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Introduction Aneurysms of the anterior inferior cerebellar artery (AICA) are rarely described in the literature. The decision regarding how to operate on AICA aneurysms (and whether to operate on unruptured cases) requires careful consideration of the risks and benefits of all available options, including endovascular and surgical approaches; however, the risks of each are imperfectly understood. We present the case of a 77-year-old female patient presenting with a ruptured, 7mm, dissecting-type AICA aneurysm involving the meatal loop. We also present an updated systematic review of case reports and case series of AICA aneurysms, summarizing how aneurysm features and management decisions have resulted in differing operative outcomes.Methods A systematic review was conducted, screening Pubmed and Embase through June 1, 2025 for article titles and abstracts with mention of AICA aneurysms. Manual review of references was additionally completed, and clinical, radiographic, and outcomes data were extracted.Results A total of 162 cases of AICA aneurysms were identified, with 108 surgical cases and 45 endovascular cases. Aneurysms were predominantly of saccular morphology (69.8%) and less often fusiform. Among the 127 cases where aneurysm location was reported, 26 (16.0%) involved the proximal segment of the AICA; 47 (29.0%) involved the meatal segment, and 24 (14.8%) involved the post-meatal segment. Attributable etiologies when present predominantly reported co-occurring vascular findings (e.g., arteriovenous malformations, arteriovenous fistulas, AICA-PICA variants, and hemangioblastomas) as well as complications of radiosurgery. The majority of patients presented with rupture (73.5%), though some patients presented with isolated focal neurological deficit (14.9%) or as an incidental finding (6.8%). Ruptured aneurysms were more likely to be managed endovascularly when compared to unruptured aneurysms (relative risk (RR) 3.03, 95% CI 1.16 - 7.90), as were aneurysms with fusiform morphology (RR 2.59, 95% CI 1.36 - 4.92). Proximal AICA aneurysms were more likely to be managed endovascularly when compared to distal (meatal or post-meatal) aneurysms, though this association did not reach significance (RR 1.24, 95% CI 0.65 - 2.36). Complication rates were higher for surgical than endovascular cases, though this difference did not reach significance (39.2% vs. 25.0%, p = 0.12). Lower complication rates following endovascular cases were primarily driven by proximal aneurysms (26.7% vs. 44.7%, p = 0.23), and complication rates for distal aneurysms were similar (30.8% vs. 31.8%, p = 0.95). Parent artery occlusion was not found to be significantly more likely to result in complications when intervening on proximal (pre-meatal) aneurysms than with distal (meatal or post-meatal) aneurysms (RR 0.91, 95% CI 0.68 - 1.21).Conclusion Careful consideration of the risks of endovascular and surgical management of AICA aneurysms should include discussion of aneurysm size, location, morphology, rupture status, and the presence of collaterals. While parent artery occlusion of the proximal AICA should be avoided, certain cases may require it.Disclosures B. Teasdale: None. P. Krieger: None. A. Rodrigues: None. N. Sujijantarat: None. A. Patel: None.