Introduction: Intracranial arteriovenous fistulas (AVFs) are abnormal vascular connections between arteries and veins, comprising approximately 10–15% of intracranial vascular malformations. Advances in neuroradiology, particularly high-resolution 3D vascular imaging, have improved the precision in locating and characterizing CCJ AVFs, though the natural history of these lesions remains incompletely understood. Treatment options include microsurgery and endovascular embolization. This study aims to assess the comparative safety and efficacy of these treatments for CCJ AVFs, providing stronger evidence to guide clinical decisions.
Methods: We systematically reviewed PubMed, Embase, Web of Science, and Cochrane Library. Both randomized and non-randomized controlled trials were included. Treatment effects, reported with 95% confidence intervals, and heterogeneity were assessed using I² statistics. Odds Ratios (OR) were used for binary event analyses, with Baujat and leave-one-out analyses applied to identify heterogeneity sources.
Results: Five studies evaluated neurological improvement via the modified Rankin Scale (mRS) in both the microsurgical (n=147) and endovascular (n=82) groups, with endovascular techniques showing a statistically significant advantage (OR = 2.05, CI = 1.03–4.07, p = 0.04, I² = 0%). For obliteration rates, the endovascular group (n=66) demonstrated superiority (OR = 6.85, CI = 2.45–19.14, p < 0.01, I² = 0%). Recurrence rates were lower in the microsurgical group (OR = 0.04, CI = 0.01–0.17, p < 0.01, I² = 0%). Complications, analyzed in eight studies (233 microsurgical and 95 endovascular cases), showed no overall significant difference (OR = 0.49, CI = 0.11–2.21, p = 0.35, I² = 68%), but subgroup analyses favored microsurgery in ischemic complications, spinal infarction, and transient respiratory arrest.
Conclusion : Endovascular treatment may offer benefits in neurological improvement and obliteration rates, microsurgery has advantages in recurrence and specific complication rates, supporting a tailored approach for managing CCJ AVFs. Further controlled studies are essential for refining treatment guidelines.
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