Objective: Few prospective randomized controlled studies have investigated the efficacy of endovascular treatment and microsurgical clipping of intracranial aneurysms, especially via microsurgical keyhole approach. We compared the efficacy of three techniques in treating patients with ruptured anterior circulation aneurysms to provide surgeons with a more objective basis for treatment selection. Methods: 150 patients with ruptured anterior circulation aneurysms were randomly assigned to endovascular treatment, conventional craniotomy, and keyhole approach groups. Aneurysm occlusion, surgical time, hospitalization time, hospitalization expenses, and surgical complications were compared between groups. Results: The complete occlusion rates of aneurysms at discharge were 90% in the endovascular group, 94% in the conventional group, and 96% in the keyhole group. No significant differences in complete occlusion rates or Glasgow Outcome Scale scores were found between groups. In the keyhole approach, conventional craniotomy, and endovascular groups, the overall surgical times were 161.78±34.51 min, 201.55±38.79 min, and 85.86±58.57 min, respectively; the hospitalization times were 11.42±6.64 d, 18.03±7.14 d, and 10.57±8.67 d; hospitalization expenses were 10574.25±4154.25 USD, 13214.54±5487.65 USD, and 20134.58±6587.61 USD; and the incidence rates of postoperative complications such as intracranial infection, cerebral vasospasm, hydrocephalus, intracranial hematoma, and epilepsy were 8%, 28%, and 20%. Conclusions: Endovascular coiling and the microsurgical keyhole approach have the advantages of simple execution, time savings, and short hospitalization. Microsurgical clipping of intracranial aneurysms needs to be updated to a minimally invasive procedure to maintain its complementary value with endovascular treatment.Clinical trial registration: The study has been retrospectively registered in clinicaltrial.org (NCT05049564) in Sep. 8th, 2021.