BACKGROUND: Craniocervical junction dural arteriovenous fistulas (CCJ-DAVFs) are rare and complex vascular malformations that are challenging to diagnose and treat. This study aims to compare surgical and endovascular treatments for CCJ-DAVFs through a systematic review and meta-analysis. METHODS: A systematic review and meta-analysis was conducted according to the PRISMA guidelines. PubMed, Scopus, and Web of Science databases were searched from inception to July 2024. RESULTS: Fifteen studies involving 266 patients were included. Of these, 143 (53.8 %) patients underwent surgical treatment alone and 123 (46.2 %) underwent endovascular treatment alone. In the surgical group, the complete obliteration rate at last follow-up was 89.8 %. Retreatment rate was 6.2 %. Periprocedural complications occurred in 21.6 % of cases. In the endovascular group, the complete occlusion rate at last follow-up was 73.6 %. Retreatment rate was 46.7 %. Periprocedural complications occurred in 18.8 % of cases. Comparative meta-analysis revealed that the rate of complete obliteration at last follow-up was significantly higher in the surgical group (OR: 0.24
CI: 0.07 to 0.89, p = 0.03). Surgical treatment had a significantly higher successful treatment rate (OR: 0.24
CI: 0.07 to 0.89, p = 0.03) and lower retreatment rate (OR: 37.13
CI: 6.31 to 218.59, p <
0.01). No significant differences were observed between the groups in terms of periprocedural complications or complete resolution of symptoms. CONCLUSION: Surgical treatment for CCJ-DAVFs achieves higher rates of complete obliteration with lower retreatment rates compared to endovascular treatment. However, endovascular treatment showed a tendency towards reducing periprocedural complications while increasing the likelihood of complete resolution of symptoms. Individualized treatment plans for CCJ-DAVFs, should be considered according to their anatomical location and potential surgical accessibility. Further studies are required to confirm these findings.