% in the SRS-only cohort and 92.1% in the embolization + SRS cohort [110].

Obliteration rates following radiosurgery varied widely, ranging from 22% to 100% across cohorts. The highest rates of complete angiographic cure were observed in small-volume or low-grade AVMs (S-M grades I-II), particularly those treated with single-session Gamma Knife radiosurgery. Zhu et al. demonstrated significantly higher obliteration rates in S-M I-II lesions compared with S-M III-IV after single-fraction SRS, while Yan et al. also highlighted the prognostic value of the modified radiosurgery-based AVM score, in which smaller nidus volume and lower scores are associated with improved treatment outcomes after SRS [13,110]. Conversely, larger, deep-seated, or eloquently located AVMs showed lower obliteration rates, typically 40%-70%, and frequently required repeat or volume-staged radiosurgical treatment. This pattern is exemplified by Shuto and Matsunaga, in whom AVMs averaging 24.8 mL treated with two- or three-stage Gamma Knife sessions achieved obliteration rates of 30.7% at three years and 58.2% at five years [113].

Complication rates ranged from 7% to 36%, depending on AVM characteristics, treatment dose, and follow-up duration. Hemorrhage during the latency period occurred in 0%-25% of patients; Abla et al. reported hemorrhagic events in up to 25% of high-grade AVM patients undergoing volume-staged SRS [31]. Radiation-induced necrosis was observed in 0%-32% of patients, although most cases were asymptomatic or transient. Lee et al. reported no necrosis in their cohort and noted that adverse radiation effects were rare and typically mild [116], whereas Choe et al. documented adverse radiation effects in 32% of patients, with only 6.6% being symptomatic and none resulting in permanent neurological deficits [115]. Neurological deficits across cohorts ranged from 0% to 96.1%, although contemporary series consistently reported persistent deficits in fewer than 15% of patients; Yan et al. demonstrated favorable long-term function in 92%-96% of treated patients [110]. Edema occurred in 0%-78.9% of patients and was generally transient; Shuto and Matsunaga observed T2 hyperintensity in 78.9% of patients, four of whom were symptomatic, although no permanent neurological deficits were reported [113]. Seizures were reported in 0%-84.6% of patients across series, yet clinically significant or new-onset seizures after SRS remained uncommon (≤15%); seizure outcomes following SRS were generally favorable. Peciu-Florianu et al. reported seizure freedom in 84.6% of patients with pretreatment epilepsy, while seizure exacerbation occurred in only 2.9% after Gamma Knife radiosurgery [66]. Reintervention for residual nidus was required in 0%-57% of patients. In the series by Esteves et al., four of seven patients with persistent AVM after radiosurgery (≈57%) underwent repeat SRS [76].

Overall complication rates were lowest in small, superficial AVMs and highest in large or eloquent lesions. Improvements in imaging-guided targeting, dose planning, and periprocedural management have significantly reduced symptomatic radionecrosis and neurological morbidity in modern series. Mortality following radiosurgery ranged from 0% to 12.5% across the included studies, with most deaths attributed to hemorrhage occurring during the latency period prior to complete obliteration, as illustrated by Abla et al. [31]. Contemporary series using modern Gamma Knife and LINAC systems reported far lower mortality rates, typically 0%-1%, reflecting improved patient selection and enhanced procedural safety. Koo et al. observed no treatment-related deaths among 154 patients treated with Gamma Knife radiosurgery [121].

Comparative Outcomes Across Modalities

A comparative overview of obliteration, complication, mortality, and functional outcomes across all treatment modalities is presented in Figure 2 and summarized in Table 2. These visual representations allow direct comparison of the relative efficacy and safety profiles of microsurgery, endovascular therapy, SRS, and multimodal approaches. Together, the figure and table highlight the substantial variability in outcomes between modalities and illustrate the strengths and limitations of each treatment strategy based on the aggregated data from all included studies.

Table 2. Summary of outcomes across AVM treatment modalities.

Values represent ranges synthesized from the studies included in this systematic review and are based on extracted data. Reported rates summarize outcomes across eligible studies evaluating surgical resection, endovascular therapy, stereotactic radiosurgery, and multimodal treatment for cerebral AVMs. Data were derived from multiple sources including Zhu et al. [13], Shah et al. [15], Abla et al. [31], Sanchez-Mejia et al. [32], Peciu-Florianu et al. [66], Huo et al. [69], Esteves et al. [76], Chen et al. [104], Yan et al. [110], Shuto and Matsunaga [113], Choe et al. [115], Lee et al. [116], Winkler et al. [119], Koo et al. [121], Zeng et al. [130], Morgan et al. [141]

AVM: arteriovenous malformation; mRS: modified Rankin Scale

Outcome Surgical resection Endovascular therapy Radiosurgery Multimodal
Complete obliteration (%) 78-100 5-92 22-100 90-100
Overall complication rate (%) 6.8-60 11.8-25 7-36 6-20
Mortality (%) 0-13.3 0-2 0-1 0-5
Favorable functional outcome (mRS 0-2, %) 4.9-92.9 71-95.5 80-95 72-92
follow-up duration (years) 0.25-10 0.25-11 1.25-15 0.17-20
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Figure 2. Summary of key outcomes across AVM treatment modalities .

