Rethinking the management of small unruptured intracranial aneurysms: risk balance and emerging strategies

Small unruptured intracranial aneurysms (UIAs) are increasingly detected by imaging modalities widely used in clinical practice. The low rupture risk of small UIAs contrasts with the substantial proportion of small aneurysms in ruptured cases. Current aneurysm rupture prediction models are insufficient to assess the rupture risk of small UIAs accurately. Multidimensional risk assessment integrating clinical variables, aneurysm morphology, haemodynamic features, imaging or biological markers is proposed. A shared decision-making balances the risks of rupture and treatment not only with the aneurysm size. For asymptomatic small UIAs, precise risk stratification, the development of pharmacological strategies and improvements in treatment safety represent important directions for future research.