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Background It is unclear which wide-necked aneurysms (WNA) benefit from endovascular therapy (EVT) or open surgery (OS). We aimed to analyze angiographic and functional outcomes of patients from the Stroke Thrombectomy and Aneurysm Registry (STAR). This is a multi-center prospective registry which reports real-world evidence on the treatment of WNAs.Methods The STAR database involved patients from 9 institutions across the United States, Europe and Asia admitted from 2013 to 2025. Patients with underlying WNA and available clinical and angiographic follow-up at 3 years were included. WNA was defined as an intracranial aneurysm with a neck width ≥ 4 mm or a dome to neck ratio < 2. Clinical presentation, demographic information, treatment modality and aneurysm location were retrieved from electronical medical records. Rates of intraoperative aneurysm rupture, retreatment and clinical outcome at follow-up were also analyzed. Angiographic occlusion outcomes were reported based on the Raymond Roy Occlusion Classification. Functional outcomes were based on the modified Rankin Scale at discharge and 3 years. Multivariable logistic regression was performed for the outcomes analysis.Results The STAR database included 3342 patients with aneurysms, and 407 WNAs were ultimately included in this analysis. From this cohort, 325/407 (79.8%) underwent EVT and 82/407 (20.1%) had OS. The most common aneurysm location in the EVT group was the superior hypophyseal segment of the internal carotid artery in 66/325 (20.3%) of cases, while the middle cerebral artery in 31/82 (37.8%) was the most common in the OS group. Neck width was larger in the EVT cohort compared to the OS cohort (median 7.0 [IQR 5.4-9.5] vs 5.6 [IQR 4.6-6.4], p < 0.001). Stent assisted coiling was the most common EVT approach in 156/325 (48.0%) of cases and single clipping in 81/82 (98.8%) of OS patients. The rates of intraoperative aneurysm rupture (0.6% vs 3.7%, p = 0.05), retreatment (6.8% vs 1.2%, p = 0.06) and re-rupture (0.6% vs 0.0%, p = 0.90) at follow-up. Patients who underwent OS were more likely to have immediate complete occlusion (OR 43.90, 95% CI 13.5-270, p < 0.001) compared to EVT, but no difference was found at 3 years (OR 3.45, 95% CI 1.00-21.70, p = 0.10). There was no association between OS and functional independence at discharge (OR 0.65, 95% CI 0.35-1.22, p = 0.20) or at 3 years (OR 1.68, 95% CI 0.73-4.54, p = 0.30).Conclusion OS achieved higher rates of immediate complete occlusion among WNAs, and no difference was found at 3 years compared to EVT. Both treatment modalities had similar complication rates and functional outcomes.Disclosures A. Gudino: None. J. Isidor: None. M. Hinojosa Figueroa: None. J. Manrique Osorio: None. M. Godoy: None. M. Cabarique: None. L. Gudino: None. B. El Baba: None. S. Eshragui: None. A. Alawieh: None. Z. Chisango: None. F. Tong: None. F. Akbik: None. A. Pabaney: None. P. Jabbour: None. S. Tjoumakaris: None. I. Maier: None. S. Wolfe: None. A. Rai: None. R.M. Starke: None. B. Gory: None. M. Psychogios: None. A. Shaban: None. N. Goyal: None. J. Kim: None. S. Yoshimura: None. P. Kan: None. R. De Leacy: None. I. Fragata: None. A. Polifka: None. J. Osbun: None. R. Williamson: None. R. Crosaa: None. M. Levitt: None. M. Moss: None. M. Park: None. A. Rivadeneira-Limongi: None. W. Casagrande: None. C. Matouk: None. S. Chowdhry: None. M. Cawley: None. J. Grossberg: None. A. Spiotta: None. E. Samaniego: None.