Background: Treatment strategies for vestibular schwannoma (VS) vary widely, and selecting the optimal approach based on individual patient characteristics remains challenging. This study systematically evaluated the impact of different treatment modalities on survival outcomes and treatment-related risks using the SEER database, and analyzed temporal trends and tumor size influences on treatment selection. Methods: A total of 10,119 patients diagnosed with vestibular schwannoma (VS) between 2004 and 2021 were identified from the SEER database. Patients were categorized into four treatment groups: no treatment, surgery alone, radiotherapy alone, and combined surgery plus radiotherapy. To minimize baseline confounding, inverse probability of treatment weighting (IPTW) was employed. Comparative analyses of overall survival and treatment-related mortality risks were conducted across the four groups using Kaplan-Meier survival curves and cumulative incidence functions (CIF). Additionally, temporal trends and tumor size influences on treatment groups were examined to provide clinical insights into individualized therapeutic strategies. Results: The surgery group showed the highest overall survival, with a 5-year survival rate of approximately 94%, compared to 78% in the no-treatment group (log-rank p < 0.001). Combined therapy and radiotherapy alone had intermediate 5-year survival rates of about 89% and 85%, respectively. These differences remained significant after IPTW adjustment. Short-term treatment-related mortality was slightly higher in the surgery (sub-HR=1.14, p<0.001) and combined therapy groups (sub-HR=1.27, p=0.030), while radiotherapy alone showed no significant increase. Treatment choices evolved over time and were strongly influenced by tumor size. Conclusions: Surgical treatment remains the cornerstone of VS management. Treatment decisions should be individualized based on patient age, tumor size, and clinical symptoms. Future research integrating multicenter clinical data is warranted to advance precision therapy and functional preservation, ultimately improving patient quality of life.