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Intraoperative auditory monitoring spans far-field auditory brainstem responses (ABR)\/brainstem auditory evoked potentials (BAEP) and near-field cochlear nerve action potentials (CNAP)\/dorsal cochlear nucleus action potentials (DNAP). Prior reports often conflate diagnostic accuracy of thresholds with interventional effectiveness. We separated these domains to deliver decision-relevant synthesis. PRISMA-guided systematic review of PubMed, ScienceDirect, and Embase. Eligible VS studies used ABR\/BAEP, CNAP, or DNAP and reported (1) diagnostic performance of prespecified intraoperative thresholds versus postoperative hearing, or (2) comparative effectiveness of monitoring-guided surgery. Primary clinical outcome: long-term serviceable hearing (GR I\u2013II or AAO-HNS A\u2013B). ROBINS-I for effectiveness and QUADAS-2 for diagnostic studies were used for risk of bias assessment. Random-effects models were used for synthesis. The study was registered at PROSPERO (CRD420251181366) before its start. We included 34 studies yielding 1,297 patients with operated VS (27 diagnostic\/threshold; 7 comparative-effectiveness). The two nonrandomized cohorts comparing any intraoperative auditory monitoring versus none were directionally favorable but imprecise (RR 1.28, 95% CI 0.54\u20133.04 and RR 2.50, 0.83\u20137.49). For far-field ABR\/BAEP, a whole-cohort ROC threshold (interaural wave V latency difference\u2009&lt;\u20091.12 ms) predicted early serviceable hearing with sensitivity 0.863, specificity 0.778. A looser \u201cany deterioration\u201d rule behaved as a sensitive sentinel for early loss (sensitivity 1.00, specificity 0.33). A standardized BAEP amplitude criterion (post-resection STIAS\u2013Am-V\u2009\u2265\u20090.05 \u00b5V) improved rule-in performance (sensitivity 0.789, specificity 0.920). For near-field CNAP, thresholds with extractable denominators showed balanced discrimination for early outcomes (&gt;\u200980% drop: sensitivity 0.889, specificity 0.667; disappearance: sensitivity 0.529, specificity 0.923), while end-of-case N1 presence ruled out immediate deafness in a small series (sensitivity 1.00, specificity 0.67). Head-to-head signals suggested potential gains from chirp-optimized ABR versus click-ABR and greater decisional value of direct CNAP over transtympanic ECochG when feasible; formal, standardized evaluations are needed to confirm these patterns. Evidence supports routine intraoperative auditory monitoring for hearing-preservation VS surgery, with ABR as a widely deployable early-warning tool and CNAP\/DNAP offering more specific, faster adjudication where attainable. Certainty is limited by nonrandomized designs, heterogeneous thresholds\/windows, and incomplete 2\u2009\u00d7\u20092 data; standardized threshold-to-action protocols and multicenter studies are needed.<\/jats:p>","DOI":"10.1007\/s10143-026-04293-y","type":"journal-article","created":{"date-parts":[[2026,4,27]],"date-time":"2026-04-27T01:51:42Z","timestamp":1777254702000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Intraoperative auditory monitoring in vestibular schwannoma surgery: Diagnostic accuracy and interventional effectiveness \u2014 a systematic review"],"prefix":"10.1007","volume":"49","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4532-9219","authenticated-orcid":false,"given":"Ad\u00e9la","family":"Buben\u00edkov\u00e1","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4243-9727","authenticated-orcid":false,"given":"Zden\u011bk","family":"F\u00edk","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6089-0071","authenticated-orcid":false,"given":"Vladim\u00edr","family":"Kouck\u00fd","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5100-4317","authenticated-orcid":false,"given":"Jan","family":"Laz\u00e1k","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-1961-3359","authenticated-orcid":false,"given":"Lenka","family":"Peterkov\u00e1","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7764-7254","authenticated-orcid":false,"given":"Petr","family":"Skalick\u00fd","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4364-5522","authenticated-orcid":false,"given":"Ond\u0159ej","family":"Brad\u00e1\u010d","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5724-006X","authenticated-orcid":false,"given":"Ale\u0161","family":"Vlas\u00e1k","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,4,27]]},"reference":[{"issue":"4","key":"4293_CR1","doi-asserted-by":"publisher","first-page":"527","DOI":"10.3171\/jns.2006.105.4.527","volume":"105","author":"M Samii","year":"2006","unstructured":"Samii M, Gerganov V, Samii A (2006) Improved preservation of hearing and facial nerve function in vestibular schwannoma surgery via the retrosigmoid approach in a series of 200 patients. 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