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Background:
Review

Is Minimally Invasive Craniotomy a More Contemporary Treatment Option for Unruptured Intracranial Aneurysms?

by
Farhan Siddiq
1,*,
Sabrina Genovese
2,
Eisha Abid Ali
3,
Dahir Ashfaq
4 and
Muhammad Shakir
1
1
Department of Neurosurgery, University of Missouri, Columbia, MO 65212, USA
2
School of Medicine, University of Missouri, Columbia, MO 65212, USA
3
Medical College, University College of Medicine and Dentistry, Lahore 53400, Pakistan
4
Medical College, Aga Khan University, Karachi 74800, Pakistan
*
Author to whom correspondence should be addressed.
J. Vasc. Dis. 2025, 4(3), 34; https://doi.org/10.3390/jvd4030034
Submission received: 1 July 2025 / Revised: 18 August 2025 / Accepted: 3 September 2025 / Published: 8 September 2025
(This article belongs to the Special Issue Current Advances in Intracranial Aneurysms: From Basic to Clinical Research)
Versions Notes

Abstract

Background/Objectives: Unruptured intracranial aneurysms (UIAs) carry a risk of subarachnoid hemorrhage (SAH), which has a high mortality rate of up to 45% and significant long-term disability among survivors. Traditional surgical clipping and endovascular treatment (EVT) are widely used, but both have limitations: EVT shows higher recurrence and retreatment rates, while open clipping poses higher procedural risks. Minimally invasive craniotomy (MIC) techniques are emerging as a promising third option, offering potential benefits in terms of safety, durability, and recovery. This study aims to compare MIC and EVT for UIAs to evaluate their relative efficacy, safety, and long-term outcomes. Methods: A systematic literature review was conducted using PubMed and Scopus. Inclusion criteria encompassed original, peer-reviewed studies reporting clinical outcomes of UIA treatments. Data extracted included study characteristics, treatment modality, complication rates, recurrence, retreatment, and patient outcomes. Results: MIC demonstrated low complication rates (1.6–5.88%), for which the percentage was significantly lower than that for stent-assisted coiling (37%) and flow diversion (17%), while maintaining similar efficacy to traditional clipping. New EVT techniques such as WEB devices showed less procedural risks (0.7%) but higher retreatment rates. Conclusions: This review shows that while traditional craniotomy for aneurysm clipping carries higher perioperative risk than EVT, most studies have failed to compare long-term recurrences. MIC has significantly lower perioperative complications rates, comparable to EVT, and provides the same durability with improved cosmetic results. MIC should be considered when selecting patients as an alternative to EVT, particularly for unruptured anterior circulation aneurysms. Further prospective studies are needed to guide treatment decisions.

