Abstract
<title>Abstract</title> <p> Purpose Stereotactic radiosurgery (SRS), delivered as either single-session (SSRS) or hypofractionated (HSRS) regimen, is used to treat residual or recurrent craniopharyngioma. However, the comparative efficacy and safety of SSRS and HSRS remain unclear. This study aimed to systematically evaluate outcomes following SRS for residual or recurrent craniopharyngioma and compare outcomes between SSRS and HSRS. Methods PubMed, Embase, Scopus, and Cochrane were searched through April 2026. Eligible studies included ≥ 3 craniopharyngioma patients treated with SRS in ≤ 5 fractions with > 6 months of follow-up, and reported on outcomes. Target endpoints were pooled using random-effects models, and meta-regression was performed to identify outcome moderators. Results Seventeen studies (782 patients) met inclusion criteria. 655 patients (83.8%) received SSRS and 63 (8.1%) HSRS. Overall tumor control was 74.7% ( <italic>p</italic> = 0.002). Among modality-attributable studies (k = 12 SSRS, k = 3 HSRS), pooled tumor control was 72.6% for SSRS versus 75.2% for HSRS ( <italic>p</italic> = 0.97). Five-year progression-free survival was higher for HSRS (76.1% vs. 69.0%, <italic>p</italic> = 0.76). Visual deficit (9.7% SSRS vs. 10.3% HSRS, <italic>p</italic> = 0.78), endocrine/hypothalamic dysfunction (8.4% SSRS vs. 4.2% HSRS, <italic>p</italic> = 0.33) and cyst enlargement (7.9% SSRS vs. 13.3% HSRS, <italic>p</italic> = 0.28) did not differ significantly by modality. Higher biologically effective dose was associated with endocrine/hypothalamic dysfunction. Conclusion SRS provides favorable tumor control for craniopharyngioma, and HSRS achieves short- and mid-term outcomes comparable to SSRS despite being reserved for anatomically higher-risk tumors. Nevertheless, limited comparative data and shorter HSRS follow-up warrant prospective, multicenter investigations with patient-level data. </p>