**Conflict of interest**

*New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review*

In our series, we identified 101 patients (11.58%) with multiple aneurysms, harboring a total of 257 lesions. The most common location was the middle cerebral artery, followed by the internal carotid and anterior communicating artery (**Figure 6**). Initially, our approach in treating them was to clip the ruptured aneurysms or the ones with the higher risk, leaving the others for a later procedure. However, after we lost two patients with MIA on the night before the second planned intervention due to the rupture of the single unclipped lesion, we overhauled our methodology. The current goal in all cases is single-stage surgery (unilateral frontopterional approach) with all aneurysms clipped during the same procedure. If this is unfeasible, we perform a second craniotomy during the same anesthesia, as we believe the process of patient waking elevates the risk of rupture of any unclipped UIA. Most patients presented with two aneurysms (57.6%). The highest number of aneurysms was six (one patient, female). The male-to-female ratio was 1:3, with the higher number of aneurysms leading to an increase of female predominance. Our series too suggests that MIA is primarily a pathology of the female gender (**Figure 7**). We analyzed the complication rate, mortality, and state at discharge between groups with unilateral and bilateral aneurysms of the anterior circulation. There were no statistically significant differences between the two groups regarding the rate of complications or the outcome (*P* > 0.05, **Table 1**). When we compared patients with mirror middle cerebral aneurysms to the rest of the lot, no statistically significant difference could be observed either (*P* > 0.05). 60.39% of patients (61)

*Comparison between the two groups on admission (Hunt and Hess scale, associated complications, and age)* 

*and on discharge (preoperative days, Glasgow Outcome Scale, complications, and mortality).*

**Parameter Statistical test Odds ratio Confidence interval 95% P** Hunt and Hess scale Mann-Whitney U — — 0.588 Associated complications Chi square 1.35 0.25–7.75 0.73 Age *t* — — 0.25 Preoperative days *t* — — 0.37 Glasgow Outcome Scale Chi square 1.5 0.9–11.53 0.69 Complications Chi square 2.6 0.53–13.11 0.22 Mortality Chi square 0.4 0.03–5.24 0.47

were discharged with a favorable neurological outcome (GOS of 4 or 5).

unruptured lesions in the context of multiple intracranial aneurysms.

**13. Final remarks and future directions**

Our data demonstrates that, with an appropriate selection of cases, surgery yields definitive and favorable results in solitary UIAs if handled by an experienced team. "Single-stage, single-opening surgery" is a viable option for treating the

Clipping of UIAs remains a valuable treatment option in preventing rupture and subsequent hemorrhagic stroke. In the hands of experienced vascular neurosurgeons, it is still a secure and long-lasting procedure, despite the relative ease and comparable safety and durability of endovascular procedures. Since aneurysmal rupture cannot be accurately predicted, clipping stands as a virtually curative procedure. Nevertheless, being an invasive procedure, it still harbors inherent risks. While our experience shows that clipping of solitary UIAs is not associated with mortality and only minimal morbidity, clipping of MIAs can pose a challenge.

**166**

**Table 1.**

The authors declare that there is no conflict of interest.
