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Background Moyamoya disease (MMD) is a rare cerebrovascular disorder characterized by progressive stenosis of the distal internal carotid arteries, leading to increased collateral flow and the development of an abnormal vascular network, which imposes shear stress on small vessels and increases the risk of aneurysm formation. Endovascular treatment (EVT) has emerged as a potential approach for managing MMD-associated intracranial aneurysms (MMD-IA), but its safety and efficacy remain unclear.Objective This systematic review and meta-analysis aimed to evaluate the safety, efficacy, and long-term outcomes of EVT in patients with MMD-IA.Methods A comprehensive search was conducted across PubMed, Embase, and Web of Science, adhering to PRISMA guidelines. Studies reporting clinical and angiographic outcomes for EVT of MMD-IA were included. The primary outcomes were complete aneurysm occlusion, functional outcomes, procedural complications, and recurrence rates. Pooled analyses with 95% confidence intervals (95% CIs) were conducted, with heterogeneity assessed using I² statistics, and a random-effects model was applied.Results Seventeen studies, comprising 506 patients (36.33% female; mean age: 49.24±10.91 years) with aneurysms were included. Of these, 181 patients underwent EVT. The pooled complete occlusion rate was 86.46% (95% CI: 39.28 to 98.44) immediately after embolization and 84.51% (95% CI: 75.67 to 90.54) at last follow-up. Procedure-related complications were 15.27% (95% CI: 9.88 to 22.85) and the prevalence of subarachnoid hemorrhage after the procedure was 5.25% (95% CI: 2.20 to 12.05). The prevalence of ischemic procedural complications was estimated at 8.69% (95% CI: 4.49 to 16.16). Functional independence (modified Rankin Scale (mRS) 0–2) was achieved in 86.93% (95% CI: 73.55 to 94.09) of cases at follow-up. The aneurysm recurrence rate was 8.08% (95% CI: 3.05 to 19.69), emphasizing the need for long-term monitoring.Conclusions EVT appears to be a safe and effective treatment for MMD-IA, demonstrating high occlusion rates and favorable functional outcomes. However, the risk of aneurysm recurrence highlights the importance of long-term follow-up. Further large studies are necessary to confirm these findings and optimize treatment strategies for this complex condition.