Intracranial Aneurysm · Observe vs Clipping vs Coiling

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Ruptured? + risk (PHASES)
   Ruptured? If unruptured, risk (size/site/symptoms, PHASES)?
   • Ruptured (subarachnoid hemorrhage, SAH) → Ruptured → treat early
   • Unruptured, low-risk (<7 mm anterior circulation, no risk factors) → Unruptured low-risk → observe
   • Unruptured, high-risk (≥7 mm/posterior circulation/symptomatic/growth/family history/young) → Unruptured high-risk · choose approach
2. [End] Ruptured → treat early
   Ruptured (SAH) → treat early (<24–72 h) to prevent rebleeding: when both feasible, endovascular coiling is often preferred (ISAT); large hematoma needing evacuation/wide neck/MCA favor clipping; plus nimodipine + monitoring for vasospasm.
3. [End] Unruptured low-risk → observe
   Unruptured low-risk → imaging surveillance (serial MRA/CTA) + BP control, smoking cessation; re-evaluate for treatment if it grows or becomes symptomatic.
4. [Decision] Unruptured high-risk · choose approach
   Coiling or clipping?
   • Endovascular coiling (± stent/flow diverter; posterior circulation/cavernous/elderly/comorbidities) → Endovascular coiling
   • Microsurgical clipping (wide neck/MCA/many branches/with hematoma/young wanting durability) → Microsurgical clipping
5. [End] Endovascular coiling
   Endovascular coiling — minimally invasive, faster recovery; preferred for posterior circulation, favorable anatomy, multiple comorbidities; needs imaging follow-up for recurrence/retreatment.
6. [End] Microsurgical clipping
   Microsurgical clipping — wide neck, MCA, many branches, need to evacuate a hematoma, young patients wanting long-term durability; craniotomy, high long-term occlusion rate.

Source guidelines & references

• Intracranial aneurysm management (AHA/ASA unruptured aneurysms; ISAT coiling vs clipping)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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