1. Introduction

Ruptured aneurysms leading to subarachnoid hemorrhage (SAH) have a high mortality rate of up 45%, with approximately 30% of survivors living with significant deficits that affect quality of life and functional independence [1]. Each year, around 30,000 people in North America and a global prevalence of 8.09 million suffer from an SAH due to a ruptured aneurysm, highlighting the importance of identifying and managing unruptured aneurysms before they become life-threatening [2,3]. Unruptured aneurysms are typically found incidentally. The two main treatments include traditional surgical clipping with craniotomy and endovascular treatment (EVT) with the deployment of a device either within the aneurysmal sac or across its neck to inhibit rupture and limit expansion [4]. The traditional intervention requiring a large craniotomy is associated with significant intraoperative complications and morbidity [5,6]. While EVT is associated with less procedural complications (3–5%), there is a significantly higher rate of aneurysm recurrence, as high as 40%, compared to surgical clipping [7,8,9,10]. Additionally, 11.4% of EVT-treated aneurysms require repeat intervention [11]. Because of these shortcomings, recent advancements have driven the adoption of minimally invasive craniotomy (MIC) using a small, targeted incision and bone flap, also known as “keyhole” surgery, for the management of unruptured intracranial aneurysms (UIAs) [6,12,13]. Common keyhole techniques include the mini-pterional craniotomy (MPC), lateral supraorbital craniotomy (LSO), orbital–pterional, and supraorbital craniotomy (SOC) [12,13,14,15,16]. The current literature has shown a significant increase in the use of MIC for unruptured aneurysm treatment in recent years. Specifically, MPC and LSO increased from 22 to 28% and orbital–pterional use increased from 11 to 20% [17]. MIC approaches are preferred in select patients because of minimized brain exposure, limited retraction trauma, reduced operative times, and less postoperative pain [16,18]. Additionally, studies have shown that MIC repair has a lower risk of supraorbital nerve injury, less temporalis muscle atrophy, fewer infections, and improved patient-reported cosmetic satisfaction compared to traditional approaches [19,20,21]. The recent literature has shown MIC clipping to have a success rate of 91–95% and a low risk of recurrence, retreatment, and rebleeding at a median of 3 years [11,22,23,24].
EVT for UIAs continues to evolve with innovations in coiling technology and techniques, newer stents, delivery catheters, and the more recent addition of flow diverters and intrasaccular devices such as the Woven EndoBridge (WEB) and Contour [25,26,27]. MIC offers a more durable aneurysm with similar surgical risks compared to EVT, prompting patients and clinicians to question preferred treatment modality. Due to higher retreatment rates, particularly in younger patients and those with wide-neck aneurysms, MIC is favored in many high-volume centers, though advances in EVT are making treatment decisions more complex. The purpose of this study is to further explore the controversy between EVT and MIC of UIAs to better understand their relative efficacy, safety profiles, and long-term outcomes. This analysis aims to guide evidence-based treatment decisions for UIAs.

2. Materials and Methods

A systematic literature search was conducted using PubMed and Scopus databases. The search aimed to identify peer-reviewed studies that reported on clinical outcomes of treatment options for unruptured intracranial aneurysms. Searches included studies published up to January 2025, without restrictions on publication year to ensure a comprehensive assessment of the available literature. The keywords for the search included the following: “unruptured intracranial aneurysm”, “clipping”, “coiling”, “flow diverter”, “endovascular treatment”, and “treatment outcomes”. Boolean operators (AND, OR) were used to combine terms appropriately. The inclusion criteria were as follows: original research articles reporting clinical outcomes (e.g., morbidity, mortality, recurrence, occlusion rates, quality of life), studies focusing on patients with unruptured intracranial aneurysms, and articles published in English. Studies involving only ruptured aneurysms, and any case reports, editorials, or abstracts, were excluded. Because this is a narrative review, no formal screening or inter-reviewer agreement procedures were applied. Instead, we selected studies judged to be clinically relevant, peer-reviewed, and represented evolving techniques in the management of UIAs. Data extracted included study characteristics (author, year, design), patient demographics, aneurysm features, treatment modality, follow-up duration, complication rates, and reported clinical outcomes. Complications were defined as those reported in each primary study, typically including perioperative morbidity (i.e., thromboembolic event, hemorrhage, focal neurologic deficit, CSF leak) and mortality.

3. Results

3.1. Open Clipping vs. Endovascular Treatment of UIA

Multiple large-scale studies demonstrate a consistently higher complication rate for surgical clipping compared to endovascular therapy for UIAs. The ISUIA study noted a 3% higher complication rate for open surgery [28]. Similar results are highlighted in Table 1, although these studies did not account for recurrence or retreatment rates, limiting their long-term comparison.

3.2. Use of Flow Diverters and WEB Devices in the Treatment of UIA

Numerous past studies highlight the low complication rate of flow diverters and intrasaccular devices. The WEB-IT study demonstrated a particularly low complication rate (0.7%) and moderate retreatment rate (5.6%) for the treatment of UIA with a WEB device [31]. The opposite was seen for flow diverters, showing higher complication rates but lower retreatment rates for flow diverters. The SCENT trial reported a higher complication rate (8.3%) but the lowest retreatment rate (0.6%) [32]. The results are outlined in Table 2.

