Management Strategies for Multiple Intracranial Aneurysms: A Comparative Systematic Review and Meta-Analysis

Multiple intracranial aneurysms (MIAs) represent a clinically challenging subset of intracranial aneurysms, with uncertainty persisting regarding optimal management strategies. In particular, whether aneurysms should be treated in a single-stage (SS) or multistage (MS) approach remains unresolved. This meta-analysis aimed to compare clinical and radiological outcomes between these 2 strategies.

A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered in International Prospective Register of Systematic Reviews (PROSPERO) (CRD420251066054). PubMed/MEDLINE, Web of Science, Scopus, and Embase were searched from January 2000 to May 2026. Studies reporting outcomes of adult patients with MIAs managed using SS or MS strategies were included. The primary endpoint was the incidence of major complications. Secondary endpoints comprised clinical outcomes and ischemic and hemorrhagic complications. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using random-effects models.

Eight studies were included, with 5 eligible for quantitative synthesis. No significant differences were observed between SS and MS strategies regarding major (RR: 0.85, 95% CI: 0.46-1.59; P = 0.617), hemorrhagic (RR: 0.50, 95% CI: 0.15-1.72; P = 0.273), or ischemic complications (RR: 1.14, 95% CI: 0.85-1.53; P = 0.373), or in favorable (RR: 1.00, 95% CI: 0.96-1.03; P = 0.870) or poor clinical outcomes (RR: 1.09, 95% CI: 0.29-4.09; P = 0.893).

SS and MS treatment strategies for MIAs demonstrate comparable safety and efficacy profiles. Treatment selection should therefore be individualized based on aneurysm characteristics, patient condition, and institutional expertise rather than an expected difference in outcomes. Prospective studies with standardized reporting are needed to further refine optimal management strategies.