Figure 2

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Comparative distribution of major clinical outcomes across surgical resection, endovascular therapy, radiosurgery, and multimodality treatment for cerebral AVMs. Bars represent reported ranges of complete obliteration, complication rates, mortality, and favorable functional outcomes (mRS 0-2). Values represent heterogeneous descriptive ranges extracted from included studies and should not be interpreted as pooled comparative estimates or direct statistical comparisons between treatment modalities. Ranges only; values are presented for descriptive purposes and are not directly comparable across treatment modalities

AVM: arteriovenous malformation; mRS: modified Rankin Scale

Image credits: This image was synthesized by the authors Flora Alrumaih, Fadwa M. Albattah, Deem A. Almethen, and Abdulrahman M. Alharbi based on [9-141]

Follow-Up and Comparative Trends Across Modalities

Based on pooled data from the included studies, substantial variability was observed in follow-up duration and outcome profiles across treatment modalities, highlighting important differences in both therapeutic objectives and durability of reported results.

Surgical series reported follow-up durations ranging from approximately 3 months to 10 years, enabling confirmation of angiographic cure and early postoperative neurological outcomes. Across these cohorts, microsurgical resection consistently achieved high rates of immediate obliteration (78%-100%) [34,38,61], although complication rates varied substantially depending on patient selection and lesion complexity, with higher rates reported in elderly or high-risk cohorts [44,132]. Mortality was generally low but reached up to 13.3% in selected high-risk populations, particularly elderly cohorts [44].

Endovascular series generally reported short- to mid-term follow-up durations (ranging from approximately three months to over 10 years, most commonly within three years), with outcomes primarily focused on procedural safety and nidus reduction rather than definitive cure. Across these studies, complete obliteration rates were highly variable (5%-92%), reflecting differences in AVM grade, embolic agents, and treatment intent [17,85]. Complication rates ranged from approximately 14% to 25%, encompassing hemorrhagic, ischemic, and procedure-related events [68,78]. These findings underscore the heterogeneous durability of endovascular outcomes and their predominant role as an adjunct within multimodal treatment strategies.

Radiosurgery cohorts reported the longest surveillance periods (approximately 15 months to 15 years), consistent with the delayed nature of nidus obliteration following SRS. Across these studies, obliteration rates ranged from 22% to 100% [13,15,110,113], contemporary mortality remained below 1% in modern series [121], and durable functional outcomes were frequently observed, with mRS 0-2 achieved in over 90% of patients in contemporary cohorts, with most studies reporting favorable outcomes in the majority of cases [110].

Multimodality strategies, including modern hybrid single-session protocols, demonstrated intermediate to long follow-up durations (two months to 20 years, most commonly 2-10 years). These approaches achieved high obliteration rates (90%-100%) [130], with complication rates reflecting a combination of hemorrhagic (6%-11%), ischemic (~4%), and infectious (10%-13%) events [69,104,130,141], and mortality generally ranging from 0% to 4% [69,104,130], reflecting the complementary integration of surgical, endovascular, and radiosurgical techniques to balance efficacy with risk.

Closing Summary

Microsurgical resection provides the most immediate and definitive obliteration, particularly for low-grade surgically accessible AVMs. Endovascular therapy demonstrates variable durability and is most commonly used as an adjunct within multimodality treatment strategies, whereas SRS achieves delayed but durable obliteration with favorable long-term outcomes. Multimodal approaches may facilitate treatment of complex lesions by combining the complementary advantages of individual modalities. Collectively, these findings highlight the importance of interpreting outcomes in the context of follow-up duration and therapeutic goals, immediate cure with surgery vs. delayed obliteration with radiosurgery, and underscore the need for individualized, lesion-specific treatment strategies tailored to angioarchitectural characteristics and patient factors [142].

Discussion

The management of cerebral AVMs remains a central challenge in neurosurgery because of their heterogeneous angioarchitecture, variable rupture risk, and differing responses to intervention. This review summarizes the reported outcomes of microsurgical resection, endovascular embolization, SRS, and multimodality strategies. Given the heterogeneity of patient characteristics, AVM features, and treatment selection across the included studies, these findings should be interpreted as descriptive rather than direct comparative evidence between treatment modalities.

Microsurgical Resection

Microsurgery consistently achieves the highest and most immediate obliteration rates, often exceeding 90% in contemporary multimodality cohorts [1]. Consensus recommendations also support microsurgical resection as the definitive curative option for small, superficially located AVMs when performed in experienced centers [2]. Additional single-institution series confirm high cure rates and acceptable morbidity for appropriately selected lesions [3]. These findings reinforce the role of surgery as first-line therapy for low-grade or surgically favorable AVMs.