3.3. Minimally Invasive Craniotomy Techniques

Minimally invasive surgical approaches such as the supraorbital (SOC), lateral supraorbital (LSO), and mini-pterional craniotomy (MPC) approaches demonstrated acceptable safety profiles. Most of the MIC studies included in this review focused on anterior circulation aneurysms (e.g., anterior communicating, middle cerebral, and internal carotid artery aneurysms). Posterior circulation aneurysms were less frequently reported in MIC series, limiting the ability to generalize findings across all aneurysm locations. The complication rates ranged from 1.6% to 5.88%, with no reported retreatments in several studies. The outcomes are shown in Table 3.

3.4. Technique-Based Comparison

Overall complication rates were assessed for all treatment options discussed. Minimally invasive surgical techniques demonstrated a favorable balance between safety and applicability. The overall complication rate for MIC approaches was 12.2% when pooling across multiple studies, offering a lower risk than stent-assisted coiling (37.0%) and flow diversion (17%), while remaining within a similar range to simple and balloon-assisted coiling (10.8% and 11.7%, respectively). The results are outlined in Table 4. By providing both pooled and individual study data, we highlight the variability in the reported outcomes. Additionally, minimally invasive techniques are particularly suited for anterior circulation aneurysms and offer superior cosmetic outcomes, making them an appreciated alternative.

