<p> Hemorrhagic isolated aneurysms of the lateral or medial lenticulostriate arteries (LLSA/MLSA) are rare; evidence is limited to case reports and small series, so the benefit of treatment versus conservative management is uncertain. We reviewed published hemorrhagic isolated (non–malformation-associated) LLSA/MLSA aneurysms, extracting demographics, imaging presentation/aneurysm size, Hunt–Hess grade, management, complications/rebleeding, aneurysm status, mRS. Patients were grouped as treated (surgery/endovascular/radiosurgery) or conservative and compared with exact tests. Three additional conservatively managed cases are described. Forty-two publications reported 48 patients (median age 41.5; 24 men/23 women; 1 unreported). LLSA aneurysms predominated (37/48). Presentation: ICH 34/48, IVH 24/48, isolated SAH 7/48. Twenty-eight patients were treated (22 surgery, 5 endovascular, 1 radiosurgery) and 20 managed conservatively. Conservative patients had higher Hunt–Hess grades (median 4 vs 3) and none had isolated SAH. Rebleeding occurred in 3/20 (15%) conservative patients and 0/27 treated patients with available data. Surgical complications occurred in 10/22 (45%), mainly basal ganglia infarction. mRS was strongly associated with initial Hunt–Hess grade; within Hunt–Hess strata (1–3 vs 4–5),“good outcome” (mRS 0–2) rates were similar between treated and conservative groups. In our 3 cases, all conservatively managed aneurysms spontaneously resolved on follow-up imaging with mRS 0–2. Rebleeding was reported only after conservative management (15%), whereas intervention secured the aneurysm; however, surgical treatment was frequently complicated (45%). Our three conservatively managed cases showed spontaneous aneurysm resolution with mRS 0-2, highlighting the complexity of individualized decision-making when balancing rebleeding risk against treatment-related ischemic injury. Future multicenter registries are needed to better define management strategies.</p>