Advances in Microsurgical Clipping for Intracranial Aneurysms: A Narrative Review of Intraoperative Technologies and Clinical Outcomes

Abstract Intracranial aneurysms carry a life-threatening risk of subarachnoid hemorrhage, and the comparative roles of microsurgical clipping and endovascular coiling continue to evolve alongside rapid technological advancement. This narrative review synthesizes contemporary evidence on microsurgical clipping for cerebral aneurysms, evaluating intraoperative adjunctive technologies, location-specific surgical strategies, clinical outcomes, and emerging future directions. A structured literature search was conducted across PubMed/MEDLINE, Scopus, and Google Scholar for peer-reviewed studies published between 2000 and 2025. Following systematic deduplication and eligibility screening, 55 studies were included in a thematic narrative synthesis. Microsurgical clipping achieves complete aneurysm occlusion in 95 to 99% of cases, with durable long-term results and low retreatment rates. Intraoperative adjuncts, particularly indocyanine green videoangiography and robotic-assisted platforms, have demonstrably reduced ischemic complications. Endovascular coiling offers comparable procedural safety for small-necked aneurysms and facilitates faster short-term recovery; however, recanalization affects a significant proportion of large or wide-necked lesions. Treatment selection is primarily determined by aneurysm morphology, anatomical location, patient comorbidities, and institutional expertise rather than rigid algorithmic criteria. Augmented reality navigation and artificial intelligence-assisted clip positioning represent the most promising emerging technologies for surgical precision and resident training. Microsurgical clipping remains the definitive treatment for intracranial aneurysms requiring long-term occlusion security. Optimal management must integrate individual aneurysm architecture and patient physiology rather than rely on a single-modality treatment algorithm.