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

Abstract

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 or multi-stage approach remains unresolved. This meta-analysis aimed to compare clinical and radiological outcomes between these two strategies. A systematic review was conducted according to PRISMA guidelines and registered in 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 single or multi-stage strategies were included. The primary endpoint was the incidence of major complications. Secondary endpoints comprised clinical outcomes, ischemic and hemorrhagic complications. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using random-effects models. Eight studies were included, with five eligible for quantitative synthesis. No significant differences were observed between single-stage and multi-stage 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). Single-stage and multi-stage 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.