Optimal timing of microsurgical resection after preoperative embolization of intracranial arteriovenous malformations: A systematic review and meta-analysis of 1,469 patients.

Preoperative embolization is frequently employed to facilitate microsurgical resection of intracranial arteriovenous malformations (AVMs), but optimal surgical timing remains debated. This study evaluated whether hybrid versus staged approaches influence surgical morbidity, resection completeness, and postembolization complications to inform standardized management. A systematic search of PubMed, Embase, and OVID/Medline through February 2025 identified studies reporting outcomes after preoperative embolization followed by microsurgical AVM resection. Studies were stratified by timing: hybrid, < 48 h, and < 1 week. Primary outcome was postembolization complications; secondary outcomes included favorable functional status, complete AVM resection, and mortality. Random-effects meta-analysis with I² statistics assessed heterogeneity. Twenty-eight studies including 1,469 patients were analyzed. Resection within 48 h of embolization was associated with fewer postembolization complications (OR 0.87, 95% CI 0.77–0.98, p = 0.019) and higher rates of complete resection (OR 1.15, 95% CI 1.03–1.28, p = 0.014) compared with delayed surgery (> 48 h). Hybrid procedures similarly demonstrated lower complication risk (OR 0.84, 95% CI 0.60–1.17, p = 0.39) and significantly improved resection completeness (OR 1.21, 95% CI 1.10–1.33, p < 0.001) relative to staged approaches. No significant differences were observed in favorable functional outcomes or mortality among timing groups. Timing of microsurgical resection after preoperative embolization impacts complication rates and completeness of AVM removal. Surgery within 48 h or using a hybrid approach may optimize these outcomes, although functional recovery and mortality appear unaffected.