Physiology-First Strategies in Intracranial Aneurysm Surgery: Integrating Cerebrovascular Dynamics into Neurosurgical Management

Background: Contemporary aneurysm surgery increasingly requires the management of complex lesions with limited physiological reserve. A growing “physiology-first” paradigm emphasizes that optimizing cerebrovascular dynamics during aneurysm treatment is essential for favorable neurological outcomes. Methods: This narrative review synthesizes current evidence and expert perspectives on cerebrovascular physiology relevant to aneurysm surgery, including cerebral perfusion, autoregulation, ischemia tolerance, neuroprotection, and intraoperative monitoring. Results: Key themes include individualized blood pressure management, recognition of impaired autoregulation—particularly after subarachnoid hemorrhage—safe application of temporary arterial occlusion, and the use of multimodal neuromonitoring to detect ischemia in real time. The strengths and limitations of neuroprotective adjuncts are critically discussed in the context of available clinical evidence. Conclusions: Integrating cerebrovascular physiology into aneurysm surgery supports informed intraoperative decision-making, minimizes ischemic injury, and enhances patient outcomes. A physiology-first approach complements technical expertise and represents a cornerstone of modern neurovascular practice.