4. Discussion

Treatment of UIA has rapidly evolved over time, with many significant key developments in neurosurgery [45,46,47]. The first open surgical treatment of intracranial aneurysm was in the 1930s [48]. From 1993 to 2015, EVT markedly increased for both ruptured and unruptured aneurysms, whereas clipping largely decreased for ruptured aneurysm but increased for UIAs [49]. Continued advancements focus on minimally invasive techniques with less surgical complications, minimal recurrence, and improved cosmetic outcomes. This shift towards endovascular treatment is reflected in the current guidelines, which state that clipping results in better occlusion rates than EVT, but it has an increased procedural complication risk [50]. However, these guidelines predate most of the MIC literature and reflect early EVT techniques, which may fail to capture current standards in EVT. However, the limitations of the guidelines persist because of a lack of robust data on the comparison of complication risk from UIA treatment. One critical limitation to the existing data is the overall poor quality of comparative assessment studies. The majority of the present literature is database analyses that do not incorporate recurrence or retreatment rates, which are fundamental when evaluating long-term efficacy.
Historically, large hemicraniectomies were used to address even the smallest of intracranial lesions. These procedures, while providing extensive exposure, were associated with high morbidity, significant cosmetic deformity, and prolonged recovery [51]. With microsurgical instrumentation advancements, the use of an intraoperative microscope, and improved neuroimaging, there was a shift from cranial surgeries to minimal exposure [52,53]. Now, the most common minimally invasive craniotomies include the supraorbital approach, lateral supraorbital, and mini-pterional. The purpose of minimally invasive craniotomies was to limit dural opening, leading to less brain exposure, less retraction, and subsequently lower infection rates, improved healing and cosmetic outcomes, and decreased morbidity [54,55,56].
The first “keyhole” surgery was reported by Donald H. Wilson in 1971 [51]. This small craniotomy allowed for adequate access to be gained to skull-based lesions and vascular abnormalities. The supraorbital keyhole approach was popularized by Axel Perneczky in the 1980s [51]. The technique uses an eyebrow incision with a small supraorbital craniotomy measuring 15–25 mm by 10–15 mm, making it among the smallest standard bone windows used in cranial neurosurgery [55,57]. This approach is appropriate for many suprasellar lesions; however, it has received criticism in vascular pathology given the limited operational flexibility of microinstruments [16,58,59].
The classic pterional approach was first described by Yaşargil in 1975 and quickly became a standard for resection of lesions in the frontotemporal region [54,60]. Despite its versatility, the large skin incision and wide temporalis muscle dissection associated with the classic pterional approach often led to cosmetic concerns, temporalis atrophy, and mastication difficulty [56]. Over the last two decades, the pterional approach has been adapted into minimally invasive lateral supraorbital (LSO) and mini-pterional approaches, specifically for use in treating anterior circulation aneurysms [57]. The LSO approach involves a small skin incision posterior to the hairline with a craniotomy, typically of 4 cm in diameter over the superior temporal line [58]. One limitation of LSO, however, is distal anterior cerebral artery aneurysms due to the depth within the interhemispheric fissure and proximity to the corpus callosum [61,62].
The mini-pterional approach was described by Figueiredo and colleagues as another modification of the classic pterional commonly used to clip anterior circulation aneurysms. This incision is also hidden within the hairline and involves an approximately 3 mm craniotomy at the pterion, the junction point of the frontal, temporal, parietal, and sphenoid bones [60]. Previous studies comparing mini-pterional to classic pterional craniotomy have shown decreased rates of infection, less postoperative pain, less mastication disability, and less permanent facial palsies while still providing adequate exposure for anterior circulation aneurysms, particularly those at the middle cerebral artery bifurcation [61,63,64]. Ultimately, approach selection depends on pathology location, patient anatomy, and surgeon experience, with all three techniques representing important tools in the modern neurosurgical armamentarium.
Endovascular therapy has been led by a desire to find a less traumatic, less invasive approach to treat aneurysms. The traditional clipping of aneurysms was considered a morbid operation; however, at this time, most patients ruptured at presentation [62]. The initial endovascular treatment of aneurysms was with detachable and non-detachable balloons. This method had a high mortality rate of up to 22% due to the high rate of intraoperative rupture from the aneurysm taking the shape of the balloon [65,66,67]. In 1989, Dr. Guglieli devised a detachable, controllable platinum coil for the treatment of brain aneurysms [68]. While still a positive step forward, early detachable coils struggled with control, detachment reliability, coil packing density, and higher recurrence incidences [69,70].