Endovascular Therapy

Endovascular embolization demonstrated variable obliteration rates, reflecting differences in indication, technique, and nidus complexity across studies [39]. Modern approaches focus on tailored nidus reduction and hemodynamic stabilization as preparation for definitive microsurgical or radiosurgical therapy. Overall, current evidence supports embolization as a risk-modifying or adjunctive therapy rather than a reliable curative monotherapy.

Stereotactic Radiosurgery

SRS is commonly selected for small, deep-seated, or eloquently located AVMs that carry higher microsurgical risk, as reflected in contemporary management guidelines [142]. Earlier framework papers also highlight key considerations for noninvasive management of unruptured lesions [97]. In elderly patients, long-term neurological outcomes and mortality were similar across different management modalities, including SRS [38].

Multimodality Approaches

Combining treatment modalities can optimize outcomes for complex AVMs; series integrating endovascular embolization with microsurgical resection have demonstrated high obliteration rates with acceptable morbidity [19]. Modern targeted endovascular techniques also play a key role in reducing hemodynamic risk and facilitating safer definitive treatment [51]. Hybrid one-stage approaches, which integrate endovascular and microsurgical techniques, have demonstrated improved intraoperative control and high obliteration rates in contemporary multimodality cohorts [1,130].

Evidence Context: ARUBA and Subsequent Analyses

The ARUBA trial reported higher early stroke and death rates with intervention compared with conservative management for unruptured AVMs [143]. Its methodological rationale and design considerations were detailed in earlier publications [97]. However, limitations including low obliteration rates, short follow-up, and restrictive inclusion criteria limit generalizability. National data subsequently demonstrated that intervention rates for unruptured AVMs did not decline following ARUBA, suggesting persistent skepticism among neurovascular specialists regarding its applicability to real-world practice [43,90]. Collectively, these findings support conservative management for low-risk unruptured lesions while recognizing that selected patients with hemorrhagic presentation, progressive deficits, or surgically favorable anatomy may still benefit from active intervention.

Clinical Implications

Collectively, the evidence supports a risk-stratified approach. Microsurgery remains the definitive curative option for low-grade, accessible AVMs; radiosurgery offers durable results for deep or eloquent lesions with minimal invasiveness; and embolization serves primarily as an adjunct or targeted protective measure. Multimodal strategies, especially one-stage hybrid procedures, combine high obliteration rates with low morbidity and should be considered in complex or higher grade cases.

Limitations and Future Directions

Heterogeneity among included studies limits direct comparison, as AVM grade, outcome definitions, and follow-up durations varied considerably. Some series failed to differentiate single-modality from multimodal outcomes, and functional scales were inconsistently applied. Furthermore, this review synthesized data descriptively rather than meta-analytically. Additionally, the available evidence was predominantly derived from retrospective observational studies, with only four randomized controlled trials, limiting the overall strength of the conclusions. Furthermore, embolization outcomes were synthesized across studies with differing therapeutic intents (curative vs. adjunctive embolization), which may have contributed to the wide variability in reported obliteration rates. Future research should emphasize standardized reporting of mRS outcomes, time-to-obliteration, and hemorrhage during latency; prospective multicenter registries integrating hybrid-suite workflows; and long-term studies that capture late complications and durability of cure.

Conclusions

The present synthesis underscores that the management of cerebral arteriovenous malformations is best guided by precision rather than preference. Across contemporary literature, durable cure and functional preservation depend more on appropriate selection and sequencing than on the superiority of any single technique. Microsurgery delivers immediate cure where anatomy permits, radiosurgery offers durable results for deep or eloquent lesions, and embolization enhances the safety and success of both when applied judiciously.

The collective evidence emphasizes that progress in AVM care lies in integration-of modalities, expertise, and technology. Future efforts should focus on prospective, data-driven frameworks that incorporate patient-specific risk modeling, hybrid neurovascular suites, and long-term functional endpoints to redefine what constitutes true cure and quality of life in AVM treatment.

Disclosures

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:

Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.

Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Author Contributions

Concept and design:  Flora Alrumaih

Acquisition, analysis, or interpretation of data:  Flora Alrumaih, Ohud T. Alharbi, Deem A. Almethen, Abdulrahman M. Alharbi, Fadwa M. Albattah, Dhay S. Alharbi, Fisal T. Alrogibah, Bader S. Alharbi, Faris A. Alalwan, Raghad S. Albiyebi, Muath I. Alfallaj

Drafting of the manuscript:  Flora Alrumaih

Critical review of the manuscript for important intellectual content:  Flora Alrumaih, Ohud T. Alharbi, Deem A. Almethen, Abdulrahman M. Alharbi, Fadwa M. Albattah, Dhay S. Alharbi, Fisal T. Alrogibah, Bader S. Alharbi, Faris A. Alalwan, Raghad S. Albiyebi, Muath I. Alfallaj

Supervision:  Muath I. Alfallaj

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