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Introduction Clinical studies suggest better functional outcomes after endovascular coiling of intracranial aneurysms (IAs) compared to neurosurgical clipping (NSC). However, it remains unclear whether this applies to modern endovascular techniques: balloon-assisted coiling (BAC), stent-assisted coiling (SAC), flow diversion (FD), or intrasaccular flow disruption (IFD).Aim of study This study compares nationwide German in-hospital outcomes of modern EVT methods and NSC with standard coiling (SC).Method Nationwide administrative data of IA treatments (ruptured/unruptured, 2013–2022) were analyzed using billing codes for SC, BAC, SAC, FD, IFD, and NSC. Primary outcomes included functional independence (discharge type), poor outcome (US National Inpatient Sample Subarachnoid Hemorrhage Outcome Measure), and mortality. Propensity score weighting was used.Results A total of 77,684 procedures were analyzed. In ruptured IAs, SAC, FD, and NSC were associated with lower functional independence (p=0.001, p=0.007, p<0.001) and higher mortality (p<0.001, p=0.001, p=0.032). Poor outcomes were more frequent after SAC (p=0.001) and NSC (p<0.001). In unruptured IAs, functional independence improved with BAC (p=0.036), SAC (p=0.045), and IFD (p<0.001), but decreased with NSC (p=0.017). Poor outcomes were less frequent with IFD (p<0.001), and mortality was lower with NSC (p=0.020) and IFD (p=0.003).Conclusion Germany-wide in-hospital outcomes reveal significant differences between techniques for IA treatment. In ruptured IAs, SAC, FD, and NSC were associated with worse outcomes compared to SC. In unruptured IAs, BAC, SAC, and IFD improved functional outcomes, while NSC was linked to poorer outcomes. Notably, IFD consistently demonstrated superior functional outcomes despite limited utilization, suggesting a potential paradigm shift towards IFD as a safer treatment option.Conflict of Interest No