By the late 1990s, improvements in coil design and delivery systems greatly enhanced safety and efficacy, allowing EVT to become mainstream. In the following two decades, major advances reshaped the field. For sidewall aneurysms, the introduction of flow diversion devices such as the pipeline embolization device revolutionized therapy, achieving complete occlusion rates exceeding 80% in anterior circulation aneurysms [71,72,73]. More recently, intrasaccular flow disruption devices such as the Woven EndoBridge (WEB) have been developed and refined for use in wide-neck aneurysms of the ICA, MCA, anterior communicating artery, and tip of basilar aneurysms [69]. However, the current literature reports recurrence rates up to 11%, most commonly of the anterior communicating artery [70]. While technologic refinements continue to be made, it will take at least another decade of innovation and clinical validation before the WEB device reaches its optimal therapeutic potential.
Modern cerebrovascular practice is therefore characterized by parallel progress being made in both EVT and microsurgical clipping. Recent trends suggest that EVT is often the favored approach for treating ruptured intracranial aneurysm due to the minimally invasive, rapid nature of the intervention [74,75]. Despite the advances in devices, EVT has limitations, especially in treating complex intracranial aneurysms. Furthermore, with unruptured aneurysms, however, recent studies suggest that MIC is the preferred intervention [76]. Ultimately, careful consideration of aneurysm morphology, rupture status, comorbidities, and institutional expertise should be assessed to allow for a more personalized approach, aligning treatment modality with patient needs.
Surgical clipping is believed to be the most definitive and durable treatment for UIA, yielding postoperative complete occlusion rates ranging between 90 and 95% [77]. However, these data have not been reported consistently [78]. Additionally, numerous studies have shown higher mortality rates for coiling compared to clipping (0.5–0.6% vs. 1.2–1.6%) [32,79]. The modern shift to MIC seems to address this discrepancy by offering occlusion rates comparable to traditional clipping (~97%) with reduced morbidity (1–1.5%) in select anterior circulation aneurysms [16,18,19]. While EVT offers shorter hospital stays (~1 day), MIC hospitalization averages remain reasonable (3.96 days) [12,32]. Additionally, minimally invasive surgical techniques offer an appealing alternative by potentially reducing the need for retreatment. However, it is important to note that the MIC technique and outcomes may vary with surgical experience [80]. Also, an important limitation of MIC treatment of UIA is the lack of evidence for posterior circulation lesions. The past literature includes only small series or case studies regarding MIC for unruptured basilar artery aneurysms and an SCA aneurysm [74,75,77,81]. While these early reports suggest feasibility, the absence of larger institutional studies means that our conclusions mainly apply to anterior circulation aneurysms.
To date, only one randomized trial evaluating treatment for UIA, the CURES trial, has been completed. Notably, the trial was conducted in Canada. This study reported higher cure rates but also higher complication rates in the traditional surgery group. Importantly, it took 10 years to recruit participants but only reported outcomes for 1 year, with no data on recurrence [78].
Our study highlights the critical importance of complication rates and retreatment in guiding treatment selection. Flow diverters and WEB devices show improved durability but higher complication rates than MIC therapy, according to our results. Recurrence remains a key limitation of EVT, especially coiling, which has been associated with recurrence rates as high as 30%, particularly in wide-neck or large aneurysms [82,83]. Although recurrent rates are higher with EVT, there may be no difference in long-term outcomes, even when retreatment is required. While this notion is primarily described in studies involving ruptured aneurysms, it is an important consideration as treatment for UIA is largely preventative, so durability must be balanced with patient preference, retreatment feasibility, and economic factors [84]. Retreatment procedures may cost patients up to USD 45,000, not including the additional complications from repeated vascular access or hospital-acquired infections [85]. Additionally, retreatment translates into increased anxiety, more time away from work, and a longer period of medical surveillance.
This review has several limitations. First, as a narrative review, our selection of studies may be subject to selection bias, and no quantitative synthesis was performed. Second, heterogeneity in the study design, reporting errors, and outcome definitions limit direct comparability. For example, complication rates varied by whether neurological, cosmetic, or minor complications were included. Third, most MIC studies report anterior circulation aneurysms, with posterior circulation approaches underrepresented, which restricts generalizability. Last, MIC datasets were relatively small compared with large EVT registries. These limitations further emphasize the need for prospective, multicenter studies directly comparing MIC and EVT using standardized outcome measures.
Each year, thousands of UIAs are treated in the U.S., yet federal investment in aneurysm research remains critically low, at only USD 2.94 annually per person affected [86]. This underinvestment underscores the urgency for more high-quality comparative data. It is also important to acknowledge that EVT for aneurysms has become a multi-billion-dollar industry, and utilization is expected to continue increasing. Physicians and healthcare policy-makers must remain vigilant about potential industry-driven biases. For this reason, high-quality independent data are especially vital to help patients weigh up the short-term safety of EVT against the long-term durability of minimally invasive surgery, particularly for younger, low-risk individuals.

