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Purpose Accurate prediction of procedural difficulty in endovascular treatment (EVT) of intracranial aneurysms (IAs) is crucial for optimal treatment planning, resource allocation, and risk stratification. Current scoring systems lack comprehensive evaluation of multiple complexity domains, limiting their clinical utility in diverse patient populations. We developed and validated the Endovascular Aneurysm Complexity Score (EACS), a novel comprehensive scoring system incorporating nine weighted factors to predict EVT complexity and clinical outcomes, addressing the critical need for standardized preprocedural assessment tools in modern neurointerventional practice.Methods This retrospective study analyzed 74 consecutive intracranial aneurysms treated with EVT at a single tertiary center (January 2023-December 2024). The EACS incorporates nine weighted factors: morphological complexity (15%), branch involvement (14%), access route difficulty (13%), size/neck complexity (12%), device suitability (11%), patient risk factors (10%), eloquence/collateral risk (9%), technical complexity (8%), and calcification/wall characteristics (8%). Two independent neurointerventionalists scored each factor 1-10, generating a composite score (1-10). Primary outcomes included periprocedural complications, procedure duration, and retreatment rates at 6-month follow-up. Correlation analysis and ROC curves assessed predictive accuracy.Results The mean EACS score was 5.7 ± 2.1 (range 2.1-9.2). Cases were stratified into five complexity tiers: Tier 1 (score 1.0-2.5, n=8, 10.8%), Tier 2 (2.6-4.5, n=18, 24.3%), Tier 3 (4.6-6.5, n=24, 32.4%), Tier 4 (6.6-8.0, n=18, 24.3%), and Tier 5 (8.1-10.0, n=6, 8.1%). Strong positive correlations were observed between EACS scores and complication rates (r=0.742, p<0.001), with complication rates increasing progressively from 0% in Tier 1 to 50% in Tier 5. Procedure duration showed significant correlation (r=0.681, p<0.001), ranging from 45±12 minutes in Tier 1 to 185±35 minutes in Tier 5. Retreatment rates also correlated strongly (r=0.658, p<0.001), increasing from 0% to 33.3% across tiers. Secondary outcomes demonstrated similar progressive trends. The area under the ROC curve for predicting major complications was 0.847 (95% CI: 0.753-0.941), indicating excellent discriminatory power with optimal cutoff at 6.5. Inter-rater reliability was excellent (intraclass correlation coefficient=0.912, 95% CI: 0.867-0.945).Conclusions The EACS demonstrates strong predictive validity for EVT complexity and outcomes, offering a standardized tool for preprocedural risk assessment and case triage. The five-tier system facilitates clinical decision-making and multidisciplinary communication. Implementation may improve patient selection, procedural planning, and resource utilization. Prospective multicenter validation is warranted before widespread clinical adoption and guideline incorporation.Disclosures O. Mansour: None. F. hassan: None. A. Hasawy: None.Abstract E-261 Figure 1