Purpose of review: Intracranial aneurysms are frequent incidental findings on cranial imaging. The decision for preventive treatment depends on the presumed risk of rupture, the efficacy and risk of complications of preventive treatment, and the quality of life having to live with an unruptured aneurysms. Data on all these factors are still incomplete, and additional data are needed.

Recent findings: The current review describes advances of the last 2 years in assessment of risk of rupture, on risks of preventive aneurysms occlusion, on follow-up imaging and on medical management of patients with unruptured intracranial aneurysms.

Summary: In addition to risk factors used to predict absolute risks of rupture, also aneurysm irregularity and aneurysm growth during follow-up are potential risk factors for rupture. To what extent these factors improve risk prediction in absolute terms is yet uncertain. Uncertainty also continues on whether endovascular or surgical occlusion is the preferred method, but a trial comparing these two strategies is ongoing. Aneurysm growth can now be predicted in absolute risks. Enhancement of the aneurysm wall on MRI probably is also related to aneurysm instability and reflects inflammation. A trial assessing the effects of anti-inflammatory treatment and blood pressure lowering on aneurysm growth and rupture is currently ongoing.