To explore the effect of different blood pressure management strategies on the prognosis of elderly patients with grade IV-V intracranial aneurysms during interventional embolization. Methods: A total of 110 elderly patients with grade Ⅳ～V intracranial aneurysms treated in our hospital were retrospectively selected and included in the training set. The patients were randomly divided into the observation group (n=55) and the control group (n=55) using the random number table method. The clinical data from the two groups in the training set were compared. The Kaplan-Meier survival curve was used to compare the incidence of 2-year poor prognosis in patients with different blood pressure management strategies. Cox univariate and multivariate regression analyses were conducted to assess factors influencing postoperative prognosis. A nomogram prediction model was constructed to predict the poor prognosis of patients after operation. The efficacy of the model was evaluated by the receiver operating characteristic curve and the calibration curve. Individual risk scores were generated according to the model, establishing a risk stratification system. Results: The incidence of poor 2-year prognosis in the observation group was significantly lower than that in the control group (P< 0.05). Hypertension, operation timing in the middle and late stages, mean arterial pressure ≥ 65 mmHg, blood pressure fluctuation ≥ 16 mmHg, and a tumor length-to-neck width ratio > 2.0 were independent risk factors for poor prognosis of interventional embolization in elderly patients with grade Ⅳ～V intracranial aneurysms (P< 0.05). Intraoperative blood pressure management strategy of controlled hypotension was a protective factor for poor prognosis in elderly patients with grade Ⅳ ～V intracranial aneurysms undergoing interventional embolization (P<0.05). The nomogram prediction model had good differentiation and accuracy. The risk stratification system divided all patients into four distinct risk groups: very low risk group (total score<30), low risk group (30≤total score<78), medium risk group (78≤total score<106) and high risk group (total score≥ 106). This risk stratification system was able to differentiate the occurrence of poor prognosis among patients with different intraoperative blood pressure management strategies (P<0.05). Conclusion: During the operation, the blood pressure management strategy of remifentanil combined with nimodipine controlled hypotension should be implemented, as it can improve the prognosis of patients.