Intracranial aneurysms (IA) are a significant global health issue, with rupture leading to high mortality and morbidity. Over the past three decades, treatment approaches have evolved dramatically, with endovascular therapy now being the primary treatment for ruptured IA based on robust randomized controlled trial data. The management of unruptured IA has also expanded, with both microsurgical clipping and endovascular treatments being used to prevent rupture. Both microsurgical and endovascular techniques have advanced, particularly with the introduction of innovative endovascular options such as flow diversion and intra-saccular flow disruption. These novel therapies allow clinicians to treat more complex and previously untreatable aneurysms. The article reviews the evolution of treatment strategies for IA over time and discusses emerging technologies that could further improve treatment safety and functional outcomes for patients with IA. Key advancements include the development of flow diverter stents, intrasaccular flow disruption devices, and other innovative endovascular devices. The selection of appropriate treatment strategies depends on multiple factors, including patient and aneurysm characteristics, hospital resources, and economic considerations. While endovascular therapy has diminished the role of open surgery, it also has its own limitations, such as the risk of recanalization and high procedural costs. Therefore, surgical therapy remains a cost-effective option for certain groups of aneurysms, particularly those with large sizes, wide necks, and bifurcation locations. The article emphasizes the importance of individualized treatment plans and the need for thorough patient discussion regarding different options and expected outcomes.Intracranial aneurysms (IA) are a significant global health issue, with rupture leading to high mortality and morbidity. Over the past three decades, treatment approaches have evolved dramatically, with endovascular therapy now being the primary treatment for ruptured IA based on robust randomized controlled trial data. The management of unruptured IA has also expanded, with both microsurgical clipping and endovascular treatments being used to prevent rupture. Both microsurgical and endovascular techniques have advanced, particularly with the introduction of innovative endovascular options such as flow diversion and intra-saccular flow disruption. These novel therapies allow clinicians to treat more complex and previously untreatable aneurysms. The article reviews the evolution of treatment strategies for IA over time and discusses emerging technologies that could further improve treatment safety and functional outcomes for patients with IA. Key advancements include the development of flow diverter stents, intrasaccular flow disruption devices, and other innovative endovascular devices. The selection of appropriate treatment strategies depends on multiple factors, including patient and aneurysm characteristics, hospital resources, and economic considerations. While endovascular therapy has diminished the role of open surgery, it also has its own limitations, such as the risk of recanalization and high procedural costs. Therefore, surgical therapy remains a cost-effective option for certain groups of aneurysms, particularly those with large sizes, wide necks, and bifurcation locations. The article emphasizes the importance of individualized treatment plans and the need for thorough patient discussion regarding different options and expected outcomes.