The evolution of intracranial aneurysm treatment: a narrative review integrating historical perspectives and contemporary evidence.

INTRODUCTION

The management of intracranial aneurysms (IAs) has undergone a century-long evolution, shifting from vessel ligation to microsurgical clipping and, more recently, to advanced endovascular therapies. This study aims to combine historical milestones with current evidence to clarify the contemporary balance between microsurgical and endovascular approaches within evidence-based practice.

METHODS

A review was conducted using PubMed/MEDLINE and Google Scholar from database inception through September 2025. Eligible studies included historical analyses, randomized trials, systematic reviews, meta-analyses, and international guidelines comparing microsurgical clipping with endovascular treatments-coiling, flow diversion, and intrasaccular devices.

RESULTS

The microsurgical era, pioneered by Yasargil and Drake, established durable anatomical reconstructions. Since the 1990s, endovascular advances-from Guglielmi detachable coils to flow diverters-have driven a global paradigm shift. Recent trials (BRAT, Darsaut et al.) and meta-analyses have demonstrated that clipping yields higher long-term occlusion rates and lower retreatment rates, while endovascular approaches offer reduced perioperative morbidity and shorter hospitalization times. Contemporary evidence also supports the importance of aneurysm location and morphology: microsurgery remains superior for large and giant anterior circulation aneurysms, whereas endovascular therapy is often favored for complex posterior circulation territories. Guideline consensus recommends early treatment of ruptured aneurysms (within 24-72 hours) and individualized management of unruptured lesions based on rupture risk, anatomy, and expert judgment.

CONCLUSIONS

Modern aneurysm treatment balances surgical durability and endovascular minimalism. Multidisciplinary, evidence-based decision-making ensures optimized, patient-specific management for both ruptured and unruptured aneurysms.