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Background Management of unruptured intracranial aneurysms (UIAs) in elderly patients remains controversial. Advanced age often favors conservative surveillance due to perceived procedural risk; however, the natural history of UIAs in geriatric populations is incompletely characterized, and contemporary treatment outcomes in elderly patients are increasingly favorable.Objective To evaluate age-stratified rupture risk among patients with UIAs undergoing surveillance and integrate these findings with outcomes of elective aneurysm treatment in octogenarians to inform risk stratification in geriatric populations.Methods A prospective population-based cohort study was conducted within a geographically defined catchment population of approximately one million people. The annual incidence of aneurysmal subarachnoid hemorrhage (aSAH) was determined from all regional presentations. Patients with incidentally detected UIAs managed with radiological surveillance were followed from first diagnostic imaging until rupture, treatment, death, or last confirmed follow-up. Rupture risk was calculated per patient-year using two analytical models: an observed follow-up model and an assumed follow-up model extending observation to the present. Age-stratified rupture risk was evaluated across predefined age groups. Procedural safety and functional outcomes were assessed in patients aged ≥80 years undergoing elective aneurysm repair (endovascular or microsurgical).Results The population incidence of aneurysmal rupture was 1.38 per 100,000 patient-years. Among patients undergoing surveillance, annual rupture risk was 1.06% per patient-year using the observed follow-up model and 0.41% using the assumed follow-up model. Rupture events were predominantly concentrated in patients aged 50–69 years, with comparatively fewer events observed in those aged ≥70 years as demonstrated in Fig 1. Despite lower natural history rupture risk in advanced age, elective intervention in octogenarians demonstrated favorable outcomes, with 88% complete or near-complete aneurysm occlusion and 92% functional independence (mRS ≤2) at six-month follow-up.Conclusion In this population-based cohort, UIA rupture risk appears to decline in advanced age, while carefully selected elderly patients can undergo aneurysm treatment with acceptable procedural risk and favorable functional outcomes. These findings highlight the importance of individualized geriatric risk stratification integrating natural history, aneurysm morphology, and patient fitness, rather than reliance on chronological age alone, when determining management strategies for elderly patients with UIAs.Disclosures J. Antony: None. R. Loomba: None. L. Yang: None.Abstract P-022 Figure 1Rate of rupture stratified by age