5. Conclusions

Evolution in techniques for the treatment of UIA has been essential for providing durable, safe treatment options for patients. This review shows that while traditional clipping carries higher perioperative risk than EVT, most studies have failed to compare long-term recurrences. MIC offers promise in reducing morbidity while retaining durability, but current evidence is limited and focuses on anterior circulation aneurysms. Further high-quality prospective studies are essential to inform evidence-based treatment guidelines.

Author Contributions

Conceptualization, F.S., S.G. and M.S.; methodology, S.G. and F.S.; data curation, F.S., S.G., E.A.A., D.A. and M.S.; writing—original draft preparation, F.S., S.G., E.A.A., D.A. and M.S.; writing—review and editing, F.S., S.G., E.A.A., D.A. and M.S. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

The original contributions presented in this study are included in the article. Further inquiries can be directed to the corresponding author.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
SAHSubarachnoid hemorrhage
EVTEndovascular treatment
MICMinimally invasive craniotomy
UIAsUnruptured intracranial aneurysm
MPCMini-pterional craniotomy
LSOLateral supraorbital craniotomy
SOCSupraorbital craniotomy
WEBWoven EndoBridge

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Table 1. Comparative outcomes of clipping vs. coiling for unruptured intracranial aneurysms.
Table 1. Comparative outcomes of clipping vs. coiling for unruptured intracranial aneurysms.
StudyEnrollment (Open/EVT)Complication Rate (%)Recurrence Rate (%)
ISUIA (2003) [28]1917/4513% higher in open group Not reported *
Higashida (2007) [29]1881/654EVT had fewer adverse outcomes (6.6% versus 13.2%), decreased mortality (0.9% vs. 2.5%)Not reported *
Alshekhlee (2010) [30]3738/34981.6% vs. 0.57%Not reported *
Brinjikji (2011) [31]29,918/34,12515.2% vs. 5.5%Not reported *
McDonald (2013) [32]1388/3551OR = 4.78 vs. 2.16Not reported *
* Not reported—data unavailable in original studies.
Table 2. Outcomes of prominent studies for flow diverters and WEB devices.
Table 2. Outcomes of prominent studies for flow diverters and WEB devices.
StudyDeviceEnrollment (n)Complication Rate (%)Retreatment Rate (%)
PREMIER (2017) [33]Pipeline embolization device (PED)1412.2%2.8%
Kiyofuji (2018) [34]Flow diverters129Mortality 21%
Morbidity 26%		5%
WEB-IT (2019) [31]WEB1500.7%5.6%
SAFE (2020) [35]Flow direction
endoluminal device (FRED)		103Thromboembolic 6.8%
Intraoperative rupture 1.9%		2.2%
SCENT (2020) [32]Surpass flow
diverter		1808.3%0.6%
CLEVER (2024) [36]WEB103Not reported *3.1%
* Not reported—data unavailable in original studies.
Table 3. Outcomes of prominent studies for minimally invasive craniotomy repair of unruptured intracranial aneurysm.
Table 3. Outcomes of prominent studies for minimally invasive craniotomy repair of unruptured intracranial aneurysm.
StudyApproachEnrollment (N)Complication Rate (%)Retreatment Rate (%)
Cha (2012) [37]LSO61Epidural hematoma 3.3
Intracerebral hematoma 1.6
Subdural hematoma 1.6		Not reported *
Cha (2012) [37]Pterional61Epidural hematoma 3.3
Stroke 1.6		Not reported *
Caplan (2014) [12]Pterional724.00
MISIAN (2021) [38]Trans eyelid36CSF leak 2.77
Stroke 5.55
Intraoperative rupture 2.66		0
MISIAN (2021) [38]Mini-pterional34CSF leak 2.94
Stroke 0
Intraoperative rupture 5.88		0
Hong (2021) [39] Keyhole111Permanent morbidity (memory disturbance, hemorrhage, infarct) 1.8% Not reported *
* Not reported—data unavailable in original studies.
Table 4. Comparison of complication rates between different treatments of unruptured intracranial aneurysm.
Table 4. Comparison of complication rates between different treatments of unruptured intracranial aneurysm.
TechniqueIdeal UseComplication Rate (%)
Simple CoilingNarrow-neck10.8 [40]
Balloon-Assisted CoilingWide-neck aneurysm11.7 [40]
Stent-Assisted CoilingComplex, wide-necked37.0 [41]
Flow DiversionLarge, fusiform17 [42]
WEB DeviceBifurcation aneurysms13.2 [43]
Minimally InvasiveAnterior circulation aneurysms, favorable cosmetic outcomes12.2 [44]
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Siddiq, F.; Genovese, S.; Ali, E.A.; Ashfaq, D.; Shakir, M. Is Minimally Invasive Craniotomy a More Contemporary Treatment Option for Unruptured Intracranial Aneurysms? J. Vasc. Dis. 2025, 4, 34. https://doi.org/10.3390/jvd4030034

AMA Style

Siddiq F, Genovese S, Ali EA, Ashfaq D, Shakir M. Is Minimally Invasive Craniotomy a More Contemporary Treatment Option for Unruptured Intracranial Aneurysms? Journal of Vascular Diseases. 2025; 4(3):34. https://doi.org/10.3390/jvd4030034

Chicago/Turabian Style

Siddiq, Farhan, Sabrina Genovese, Eisha Abid Ali, Dahir Ashfaq, and Muhammad Shakir. 2025. "Is Minimally Invasive Craniotomy a More Contemporary Treatment Option for Unruptured Intracranial Aneurysms?" Journal of Vascular Diseases 4, no. 3: 34. https://doi.org/10.3390/jvd4030034

APA Style

Siddiq, F., Genovese, S., Ali, E. A., Ashfaq, D., & Shakir, M. (2025). Is Minimally Invasive Craniotomy a More Contemporary Treatment Option for Unruptured Intracranial Aneurysms? Journal of Vascular Diseases, 4(3), 34. https://doi.org/10.3390/jvd4030034

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